A SECOND SUPERIOR GLUTEAL ARTERY PERFORATOR FLAPWITH PREVIOUS LIPOSUCTION TO THE SAME BREAST AFTERRESECTION OF INITIAL SGAP BREAST RECONSTRUCTION DUETO CANCER RECURRENCE

YASH J. AVASHIA, B.S.,1 ARTHUR E. DESROSIERS III, M.D.,2 and JAIME I. FLORES, M.D., F.A.C.S.3*

Free superior gluteal artery perforator (SGAP) flaps are a reliable option for breast reconstruction in patients with insufficient abdominal tis-sue or abdominal scarring. Liposuction in a donor site is a relative contraindication for harvesting a free flap, despite current case reportschallenging this tenet. We describe a case of a 36-year-old woman who underwent unilateral breast reconstruction with free SGAP flap.She underwent liposuction of the contralateral buttock for symmetry. Approximately, one year post-operatively, she developed local recur-rence of the breast cancer. Previously liposculpted buttock was used as donor site for a second free SGAP flap anastomosed to internalmammary artery. VVC 2012 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2012.

Free superior gluteal artery perforator (SGAP) flaps are

a reliable option for autologous breast reconstruction in

patients with insufficient abdominal tissue or abdominal

scarring.1,2 Liposuction in a donor site is a relative contra-

indication for harvesting a free flap. However, there are

case reports demonstrating successful breast reconstruction

using free flaps that have previously undergone liposuc-

tion.3 In this report, we describe a unique case on employ-

ing two free SGAP flaps for unilateral breast reconstruction

for recurrent breast cancer after a previously liposuctioned

free SGAP flap and use of internal mammary vessels.

CASE REPORT

A 36-year-old female presented with multifocal ductal

carcinoma in situ of the right breast. In July 2007, the

patient underwent mastectomy and negative sentinel node

biopsy with immediate breast reconstruction. Because of

the grossly inadequate excess tissue from her abdomen,

free superior gluteal artery perforator flap was harvested

from the right buttock and inset into the defect in the

right chest. Preoperative CT angiography and intra-opera-

tive hand-held doppler ultrasound were used as imaging

modalities to visualize perforator artery anatomy. The

free flap weighed 331 g and replaced 130 g breast tissue.

Her operative and postoperative course was uneventful.

The patient later underwent a left breast implant aug-

mentation, right nipple reconstruction, and right breast

liposuction for symmetry. A total of 150 ml of fat was

injected into the right buttock for symmetry. This was

harvested via suction-assisted liposuction from her abdo-

men, outer flanks, inner thighs, and left buttock. Regard-

ing the left buttock, two separate entry port sites, medial

and lateral, were created. The marked area was injected

via high pressure with tumescence solution consisting of

1 l lactated ringers solution mixed with one ampoule epi-

nephrine and 30 cc of plain 1% lidocaine. After 30 min,

a 4-mm cannula was used via straight mechanical lipo-

suction for the deep plane, followed by a 2.5-mm cannula

for the superficial layers.

In July 2008, the patient presented with recurrence of

her breast cancer above her SGAP skin paddle, medial to

the lumpectomy scar of her right breast. The patient sub-

sequently underwent a wide local excision and removal

of the SGAP flap with placement of a tissue expander

and biologic material. Chemotherapy and local radiother-

apy followed.

In September 2009, she underwent tissue expander re-

moval and right breast scar excision. After local tissue

rearrangement of the pectoralis muscle and resection of

the third rib, free SGAP flap was harvested from her left

buttock and transferred to the right chest (Fig. 1). The

same imaging modalities were employed as in the first

SGAP breast reconstruction. With distal vessel damage

from the local radiation, saphenous vein graft of 12 cm

was used to increase vascular pedicle length. Flap weight

was 518 g and ischemia time was 1 hour 46 min. Her

immediate operative course and postoperative course was

uneventful. However, 4 days post operation she devel-

oped erythema of her mastectomy skin, with increased

tenderness. This cellulitis was resolved with a brief

course of intravenous antibiotics and the patient was

discharged with no further complications.

The patient later underwent left periareolar mastopexy

with right breast revision. A total of 42 cm3 of fat was

1Miller School of Medicine, University of Miami, Miami, FL2Division of Plastic Surgery, Miami Children’s Hospital, Miami, FL3Plastic Surgeon, Aesthetics and Reconstructive Surgery, Miami, FL

*Correspondence to: Jaime Flores, M.D., 3661 S. Miami Avenue, Suite 1003,Miami, FL 33131. E-mail: jifloresmd@gmail.com

Received 1 October 2011; Revision accepted 3 March 2012; Accepted 7March 2012

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.21989

VVC 2012 Wiley Periodicals, Inc.

grafted to the right SGAP incision and central mound for

projection. Finally, in April 2010, the patient underwent

bilateral revision with liposuction of the reconstructed

breasts and revisions to her nipple and mastopexy (Fig.

2). Two year post-operative follow-up showed patient

with no complications and extremely satisfied with aes-

thetic result.

DISCUSSION

Breast perforator flaps allow the transfer of the

patient’s own skin and fat, in a functional manner, with

minimal donor site morbidity.4 Autologous breast recon-

struction provides natural and long-lasting aesthetic

results.5,6 While the abdomen commonly harbors excess

tissue used in free flap breast reconstruction, patients who

are extremely thin or have excessive abdominal scarring

are not good candidates for free flaps harvested from the

abdominal region (DIEP, SIEA, and TRAM flaps). The

gluteal region has proven over the past decade to be a

reliable second option in this group of select patients.7 In

our case, the patient did not have sufficient excess

abdominal fat and the free SGAP flap was employed for

both breast reconstructions.

Preoperative imaging to visualize perforator anatomy

is a necessary step that reduces operative time, surgery

cost, and provides the surgeon with anticipation of perfo-

rator during flap dissection.8 Imaging modalities include

CT angiography (CTA) and color duplex ultrasound.

CTA provides precise three-dimensional anatomical infor-

mation for perforator localization (size, position, and

course). It aids in flap design, planning of incisions, and

extent of dissection to perforators. Color duplex ultra-

sound provides information on number of perforators and

individual details including flow velocity inside vessel,

thickness of subcutaneous fat layer, anatomical character-

istics of underlying muscles and fascia. Specific advant-

age of CTA over duplex ultrasound is length of imaging

(roughly 15 vs. 30 min). Disadvantages include radiation

exposure, invasive nature of imaging, contrast allergy, and

the strict contraindication of CTA in patients with impaired

renal function. Because CTA aids in accurately evaluating

perforator location and its course through the gluteus mus-

cle near the sciatic foramen, our patient’s preoperative

work-up included CTA. The use of handheld doppler aided

in confirming perforator location intraoperatively.

Compared to its predecessor, the free SGAP flap pro-

vides excellent soft tissue quality for reconstruction. By

avoiding resection of the gluteal muscles, donor site mor-

bidity is minimized.9 Harvesting tissue from the central

region of the buttock creates a depression in the projec-

tion.10 Vascular dissection is extended to the ‘‘medusa

head’’ of the superior gluteal artery, an area under the sub-

gluteal fascia that has numerous large vessel branches.7

Variation in gluteal vascular anatomy increases dissection

complexity.10 Vascular pedicle length can be increased by

vein grafts similar to the one used during this patient’s sec-

ond free SGAP flap. In our patient’s case, the first SGAP

vascular pedicle was unable to be preserved during resec-

tion, and subsequent local radiation affected the smaller

vessels distally. Proximal vessels were too large for use,

thus necessitating the use of saphenous vein graft.

Abdominal scarring, prior Caesarian section, and pre-

vious liposuction to abdominal regions are risk factors for

free DIEP flaps.7 Today, liposuction is considered one of

the most common cosmetic procedures performed.7 Scar-

ring and vascular disruption of perforators to the tissue

after liposuction jeopardizes the viability of the free flap.

During the dissection of our patient’s second SGAP per-

forator flap, an increased amount of subcutaneous scar-

ring was noted. De Frene et al. recently published their

experience with breast reconstruction using five DIEP

flaps and one SGAP flap, after previous liposuction of

the donor site.7 Preoperative color duplex examination

Figure 1. Preoperative markings for second SGAP. [Color figure

can be viewed in the online issue which is available at wileyonline

library.com.]

Figure 2. Right breast status post-second SGAP and nipple revi-

sion. [Color figure can be viewed in the online issue which is avail-

able at wileyonlinelibrary.com.]

2 Avashia et al.

Microsurgery DOI 10.1002/micr

suggested a true positive rate of 96.2% and a positive

predictive value of 100%. Flap dissection was more diffi-

cult due to fibrosis and scarring of the subcutaneous tis-

sue from liposuction. These factors contribute to the

higher risk of partial or complete flap loss in free flaps

that have previously undergone liposuction. The use of

ultrasound-assisted liposuction over conventional suction-

assisted liposuction has shown no significant difference

for perforator flap preservation.11

In summary, the value of this case stems from two mu-

tual aspects of ‘‘tertiary" unilateral breast reconstruction

with free SGAP flap to the same breast previously recon-

structed with free SGAP flap of the opposite buttock and

the use of gluteal donor site with previous liposuction to

harvest free SGAP flap for breast reconstruction. Perforator

flaps harvested from donor sites with previous liposuction

are generally contraindicated. However, this case suggests

that with proper pre-operative diagnostic imaging and care-

ful perforator flap harvesting, such donor sites can still pro-

vide viable free flaps for breast reconstruction.

REFERENCES

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2. Blondeel PN. The sensate free superior gluteal artery perforator(S-GAP) flap: A valuable alternative in autologous breast reconstruc-tion. Br J Plast Surg 1999;52:185–193.

3. De Frene B, Van Landuyt K, Hamdi M, Blondeel P, Roche N, VoetD, Monstrey S. Free DIEAP and SGAP flap breast reconstructionafter abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg2006;59:1031–1036.

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7. De Frene B, Van Landuyt K, Hamdi M, Blondeel P, Roche N, VoetD, Monstrey S. Free DIEAP and SGAP flap breast reconstructionafter abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg2006;59:1031–1036.

8. Smit JM, Dimopoulou A, Liss AG, Zeebregts CJ, Kildal M,Whitaker IS, Magnusson A, Acosta R. Preoperative CT angiographyreduces surgery time in perforator flap reconstruction. J PlastReconstr Aesthet Surg 2009;62:1112–1117.

9. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap forbreast reconstruction. Plast Reconstr Surg 1995;95:1207–1212.

10. Rad AN, Flores JI, Prucz RB, Stapleton SM, Rosson GD. Clinicalexperience with the lateral septocutaneous superior gluteal arteryperforator flap for autologous breast reconstruction. Microsurgery2010;30:339–347.

11. Blondeel PN, Derks D, Roche N, Van Landuyt KH, Monstrey SJ.The effect of ultrasound-assisted liposuction and conventional lipo-suction on the perforator vessels in the lower abdominal wall. Br JPlast Surg 2003;56:266–271.

Previous Liposuction in Second Unilateral SGAP Flap 3

Microsurgery DOI 10.1002/micr