Breast Reconstruction With SGAP and IGAP Flaps

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BREAST

Breast Reconstruction with SGAP and IGAP FlapsMaria M. LoTempio, M.D.

Robert J. Allen, M.D.

Charleston, S.C.; and Metairie, La.

Background: Perforator flaps represent the latest in the evolution of soft-tissueflaps. They allow the transfer of the patient’s own skin and fat in a reliable

manner with minimal donor-site morbidity. The powerful perforator flap con-cept allows transfer of tissue from numerous, well-described donor sites toalmost any distant site with suitable recipient vessels. Large-volume flaps can bereliably supported with perforators from areas such as the buttock and trans-ferred microsurgically for breast reconstruction.Indications: The ideal tissue for breast reconstruction is fat with or without skin,not implants or muscle. Absolute contraindications specific to perforator flapsin our practice include history of previous liposuction of the donor site, someprevious donor-site surgery, or active smoking (within 1 month before surgery).Methods: Perforator flaps are supplied by blood vessels that arise from named,axial vessels and perforate through or around overlying muscles and septa to

vascularize the overlying skin and fat. During flap harvest, these perforators are

meticulously dissected free from the surrounding muscle, which is spread in thedirection of the muscle fibers and preserved intact. The pedicle is anastomosedto recipient vessels in the chest, and the donor site is closed without the use of synthetic mesh.Conclusion: Perforator flaps allow for safe, reliable tissue transfer from a variety of sites and provide ideal tissue for breast reconstruction, with minimal donor-site morbidity. (Plast. Reconstr. Surg. 126: 393, 2010.)

In breast reconstruction, plastic surgeons com-monly use silicone or saline implants. This tech-nique has the advantages of minimal morbidity,

including immediate reconstruction, absence of adonor site, and technical simplicity. Aesthetic re-sults can range from acceptable to excellent withimplant placement, although these patients re-port that their result never feels natural. Approx-imately 25 percent of the women who present toour group for breast reconstruction have had previous attempted implant reconstruction with fail-ure. This accounts for approximately 600 breast reconstructions over the past 17 years.

Breast reconstruction with perforator flaps hasallowed the transfer of the patient’s own skin and

fat in a reliable manner, with minimal donor-sitemorbidity since 1992.1 This is the most recent de- velopment in the evolution of flaps for breast re-construction. Flaps that relied on a random pat-tern blood supply were soon replaced by pedicled,

axial pattern flaps that could reliably transfer greateramounts of tissue. The inception of free tissue trans-fer allowed an infinite range of possibilities to ap-

propriately match donor and recipient sites.2

Perforator flaps are not without their chal-lenges, including variability of vascular anatomy. Judgment as to how many, what size, and the lo-cation of perforators affect factors such as lengthof surgery and incidence of postoperative fat ne-crosis. Flap insetting and vascular territory dependon the above factors affecting flap circulation.

Fujino et al. first described the superior glutealmyocutaneous free flap in 1975 for breast recon-struction. Shaw popularized the myocutaneous su-perior gluteal artery free flap; however, a short

vascular pedicle often led to additional vein graft-ing, thus limiting its popularity.3–7 In 1978, Le-Quang performed the first breast reconstruction with an inferior gluteal myocutaneous free flap.8

The inferior gluteal myocutaneous flap champi-oned by Paletta et al. was mostly abandoned, pre-

From the Division of Plastic Surgery, Medical University of South Carolina, and the Section of Plastic Surgery, Omega Hospital, Louisiana State University Health Sciences Center.Received for publication June 5, 2007; accepted February 10,2010.Copyright ©2010 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181de236a

Disclosure: The authors have no financial interest in this research project or in any of the techniques or equipment used in this study.

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sumably because of sciatic nerve injury exposureand pain when sitting.9

The superior gluteal artery perforator flap(SGAP) and the inferior gluteal artery perforator(IGAP) flap were first introduced by our group in1993. The advantages of the gluteal artery perfo-

rator flap include preservation of the gluteusmaximus muscle and elongation of the pedicle. Inour group, bilateral simultaneous SGAP/IGAPflaps are performed but require two skilled mi-crosurgeons to harvest the flaps.10,11 With preop-erative use of computed tomographic/magneticresonance imaging angiograms, septocutaneousSGAP/IGAP flaps for breast reconstruction arenow being performed.12 The angiograms allow usto visualize the key perforators being musculocu-taneous or septocutaneous, and the caliber, loca-tion, and course. As with other perforator flaps,

donor-site morbidity is minimal and no sacrifice of muscle is required. Overall, we have used theSGAP flap more than the IGAP flap, but the upperbuttock donor site may have a scooped-out ap-pearance. The IGAP flap is a good option whenbuttock tissue is used and the patient has a “saddle-bag deformity” because of an improved donor-sitecontour and the scar is hidden in the crease.13–15

However, these techniques have brought new diffi-culties and problems that must be addressed. First and foremost, these techniques require microsurgi-cal expertise. Dr. Bill Shaw expressed that a super-

specialist might perform certain types of free flapsbeyond the realm of the occasional microsurgeonsuch as gluteal artery perforator flap breast recon-struction. The learning curve for perforator flapbreast reconstruction is estimated to be approxi-mately 50 to 100 procedures.

The buttock is a good choice for breast recon-struction when the abdomen is not a viable option,as is the medial thigh free flap. In our patient population, the buttock is the donor site in 15percent, the abdomen in 7 percent, and the me-dial thigh in 15 percent. Donor-site morbidity is

minimal, and no sacrifice of muscle is required. Various locations, orientations, and dimensions of the skin island have been attempted over the years.Each has advantages and disadvantages. Initially, we used an oblique ellipse totally over the muscleoriented in the direction of the muscle fibers. Thisgave the greatest chance of finding an adequateperforator under the flap. With better apprecia-tion of the vascular anatomy and confidence inpreoperative computed tomography and mag-netic resonance imaging, there is more freedom isdesigning the skin island. An oblique ellipse ex-

tending in the upper buttock superior from me-

dial to lateral has the advantage of concealing thescar in swimwear and undergarments. By bevelingsuperiorly, a nicely shaped flap with less contourdeformity can be obtained. In 2004, we begandesigning the IGAP flap so that the scar would bein the natural inferior crease. By harvesting tissue

from the lowest part of the buttock and bevelinginferiorly, the shape of the rounded upper but-tock was preserved. The pedicle length was oftenlonger than that of the SGAP flap, making theanastomosis easier andnegating the need to removerib cartilage because less length was required on therecipient vessels. However, sitting directly on thehealing incision causes more pain than the SGAPflap in the early postoperative period, and the rateof dehiscence increases. This is particularly true inbilateral simultaneous reconstructions where the pa-tient cannot shift weight bearingto the nonoperated

side. The sciatic nerve has never been a problem inour experience with approximately 120 IGAP flaps.However, some small sensory nerves may have to bedivided with flap harvest. The ideal candidate issomeone with a large buttock (pear shape) and a Bsize breast. In the right candidate, the in-the-creaseIGAP flap can give an excellent breast reconstruc-tion with a hardly noticeable donor site. After initialenthusiasm with the in-the-crease IGAP flap, we arenow using the SGAP flap in slightly more than 50percent of our patients. Ultimately, the women dotheir research and come with their opinions about

which donor site they prefer. Advantages and dis-advantages of SGAP and IGAP donor sites are com-pared in Table 1).

The gluteal artery perforator is an excellent option for breast reconstruction. This flap can alsobe used as a pedicled flap for coverage of otherareas, in particular, pressure sores.15–18

INDICATIONS Women who have undergone mastectomies

and wish to undergo reconstruction with autolo-

gous tissue are potential candidates for SGAP orIGAP flaps. Those in whom the abdomen cannot be used as a donor site either because of previous

Table 1. Advantages and Disadvantages of SGAPand IGAP Donor Sites

Donor-Site Comparison SGAP IGAP

Scar concealed with swimsuit Yes NoUpper buttock fullness maintained No YesSaddlebag correction No YesPossible hip roll improvement Yes NoTenderness sitting early postoperatively No YesLonger pedicle No Yes

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abdominoplasty or liposuction or who have moreexcess tissue in the buttock area than in the ab-domen are the best candidates. The buttock has ahigh fat-to-skin ratio, whereas the abdomen has ahigh skin-to-fat ratio. Patients who require mostly fat and little skin may be candidates for SGAP/

IGAPS flaps. A significant amount of tissue may beharvested and, in our experience, the average finalinset weights of our SGAP and IGAP flaps wereslightly greater than weights of the mastectomy specimens removed.

Absolute contraindications specific to SGAP/IGAP flap breast reconstruction include previousliposuction at thedonor site or activesmokingwithin1 month before surgery. Liposuction of the upperbuttock is rare and does not often affect harvestingof the SGAP flap; however, liposuction of the sad-dlebag area can affect the IGAP flap viability.

ANATOMY The superior gluteal artery is a continuation of

the posterior division of the internal iliac artery. It is a short artery, which runs dorsally between thelumbosacral trunk and the first sacral nerve. It em-anates from the pelvis above theupper border of thepiriformis muscle, where it soon divides into bothsuperficial and deep branches. The deep branchtravels between the iliac bone and gluteus mediusmuscle. The superficial branch continues to give off contributions to the upper portion of the gluteus

muscle and overlying fat and skin. Anatomical loca-tion is planned when the femur is slightly flexed androtated inward; a line is drawn from the posteriorsuperior iliac spine to theposterior superior angle of the greater trochanter. The point of entrance of thesuperior gluteal artery from the upper part of thegreater sciatic foramen corresponds to the junctionof the upper and middle thirds of this line. Perfo-rating vessels are found off the superior branch of the superior gluteal artery.19,20

The inferior gluteal artery is a terminal branchof the anterior division of the internal iliac artery

and exits the pelvis through the greater sciaticforamen.21,22 Landmarks can also be used to iden-tify the location of the emergence of the inferiorgluteal artery outside the pelvis. A line is drawnfrom the posterior superior iliac spine to the outerpart of the ischial tuberosity; thejunction of its lower with its middle third marks the point of emergenceof the inferior gluteal and its surrounding vesselsfrom the lower part of the greater sciatic foramen.The artery accompanies the greater sciatic nerve,internal pudendal vessels, and the posterior femoralcutaneous nerve. In this subfascial recess, the infe-

rior gluteal vein will receive tributaries from other

pelvic veins. The inferior gluteal vasculature contin-ues toward the surface by perforating the sacral fas-cia. It exits thepelvis caudal to thepiriformis muscle.Once under the inferior portion of thegluteus maxi-mus, perforating vessels are seen branching out through the substance of the muscle to feed the

overlying skin and fat. The course of the inferiorgluteal artery perforating vessels is more obliquethrough the substance of the gluteus maximus mus-cle than the course of the superior gluteal artery perforators, which tend to travel more directly to thesuperficial tissue up through the muscle. Thus, thelength of the inferior gluteal artery perforator andthe resultant pedicle length for the IGAP flap is 7 to10 cm. The SGAP pedicle is 5 to 8 cm in length.Because the skin island is placed inferior to the or-igin of the inferior gluteal vessels, a longer pedicleis usually obtained.

The direction of the perforating vessels can besuperior, lateral, or inferior. Perforating vesselsthat nourish the medial and inferior portions of the buttock have relatively short intramuscularlengths, between 5 and 7 cm, depending on thethickness of the muscle. Perforators that nourishthe lateral portions of the overlying skin paddleareobserved traveling throughthe musclesubstancein an oblique manner 4 to 6 cm before turningupwardtowardtheskin surface. By traveling throughthe muscle for relatively long distances, these vesselsare longer than their medially based counterparts.

The perforating vessels can be separated from theunderlying gluteus maximus muscle and fascia andtraced down to the parent vessel, forming the basisfor the inferior gluteal artery perforator flap. Be-tween two and four perforating vessels originatingfrom the inferior gluteal artery will be located in thelower half of the gluteus maximus.12

After giving off perforators in the buttocks, theinferior gluteal artery then descends into the thighaccompanied by the posterior femoral cutaneousnerve and follows a long course, eventually sur-facing to supply the skin of the posterior thigh.15

The branches of the inferior gluteal nerve (fifthlumbar and first and second sacral nerves) supply the skin of the inferior buttock. A neurosensory flap can be elevated if these nerves are preservedin the dissection of the flap.16,17

The superior gluteal nerve arises from the dor-sal divisions of the fourth and fifth lumbar and first sacral nerves. It exits the pelvis through the greatersciatic foramen above the piriformis muscle, ac-companied by the superior gluteal vessels, anddivides into both superior and inferior branches.The superior and inferior branches of the nerves

travel with their corresponding arterial branches

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to end up in the gluteus medius, gluteus minimus,and tensor fasciae latae, respectively.

The inferior gluteal nerve arises from the dor-sal divisions of the fifth lumbar and first and sec-ond sacral nerves. It exits the pelvis through thegreater sciatic foramen, below the piriformis mus-

cle, and divides into branches that enter the deepsurface of the gluteus maximus.

The posterior femoral cutaneous nerve inner- vates the skin of the perineum and posterior surfaceof the thigh and leg. It arises partly from the dorsaldivisions of thefirst andsecond andfrom the ventraldivisions of the second and third sacral nerves, andissues from the pelvis through the greater sciaticforamen below thepiriformis muscle, along with theinferior gluteal artery. It then descends beneath thegluteus maximus, the fascia lata, and travels overthe long head of the biceps femoris to the posterior

knee. Finally, it pierces the deep fascia and accom-panies thelesser saphenous vein to themiddle of theposterior leg. Some terminal branches communi-cate with the sural nerve. All its branches are cuta-neous and distributed to the gluteal region, the per-ineum, and the posterior thigh and leg.

SURGICAL TECHNIQUEThe patient usually is seen in our office 1 day be-

fore surgery. The surgical plan again is reviewed withthepatient, andanyremaining questionsareanswered.

The chest is marked in the sitting position.The midline and the inframammary crease onboth sides are marked. For patients undergoingimmediate breast reconstruction, suggested skinmarkings are drawn on the breast, which includemarks around the nipple-areola complex and previous biopsy site. In patients who are undergoinga nipple-sparing mastectomy, a vertical, lateral, orinframammary incision is marked.

For unilateral SGAP flap markings, the patient isplaced in the lateral decubitus position. Preopera-tive computed tomography, magnetic resonance an-

giography, and/or a Doppler probe is used to locateperforating vessels from the superior gluteal artery.These areusually locatedapproximatelyone-third of the distance on a line from the posterior superioriliac crest to the greater trochanter. Additional per-forators may be found slightly more lateral fromabove. It should be noted that perforators locatedlaterally would produce longer pedicles. Septocuta-neous perforators are the most lateral and coursebetween the gluteal maximus and medius. The skinpaddle is marked in an oblique pattern from infero-medial to superolateral to include these perforators.

On average, the flapheight is 7 to 10 cm and the flap

length is 18 to 22 cm. For bilateral SGAP planning,the patient is marked in the prone position.

For the IGAP flap, the gluteal fold is noted withthe patient in the standing position. The inferiorlimit of the flap is marked 1 cm inferior and parallelto the gluteal fold. The patient is then placed in the

lateral position for unilateral reconstruction and theprone position for bilateral reconstruction. Com-puted tomography or magnetic resonance angiog-raphy and the Doppler probe are used to locateperforating vessels from the inferior gluteal artery. An ellipse is drawn for the skin paddle to includethese perforators, which roughlyparallelstheglutealfold with dimensions of approximately 7 18 cm.For correction of a saddlebag deformity, the skinpattern is shifted laterally. This also prevents harvesting the fat pad over the ischial tuberosity medialto the gluteus maximus muscle.

For unilateral procedures, the patient is placedin the lateral decubitus position and a two-team ap-proach is used. The recipient vessels are prepared while the SGAP/IGAP flap is harvested. For breast reconstruction, the internal mammary vessels orinternal mammary perforators are preferred, asanastomosis to these vessels allows easier medial-ization of the flap when it is inset. The IGAP flapoften has a long enough pedicle that will reach tothe thoracodorsal vessels; however, the SGAP flapmay be challenging because of a shorter pedicle.For bilateral simultaneous gluteal artery perfora-

tor flap reconstruction, the procedure is startedsupine. After mastectomy and recipient vesselpreparation, the patient is positioned for flap harvest. Then, the patient is repositioned supine foranastomosis and insetting.

The skin incisions are made and Bovie elec-trocautery is used to divide the flap down to themuscle of the gluteus maximus. Significant bevel-ing is used as needed, particularly lateral to themuscle superior and inferior to harvest enoughtissue for width and volume to create a naturalbreast shape. The flap is elevated from the muscle

in the subfascial plane and the perforators ap-proached beginning from lateral to medial or me-dial to lateral. Use of a single large perforator ispreferred, if it is present, but several perforators, which lie in the same plane and the direction of the gluteus maximus muscle fibers, can be takentogether as well. The muscle is then spread in thedirection of the muscle fibers and the perforatorsfollowed through the muscle. The dissection con-tinues until both the artery and the vein are of sufficient size to be anastomosed to the recipient vessels in the chest. The artery usually is the lim-

iting factor in this dissection. The arterial perfo-


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rator is visualized and preserved as it enters themain ascending superior gluteal artery or the de-scending inferior gluteal artery. The preferableartery and vein diameter for anastomosis is 2.0 to2.5 mm and 3.0 to 4.0 mm, respectively. Whenusing the internal mammary vein perforators as

recipient, a shorter pedicle and smaller artery willsuffice, thereby simplifying flap harvest.Harvesting the in-the-crease IGAP flap allows

more beveling superiorly and inferiorly becausesoft-tissue deficiency in the crease is normal. Lat-erally thicker fat from the trochanteric area can betaken, increasing flap volume and decreasing thesaddlebag deformity. When harvesting the IGAPflap, care must be taken to preserve the lightercolored medial fat pad, which overlies the ischiummedial to the gluteus maximus muscle. Preserva-tion of this specialized fat pad will prevent possible

donor-site discomfort when sitting in the future.

When the recipient vessels are ready, thegluteal artery and vein are divided and the flapharvested and weighed. The skin and fat over-lying the gluteus maximus muscle and posteriorthigh with the IGAP flap are elevated superiorly and inferiorly to allow layered approximation of

the fat of the donor site to prevent a contourdeformity. The donor site is closed in layers overa suction drain with absorbable suture. Addinga permanent removable skin suture increasesthe strength of the skin closure.

The anastomosis is performed to the recipient vessels under the operating microscope. The flapis inset over a suction drain into the breast pocket, with care taken not to twist or kink the pedicle. Tocreate a spherical flap, the ends of the ellipse areexcised or approximated. The flap may be inset horizontally, vertically, or obliquely, depending

on the situation.

Fig. 1. Case 1. ( Above, left ) Preoperative view of a patient with ductal carcinoma in situ of the left breast who underwent amastectomy with SGAP flap reconstruction and a symmetrical procedure of the right breast with SGAP flap reconstruction.

(Below,left ) Preoperativeview of thedonorSGAP flap site. ( Above, right ) Appearance after thepatient hadundergone recon-

struction with bilateral SGAP flap and second-stage nipple reconstruction. (Below , right ) Postoperative view of the healed

bilateral SGAP flap donor sites.


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CASE REPORTS

Case 1 A 52-year-old woman presented with a history of ductal car-

cinoma of the left breast. She underwent a left skin-sparingmastectomy with an SGAP flap reconstruction. On the con-tralateral side, she underwent a right prophylactic nipple-spar-ring mastectomy with breast reconstruction using an SGAP flap(Fig. 1). Her gluteal region shows adequate adiposity to makea full B-cup size (Fig. 1). Her scars were symmetrical, preservingthe natural buttock contour (Fig. 1).

Case 2 A 44-year-old patient presented who had undergone a right

mastectomy for invasive ductal carcinoma (Fig. 2). In Figure 2,the preoperative markings are shown. She has more inferiorgluteal adiposity versus superior gluteal fat with which to re-construct her right breast to match heroppositebreast. Patients

will often have an opinion regarding the location from whichthey would like the gluteal tissue to be taken. This patient preferred her lower buttock to be used. The marks are where

the best Doppler signals were heard. The skin pattern is drawnin relations to these perforators. At 6-month follow-up, thepatient has a right reconstructed breast matching her left sideThe buttock scar is in the crease (Fig. 2).

Case 3 A 42-year-old patient presented who had bilateral mastecto-

mies for ductal carcinomawith tissue expander placement (Fig.3). In Figure 3, the preoperative markings for a bilateral sep-tocutaneous gluteal artery perforator flap are drawn based ona computed tomographic angiogram depicting the septocuta-neous gluteal artery perforators. Figure 3 shows the computedtomographic angiogram and the patient 6 months after bilat-eral septocutaneous SGAP flap reconstruction.

POSTOPERATIVE CARECurrently in our unit, patients have a 1- to

2-hour stay in the recovery room and then aretransferred to their private room, where they have monitoring of the flap circulation every 2hours for the night and then every 4 hours.The intensive care unit is not needed. Patientstypically go home on the third or fourth post-operative day. The drain at the donor site usu-ally will be left in place for at least 10 days.Breast drains are usually removed on postoper-ative day 3.

Fig. 2. Case 2. ( Above, left ) Preoperative view of a woman who had undergone a right mastectomy secondary to breast cancer.

(Below, left ) Preoperativeviewof therightIGAPflap donor site.( Above, right ) Postoperative view of thepatientaftera right IGAP flap

breast reconstruction. (Below , right ) Postoperative view of the healed right donor sites of the IGAP flap.


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ADVANTAGESBoth the SGAP flap and the IGAP flap are ex-

cellent for breast reconstruction, especially when200 to 600 g is needed. The SGAP flap is a thick flap,

with an adequate pedicle (5 to 7 cm) for breast

reconstruction. It has a better donor site with thesuperior lateral flap design,and the scar is concealedby a swimsuit.

The IGAP flap is a thick flap, with longer pedi-

cle (7 to 10 cm). The scar is hidden if done in the

Fig. 3. Case 3. ( Above , left ) Preoperative view. (Above, right) Computed tomographic angiogram showing the sep-

tocutaneous gluteal artery perforators. (Center, left and center, right ) Preoperative markings of the septocutaneous

gluteal artery perforator flap. (Below, left and below, right ) Appearance 6 months postoperatively.


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crease, there are fewer contour defects compared with the SGAP flap, and there is a long pedicle that can be anastomosed to the thoracodorsal systemfor breast reconstruction if the internal mammary vessels are not available.

DISADVANTAGESDisadvantages of the SGAP flap include con-

tour defects, visible scar, and loss of padding onthin patients. Disadvantages of the IGAP flap in-clude the fact that the donor site may be painfulto sit on for 3 to 6 weeks. Injury to the smallcutaneous nerves during pedicle dissection is apossibility. There is also donor scar show withFrench cut swimsuits.

COMPLICATIONSIn a review of 492 gluteal artery perforator

flaps performed by our unit for breast recon-struction, the incidence of complications waslow. The overall take-back rate for vascular com-plications was 6 percent, with the most commonbeing venous (4 percent) and arterial (2 per-cent). The total flap failure rate was approxi-mately 2 percent. Donor-site seroma occurred in15 percent of patients, requiring aspiration. Ap-proximately 20 percent of patients required revision of the donor site at the second stage of breast reconstruction.19,21

The most common reason for donor-site re-

visions of the SGAP flap is contour deformity of the upper buttock. The most common revision forthe donor site IGAP flap is liposuction of the lat-eral trochanter fat for contouring. Dog-ear revi-sions are often performed at the time of second-stage breast reconstruction for both SGAP andIGAP flaps.

Recipient-site complications include a fat ne-crosis rate of 8 percent, with both SGAP and IGAPflaps requiring revision. Breast flap contour asym-metry requires fat grafting or revision in approx-imately 10 percent of cases.

CONCLUSIONSPerforator flaps have raised the standard in

breast reconstruction. By replacing like with like, we can achieve permanent natural results withminimal donor-site deformities. Being able tochoose from many donor-site options makes vir-tually all patients candidates for this method of autogenous reconstruction. To make this optionmore available and desirable, there is plenty of room for improvement. The length of the proce-dure needs to be decreased, scars and buttock

contour need to be improved, and complications

need to be decreased. With improvements in tech-nology and technique, these goals can be realized.The in-the-crease IGAP flap offers preservation of buttock shape, a scar hidden in a natural crease,and adequate thickness fat for a youthful, at-tractive breast. The SGAP flap has little or nopostoperative pain and leaves a scar easily con-cealed with swimwear. The septocutaneousSGAP flap allows a more favorable donor sitemore superolateral in the hip roll area. Thecontour can be quite good without taking a flapthat is too large and performing a buttock lift with proper-layered closure.

Maria M. LoTempio, M.D.55 East 87th Street

New York, N.Y. [email protected]

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2. Taylor GI, Daniel RK.The anatomy of severalfree flap donorsites. Plast Reconstr Surg. 1975;56:243–253.

3. Shaw WW. Breast reconstruction by superior gluteal microvascular free flaps without silicone implants. Plast Reconstr Surg. 1983;72:490–501.

4. ShawWW. Microvascularfree flap breast reconstruction. Clin Plast Surg. 1984;11:333–341.

5. Shaw WW. Superior gluteal free flap breast reconstruction.Clin Plast Surg. 1998;25:267–274.

6. Codner MA, Nahai F. The gluteal free flap breast recon-struction: Making it work. Clin Plast Surg. 1994;24:289–296.

7. Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasiaof the breast and pectoral region by microvascular transferof a free flap from the buttock. Plast Reconstr Surg. 1975;56:178–181.

8. Le-Quang C. Secondary microsurgical reconstruction of thebreast and free inferior gluteal flap (in French). Ann Chir Plast Esthet. 1992;37:723–741.

9. Paletta CE, Bostwick J III, Nahai F. The inferior gluteal freeflap in breast reconstruction. Plast Reconstr Surg. 1989;84:875–883.

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perforator (SGAP) flaps. Ann Plast Surg. 2004;53:305–310.11. DellaCroce FJ, Sullivan SK. Application and refinement of

the superior gluteal artery perforator free flap for bilateralsimultaneous breast reconstruction. Plast Reconstr Surg. 2005;116:97–103; discussion 104–105.

12. Tuinder S, Van Der Hulst R, Lataster A, Boeckx W. Supe-rior gluteal artery perforator flap based on septal perfo-rators: Preliminary study. Plast Reconstr Surg. 2008;122:146e–148e.

13. Allen RJ, Tucker C Jr. Superior gluteal artery perforator freeflap for breast reconstruction. Plast Reconstr Surg. 1995;95:1207–1212.

14. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferiorgluteal artery perforator flap for breast reconstruction. Plast

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15. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast recon-struction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59:571–579.

16. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A.The gluteal perforator-based flapfor repair of sacral pressuresores. Plast Reconstr Surg. 1993;91:678–683.

17. Windhofer C, Brenner E, Moriggl B, Papp C. Relationship

between the descending branch of the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flapsurgery. Surg Radiol Anat. 2002;24:253–257.

18. Blondeel PN. The sensate free superior gluteal artery per-forator (S-GAP) flap: A valuable alternative in autologousbreast reconstruction. Br J Plast Surg. 1999;52:185–193.

19. Guerra A, Metzinger S, Gill Bidros R, et al. Breast recon-struction with gluteal artery perforator (GAP) flaps: A critical analysis of 142 cases. Ann Plast Surg. 2004;52:118–125.

20. Strauch B, Yu HL. Gluteal region. In: Strauch B, Yu HL, eds.Atlas of MicrovascularSurgery: Anatomyand Operative Approaches .New York: Thieme Medical; 1993:102–119.

21. Ao M, Mae O, Namba Y, Asagoe K. Perforator-based flap forcoverage of lumbosacral defects. Plast Reconstr Surg. 1998;101:987–991.

22. Roche NA, VanLanduyt K, Blondeel PN,MattonG, Monstrey SJ. The use of pedicled perforator flaps for reconstruction of lumbosacral defects. Ann Plast Surg. 2000;45:7–14.

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● http://www.trialregister.nl/trialreg/index.asp (Netherlands Trial Register)

● http://www.umin.ac.jp/ctr (UMIN Clinical Trials Registry)

More information on registering clinical trials can be found in the following article: Rohrich, R. J., andLongaker, M. T. Registering clinical trials in Plastic and Reconstructive Surgery. Plast. Reconstr. Surg. 119: 1097,

2007.


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