BREAST

Breast Reconstruction with Perforator FlapsJay W. Granzow, M.D.,

M.P.H.Joshua L. Levine, M.D.

Ernest S. Chiu, M.D.Maria M. LoTempio, M.D.

Robert J. Allen, M.D.

New Orleans, La.; Charleston, S.C.;and Torrance, Calif.

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 reliablemanner, 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 besupported reliably with perforators from areas such as the abdomen, buttock,or flank and transferred 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 the authors’ practice include history of previous liposuction of the donor site,some previous donor-site surgery, or active smoking (within 1 month beforesurgery).Technique: Perforator flaps are supplied by blood vessels that arise fromnamed, axial vessels and perforate through or around overlying muscles andsepta to vascularize the overlying skin and fat. During flap harvest, these per-forators are meticulously dissected free from the surrounding muscle, which isspread in the direction of the muscle fibers and preserved intact. The pedicleis anastomosed to recipient vessels in the chest, and the donor site is closedwithout the use of mesh.Conclusion: Perforator flaps allow for safe, reliable tissue transfer from a varietyof sites and provide ideal tissue for breast reconstruction, with minimal donor-site morbidity. (Plast. Reconstr. Surg. 120: 1, 2007.)

The most common type of breast reconstruc-tion involves the use of saline or silicone gelimplants. This technique has the advan-

tages of simplicity and the absence of a donorsite. Aesthetic results can be quite good, al-though in the senior author’s experience thesepatients have consistently reported that the re-sult never feels natural and always feels like animplant under the chest muscle. Approximately25 percent of the women seen for breast recon-struction in the senior author’s practice haveundergone previous attempted implant recon-struction.

The transverse rectus abdominis musculocuta-neous (TRAM) flap in the early 1980s ushered inthe new era of autogenous reconstruction. Everyplastic surgeon set out to learn this technique.

Over time, the magnitude of the donor-site mor-bidity became more apparent. As plastic sur-geons, we are always looking for better ways to dothings. The deep inferior epigastric perforator(DIEP) and superficial inferior epigastric artery(SIEA) flaps have certainly decreased donor-sitemorbidity. However, these techniques havebrought new difficulties and problems that mustbe addressed. First and foremost, these tech-niques require microsurgical expertise. Bill Shawonce said that the super specialist might performcertain types of free flaps beyond the realm ofthe occasional microsurgeon. What is the learn-ing curve for perforator flap breast reconstruc-tion? Perhaps 50 to 100 procedures.

The variability of vascular anatomy contributesto the difficulties with these procedures. Judg-ment as to how many and what size and locationof perforators to select affect factors such aslength of operation and incidence of fat necro-sis. Vascular territory depends on the above fac-tors. It is amazing how little blood supply isactually necessary to adequately perfuse skin andfat. Flap insetting also affects flap circulation.

Perforator flaps have allowed the transfer ofthe patient’s own skin and fat in a reliable man-ner, with minimal donor-site morbidity, for more

From the Section of Plastic Surgery, Louisiana State Uni-versity Health Sciences Center; Division of Plastic Surgery,Medical University of South Carolina; and Division of Plas-tic Surgery, Harbor-UCLA Medical Center.A Master Series article from Plastic Surgery 2004.Received for publication May 18, 2005; accepted February15, 2006.Copyright ©2007 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000256044.66107.a6

www.PRSJournal.com 1

than a decade.1 They represent the most recentdevelopment in the evolution of flaps for breastreconstruction. Flaps that relied on a randompattern blood supply were soon supplanted bypedicled, axial pattern flaps that could reliablytransfer greater amounts of tissue. The advent offree tissue transfer allowed an even greater rangeof possibilities to appropriately match donor andrecipient sites.2

In 1989, the quest to further reduce donor-sitemorbidity and flap bulk was led by Koshima andSoeda.3 They succeeded in transferring skin ter-ritory above the rectus abdominis muscle basedoff a perforator vessel to reconstruct a floor-of-mouth and groin defect. In 1992, breast recon-struction using the same principles was devel-oped by Allen and Treece and Allen andTucker.1,4 Abdominal tissue supplied by perfora-tors to the rectus abdominis muscle was trans-ferred with the deep inferior epigastric perfora-tor flap, buttock tissue overlying the gluteusmaximus muscle was transferred with the glutealartery perforator flap, back tissue overlying thelatissimus dorsi muscle was rotated with the tho-racodorsal artery perforator flap, and lateralthigh skin and fat overlying the tensor fasciaelatae muscle were transferred as the lateralthigh perforator flap as new options for breastreconstruction.

The flow of a noncompressible liquid througha tube is governed by Poiseuille’s law accordingto the following equation:

�V ��r4

8�

�p*

lThe flow of a volume of liquid, �V, is propor-

tional to the fourth power of the radius of thetube through which it is carried. Thus, a singlelarge perforating vessel that is 2.0 mm in diam-eter will carry approximately 16 times the bloodflow of an otherwise similar vessel that is only 1.0mm in diameter. Therefore, it is preferable touse a single large perforator than multiple,smaller perforators when choosing among ves-sels to carry a perforator flap.

Relative contraindications for perforator flapsinclude active nicotine use, obesity with a bodymass index greater than 30, and previous lipo-suction. Immediate perforator breast reconstruc-tion is not recommended in patients scheduledto have radiation therapy after mastectomy.9

DIEP FLAPA good source of this soft tissue for a free flap

is the patient’s own lower abdomen. Previously, a

TRAM flap could have been used to carry reliablythe abdominal skin and fat at the expense of sac-rificing the abdominal rectus muscle and fascia.The DIEP flap can carry the same tissue withoutthe sacrifice of the rectus muscle or fascia, therebyminimizing donor-site morbidity and pain andshortening recovery time.5–7

IndicationsMost women who have had or will have mas-

tectomies for breast cancer are possible candi-dates for the DIEP flap. In addition, DIEP flapreconstruction may be used for women requiringadditional breast tissue for defects such as a con-genital deficiency or lumpectomy defect.8 In mostpatients, DIEP flaps may also be used for head andneck reconstruction or extremity wounds.

Absolute contraindications specific to DIEPflap breast reconstruction in our practice includehistory of previous abdominoplasty or abdominalliposuction, and active smoking (within 1 monthbefore surgery). Relative contraindications in-clude large transverse or oblique abdominalincisions.

In the case of breast reconstruction, we preferto have the patient complete any radiation therapyand a delay of 6 months before placement of thefree flap. Although the perforator flaps usuallytolerate radiation well, a superior long-term resultis typically obtained in reconstructions performedafter rather than before chest wall irradiation.This spares the flap the damaging effects of radi-ation and typically results in a better long-termresult. It also allows the removal of any thick, stiffirradiated chest wall skin and its replacement withsoft and nonirradiated abdominal skin and softtissue.9

AnatomyLike the free TRAM flap, the DIEP flap is

based on the deep inferior epigastric artery andvein. Two rows of perforating arteries and veinspenetrate the rectus muscle on each side of theabdomen to provide the blood supply for the over-lying skin and fat. The deep inferior epigastricartery is typically between 2 and 3 mm in diameterand the accompanying veins are between 2 and 3.5mm in size.

Unlike a TRAM flap, the rectus muscle andfascia are spared. Instead, the perforating vesselsthat supply the overlying skin and fat are carefullyfollowed through the rectus muscle to their ori-gins from the deep inferior epigastric vessels. Dur-ing the dissection, the rectus muscle itself is spared

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and atraumatically separated in the direction ofthe muscle fibers.

Preoperative EvaluationThe patient is usually seen in the office on the

day before surgery for preoperative markings andDoppler studies. The surgical plan again is re-viewed with the patient, and remaining questionsare also answered at this time.

Standard abdominoplasty markings are madein the sitting or standing position. The side of theabdomen contralateral to the side to be recon-structed is preferred, as this provides for easierinsetting at the time of surgery. Flaps are typicallymarked approximately 12 cm high at the midlineand extend approximately 22 to 24 cm laterallyfrom the midline. Then, with the patient in thesupine position, a Doppler probe is used to iden-tify the main perforators of the medial and lateralbranches of the deep inferior epigastric artery.The superficial inferior epigastric artery and veinare likewise found with the Doppler probe andmarked.

Surgical TechniqueA two-team approach is used, with simulta-

neous raising of the flap and preparation of therecipient vessels. The deep inferior epigastric ar-tery usually is between 2.0 and 2.5 mm in diameter,and the accompanying vein usually is between2.5 and 3.0 mm in diameter. Careful prepara-tion of recipient vessels with similar diameters ispreferred.

For breast reconstruction, the internal mam-mary artery and vein are the recipient vessels ofchoice and are used in over 90 percent of ourcases. The internal mammary vessels are of con-sistent location and diameter in the majority of thecases. They are not damaged during axillary dis-section and typically not negatively affected byradiation therapy. Their central position in thechest makes medial placement of the flap easieron insetting. The vessels are dissected in the sec-ond or third intercostal space. A working field witha width of 2 to 3 cm makes the anastomosis to therecipient vessels easier. If the rib space is less than3 cm in width, the removal of a portion the lowerrib is performed. The advantage is to gain lengthon the recipient vessels, prevent a contour defi-ciency superior on the chest wall, and preventinjury to the vessels by dissecting more distally.The longer pedicle allows for greater ease of vesselorientation. In approximately 10 percent of cases,we use the internal mammary perforators as re-

cipient vessels. The vein is often 3 mm in diameter.The artery varies from 1 to 2 mm.

The internal mammary recipient vessels areparticularly suited to a shorter DIEP pedicle, anSIEA flap, or a gluteal artery perforator (GAP) flapwhere the flap artery match is better. We use thethoracodorsal vessels when the internal mammaryvessels prevent proper flap insetting and geome-try, such as in cases of partial breast reconstructionwhere lateral placement of tissue is required. Thethoracodorsal vessels are also used with nipple/areola-sparing mastectomy through an axillaryincision.

After the superior and inferior skin incisionsare made, the superficial inferior epigastric vesselsare identified. If these are found to be of sufficientsize and quality, they are followed down to theirorigin from the common femoral artery and anSIEA flap is performed instead. Often, only thesuperficial inferior epigastric vein is present ofsufficient size, and this is dissected free for severalcentimeters. This can be used as a backup for thevenous drainage of the flap if venous congestionis present after the anastomosis is performed inthe chest.

The abdominal skin island is carefully elevatedfrom lateral to medial until the lateral row of per-forators is encountered. The lateral perforatorsare carefully inspected. If a large lateral perforatoris found, the flap may be based on this vessel.Additional perforators in the same row may also bedissected and included with the flap for additionalperfusion. If no large lateral row perforators arefound, the medial row is approached in a similarfashion. If no dominant single perforators arefound, two or even three smaller perforators in thesame lateral or medial row may be taken to carrythe flap. In cases where more than one large per-forator is present, the perforator with a more cen-tral location to the proposed flap is used. In ourexperience, approximately 25 percent of flaps arebased on one perforator, 50 percent are based ontwo perforators, and 25 percent are based on threeor more perforators. We prefer a flap to be basedon a single large perforator. As described above,one large perforator can carry more blood flowthan several smaller perforators and is associatedwith a lower incidence of fat necrosis in the flap.10

In the case of a unilateral DIEP flap reconstruc-tion, if the medial and lateral row perforators onthe initially approached side of the abdomen arefound to be less than optimal, the perforators onthe opposite side of the abdomen are investigated,as the contralateral side often yields a perforatorof better quality.

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Once the appropriate perforators are chosen,the anterior rectus sheath is opened around theperforators and the vessels are carefully dissecteddown through the rectus muscle to the deep in-ferior epigastric artery and vein (Fig. 1). The mus-cle is spread apart in the direction of the fibers,and care is taken to identify and preserve anyintercostal nerves innervating the medial aspect ofthe muscle that might cross the pedicle. Dissectioncontinues until the pedicle is of sufficient length,typically 8 to 10 cm long, and the vessels are asufficient caliber to match the recipient vessels inthe chest. High-power, 4.5� or greater loupe mag-nification and careful microsurgical techniquesare essential during this dissection. Pure sensorynerves that innervate the flap skin paddle typicallyrun with the perforators and may also be dissectedfree for anastomosis into divided recipient sensorynerves in the chest.

When the recipient vessels are prepared, theanterior surfaces of the pedicle vessels at theirorigin are marked with a surgical marker for vesselorientation in the chest to prevent possible kink-ing or twisting. The artery and then veins of thepedicle are ligated and the pedicle slid out un-derneath any crossing intercostal nerves. Some-times, it is necessary to divide a crossing motorintercostal nerve to release the vascular pedicle. Inthese cases, the nerve is repaired with two inter-rupted 8-0 nylon sutures before closure of theabdominal fascia. The flap is then weighed andtransferred to the recipient site. Great care istaken to lay the donor pedicle to the recipientvessels without any twists or kinks in the vessels.Although the overall incidence of vascular com-plications is low, experience has shown that many

cases of venous compromise can be traced to akinked pedicle. Temporary stay sutures are placedin the flap with the orientation of the 180 degreeswith the umbilicus inferiorly. This allows for thethicker part of the flap to lie medially on the chestwall. The operating microscope is brought intoposition.

Under magnification, the anterior surface ofthe recipient artery and vein are also labeled witha surgical marker and the larger vein is ligateddistally. An anastomotic coupling device typicallyis used to connect the recipient and flap veins. Thecoupling device makes the anastomosis easier andfaster, and has the additional benefit of stentingthe vein open after the vessels are joined. Thearterial anastomosis is typically performed with anylon 9-0 suture with a 100-�m needle. In the caseof a good size match between the flap and recip-ient arteries, a running suture is used. Otherwise,interrupted sutures are used with a 10-0 suture anda 75-�m needle. If a size mismatch is observed,identification of a side branch of the artery allowscreation of a larger lumen when cut in a planeparallel to the side branch. Other techniques toadjust for the size mismatch are to cut obliquely onthe smaller artery or to obtain a vein graft to in-terpose between the donor and recipient artery. Inthe literature, reports of telescoping the small re-cipient artery into the donor artery and also end-to-side anastomosis have been reported.

After completion of the anastomosis, thereshould be a palpable pulse in the pedicle. We callthis the Khoobehi sign after one of our associates,Dr. Kamran Khoobehi, who pointed out its im-portance. Roger Khoury’s prospective study oncenters of microsurgical excellence revealed that20 percent of all microanastomoses have to beredone. Thus, if excellent flow is not present de-spite adequate blood pressure, one should nothesitate to revise the anastomosis.

Donor-site closure proceeds either during themicroanastomosis or concurrent with flap inset-ting. The abdominal fascia is closed and tied se-curely with running size 0 absorbable sutures.Mesh or other synthetic materials are not used inabdominal wall closures. The edges of the umbi-licus are tacked down to the fascia with 2-0 Vicrylsuture (Ethicon, Inc., Somerville, N.J.). The upperabdominal flap is elevated, the patient flexed, andthe wound closed in layers over two closed suctiondrains. Care is taken to approximate Scarpa’s fas-cia with 2-0 interrupted Vicryl sutures. As in anabdominoplasty, the umbilicus is brought outthrough the abdominal flap and secured in place.

Fig. 1. Perforating vessels of the lateral branch of the deep in-ferior epigastric artery are visible coursing through the rectussheath.

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The insetting and closure are performedover a suction drain, and great care is used tomonitor the integrity of the pedicle during theinsetting of the flap at all times. If a contralateralflap is used, the flap is turned between approx-imately 90 and 120 degrees such that the medialportion of the abdominal flap becomes the baseof the reconstructed breast. The apex of thetriangular flap becomes the “tail” of the re-constructed breast. The lateral portion of fatflap may be stabilized with absorbable suturesto the lateral aspect of the pectoralis major mus-cle to keep the flap from falling out into theaxilla and creating additional tension on theanastomosis.

Excess skin is deepithelialized superiorly andinferiorly and the flap inset with a visible skinpaddle left in place. A large skin paddle allowseasier postoperative monitoring for signs of ve-

nous congestion as well. The external Dopplerprobe is used to identify the locations on the flapwith good arterial and venous signals, and theselocations are marked for postoperative monitor-ing in the intensive care unit and on the floor withthe handheld Doppler probe.

An implantable Doppler probe may be usedon the vein and/or artery to facilitate postopera-tive monitoring. This is especially useful in caseswhere a smaller skin paddle is left or no dominantpoint can be found on the exposed skin portionof an otherwise healthy flap to allow easy moni-toring with the handheld Doppler. Care must betaken with placement of these probes. A Dopplersleeve placed too loosely around the vessel mayresult in loss of signal despite the presence of goodblood flow, whereas a tight sleeve or wire connec-tion may kink or otherwise compromise the ves-sel’s patency (Figs. 2 and 3).

Fig. 2. (Above, left) Preoperative markings for a patient with right breast carcinoma. (Below, left) A DIEP flap raised on the perforator.(Below, right) A DIEP flap after harvest. (Above, center) Photographs of the patient 3 months after initial flap transfer and (above, right)3 months after nipple construction.

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Postoperative CarePostoperatively, the patient is observed in the

surgical intensive care unit overnight and trans-ferred to the floor in the morning of the firstpostoperative day. As the postoperative pain issignificantly less than with TRAM flap reconstruc-tion, oral pain medications are given also begin-ning on postoperative day 1. Typically, the patientambulates on postoperative day 1 and is dis-charged to home on postoperative day 4.

ComplicationsComplications are infrequent. In our pub-

lished series of over 750 DIEP flap reconstructionsand in subsequent work, 6 percent of patients werereturned to the operating room for flap-relatedproblems, but partial flap loss occurred in 2.5percent and total flap loss occurred in less than 1percent of all cases. Problems with the vein or

venous anastomosis were almost eight times morelikely than problems with the artery or arterialanastomosis. Fat necrosis appeared in 13 percentof flaps. Seroma formation at the abdominal do-nor site was approximately 5 percent and abdom-inal hernia occurred in 0.7 percent of cases.10

SIEA FLAPThe SIEA flap provides the same abdominal

skin and fat for reconstruction as the DIEP flap. Ofthe two flaps, the SIEA causes less donor-site mor-bidity, as no incision must be made in the abdom-inal fascia and no vessel dissection is performedthrough the rectus abdominis muscle. There isminimal to no risk of a new abdominal hernia andeven less abdominal pain than with other abdom-inal flaps.

However, the SIEA flap is limited by variabilityin its vascular anatomy and skin territory. Thesuperficial inferior epigastric artery and vein are

Fig. 3. (Above) Preoperative views of a patient with right breast carcinoma for mastectomy with DIEP flap reconstruction.(Below) Views of the patient approximately 3 months after a second-stage procedure after DIEP flap surgery.

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only inconsistently present in sufficient caliber toreliably support sufficient tissue for a breast re-construction. The superficial inferior epigastricartery and the superficial circumflex iliac arteryenter into the common femoral as a commontrunk only 60 percent of the time. Therefore, timeand energy may be invested in a dissection thatyields only an artery of insignificant caliber at theend of the dissection. A common trunk usuallymeans a better size match with the internal mam-mary artery.

The amount of skin and fat that may be safelycarried by an SIEA flap is limited to zones I and II(the ipsilateral side). Of course, this varies de-pending on the particular vascular anatomy,which is quite variable. Because the course of theSIEA is lateral to the anterior rectus sheath, onewould expect the vascular territory to be differentfrom the DIEP flap. Because the vascular pedicleextends from one side of the flap, insetting at therecipient site may be more difficult as comparedwith the DIEP flap. The flap often needs to berotated counterclockwise to avoid kinking and re-dundancy of the pedicle.

IndicationsThe indications for the SIEA flap are the same

as those for the DIEP flap.

AnatomyThe SIEA flap is based on the superficial in-

ferior epigastric artery and vein. The anatomy ofthese vessels is quite variable. In two series, thesuperficial inferior epigastric artery was present in65 to 72 percent of cases.2,11 In the series by Allenet al., the average diameter at the point the arterycrossed the inguinal ligament was 1.66 mm. Theartery was present in 58 percent of both groins andabsent in 9 percent of both groins.12 The veins canalso be variable. The venae comitantes may be ad-equate to drain the flap, or the separate, more me-dial superficial inferior epigastric vein may be nec-essary to drain the flap.

Surgical TechniqueThe markings, preoperative preparation, and

operating room setup are the same for the SIEAflap as with the DIEP flap. During flap harvest, thesuperficial inferior epigastric vessels are ap-proached first. If these vessels are found to havesufficient caliber (approximately 1.0 to 1.5 mm) atthe level of the inferior flap incision, they arefollowed down to their origin from the commonfemoral artery and saphenous vein.

Preparation of the recipient site is the same asdescribed above for the DIEP flap. However, as theartery of the SIEA flap pedicle is typically smallerthan that of a DIEP flap, the procurement ofsmaller recipient vessels is preferable. If obtain-able, the internal mammary artery perforatorshave a better size match than the internal mam-mary artery itself. The thoracodorsal vessels offeran advantage also, as they provide a greater rangeof arterial sizes to better match the SIEA.

The microsurgical anastomosis, flap insetting,and abdominal closure proceed as describedabove. Abdominal fascial closure is unnecessary(Fig. 4). An SIEA flap may be harder to insetbecause of the location of the pedicle, which exitsat the edge of the flap. Also, a pedicle that is toolong may kink when using the internal mammaryvein unless the flap is rotated.

Postoperative CareThe postoperative care is the same as with the

DIEP flap, and patients typically go home on thefourth postoperative day.

ComplicationsComplications for the SIEA flap are similar to

those for the DIEP flap. In a review of over 200SIEA flap breast reconstructions, rates of return tothe operating room and arterial and venous in-sufficiency are similar to those found with DIEPflap reconstructions. Only one flap loss occurredin our series. The rate of abdominal seroma for-mation was slightly higher; approximately 9 per-cent versus 3.5 percent for the DIEP flap, possiblybecause of the increased dissection causing dis-ruption around the inguinal lymphatics as re-quired by this procedure.13 It is necessary to con-tinue drain placement until the drainage is lessthan 40 cc in a 24-hour period.

GAP FLAPSThe GAP flap for breast reconstruction was

first introduced by our group in 1993.4 It is a goodchoice for breast reconstruction when the abdo-men is not. In patients we see for breast recon-struction, the buttock is the donor site in 22percent and the abdomen in 78 percent. As withthe DIEP and SIEA flaps, donor-site morbidity isminimal and no sacrifice of muscle is required.Various locations, orientations, and dimensions ofthe 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. This gives

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the greatest chance of finding an adequate per-forator under the flap. With better appreciation ofthe vascular anatomy and confidence in the hand-held Doppler, there is more freedom is designingthe skin island. An oblique ellipse extending su-perior from medial to lateral has the advantageof concealing the scar in swimwear and under-garments. By beveling superiorly, a nicely shapedflap with less contour deformity can be obtained.We have used both the superior GAP (SGAP) andthe inferior GAP (IGAP) flap since 1993. In 2004,we began designing the IGAP flap so that the scarwould be in the natural inferior crease.14 By har-vesting tissue from the lowest part of the buttock,the shape of the rounded upper buttock waspreserved. The pedicle length was also longerthan that of the SGAP flap, making the anasto-

mosis easier and negating the need to removerib cartilage because less length was required onthe recipient vessels. However, sitting directly onthe healing incision causes more pain than theSGAP flap, and the rate of dehiscence increases.This is particularly true in bilateral simultaneousreconstructions, where the patient cannot shiftweight bearing to the side that was not operatedon. The sciatic nerve has never been a problemin my experience of 329 GAP flaps (approxi-mately 100 IGAP flaps). The ideal candidate issomeone with a large buttock (pear shape) anda B size breast. In the right candidate, the in-the-crease IGAP flap can provide for excellentbreast reconstruction, with a hardly noticeabledonor site. After initial overenthusiasm with thein-the-crease IGAP flap, we are now back to the

Fig. 4. (Above, left) Preoperative markings. (Below) The SIEA flap after harvest. (Above, right) Photo-graph of the patient approximately 3 months following the second stage after SIEA reconstruction.

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SGAP flap in slightly more than 50 percent ofpatients. The women do their research andcome with their opinions about which GAP flapthey prefer.

IndicationsThe buttock has a high fat-to-skin ratio,

whereas the abdomen has a high skin-to-fat ratio.Patients who require mostly fat and little skin maybe candidates for GAP flaps. Patients in whom theabdomen cannot be used as a donor site or whohave more tissue in the buttock area than in theabdomen are the best candidates. In our experi-ence using GAP flaps for breast reconstruction,the average final inset weights of our GAP flapswere slightly greater than weights of the mastec-tomy specimens removed.15,16

Absolute contraindications specific to GAPflap breast reconstruction in our practice are sim-ilar to those mentioned above, and include historyof previous liposuction at the donor site or activesmoking (within 1 month before surgery). Lipo-suction of the central buttock is rare, but liposuc-tion of the saddlebag area can affect the IGAP flapand liposuction of the hips can affect the SGAPflap.

AnatomyThe SGAP and IGAP flaps are based on per-

forators from the superior and inferior glutealarteries and veins, respectively. The superior glu-teal artery arises from the internal iliac artery andexits the pelvis superior to the piriformis muscle.It enters the gluteus maximus muscle approxi-mately one-third of the distance along the linebetween the posterior superior iliac spine and thegreater trochanter.

The inferior gluteal artery is a terminal branchof the internal iliac artery and leaves the pelvisthrough the greater sciatic foramen inferior to thepiriformis muscle. The artery is accompanied bythe greater sciatic nerve, the internal pudendalvessels, and the posterior femoral cutaneousnerve. The course of the inferior gluteal vessels ismore oblique through the gluteus maximus mus-cle substance than the course of the superior glu-teal vessels. Therefore, IGAP pedicle is typicallylonger than that of the SGAP. Between two andfour perforating vessels from the inferior glutealartery will be located in the lower half of eachgluteal muscle.

Perforating vessels that nourish the medialportions of the buttock have relatively short in-tramuscular lengths, whereas perforators that

nourish the lateral portions of the overlying skinpaddle must travel through the muscle in a moreoblique manner. Therefore, pedicles based onperforators from the lateral aspects of the skinpaddle tend to be longer than those based onmore medial perforators.

Surgical TechniqueThe patient usually is seen in the office 1 day

before surgery. The surgical plan again is reviewedwith the patient, and any remaining questions areanswered.

In SGAP flap marking for unilateral recon-struction, the patient is placed in lateral decubitusposition and the Doppler probe used to find per-forating vessels from the superior gluteal artery.These are usually found approximately one-thirdof the distance on a line from the posterior supe-rior iliac crest to the greater trochanter. Addi-tional perforators may be found slightly more lat-eral from above. The skin paddle is marked in anoblique pattern from inferior medial to supero-lateral to include these perforators (Fig. 5, above,left, and center, left). The lateral third of the flap isnot over the gluteus muscle. In bilateral simulta-neous reconstructions, the flaps are marked withthe patient prone because this is the position inwhich the flaps will be harvested simultaneously.

For the IGAP flap, the gluteal fold is notedwith the patient in the standing position. The in-ferior limit of the flap is marked 1 cm inferior andparallel to the gluteal fold. The patient is thenplaced in the lateral position and the Dopplerprobe is used to find perforating vessels from theinferior gluteal artery. An ellipse is drawn for theskin paddle to include these perforators, whichroughly parallels the gluteal fold with dimensionsof approximately 8 � 18 cm. As with the SGAPflap, bilateral cases are marked with the patient inthe prone position.

For unilateral procedures, the patient isplaced in the lateral decubitus position and a two-team approach is used. The recipient vessels areprepared as described above while the GAP flap isharvested. For breast reconstruction, the internalmammary vessels are preferred, as anastomosis tothese vessels allows easier medialization of the flapwhen it is inset. This is especially important for theSGAP flap, which typically has a shorter pediclethan the IGAP flap. However, the IGAP flap oftenhas a long enough pedicle to reach the thora-codorsal vessels.

The skin incisions are made and Bovie elec-trocautery is used to divide the flap down to the

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muscle of the gluteus maximus. Significant bevel-ing is used as needed, particularly in the superiordirection to harvest enough tissue for a goodbreast reconstruction. The flap is elevated fromthe muscle in the subfascial plane and the perfo-

rators approached beginning from lateral to me-dial. It is preferred to use a single large perforator,if it is present, but several perforators that lay inthe same plane and the direction of the gluteusmaximus muscle fibers can be taken together as

Fig. 5. (Above, left and center, left) Preoperative marking of patient to undergo left breast reconstruction with the SGAP flap. (Below,left and right) IntraoperativeviewsoftheSGAPflapandpedicle. (Above, right, and center, right)Viewsofthepatient3monthsfollowingsecond-stage surgery and nipple creation.

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well. Subfascial elevation is also performed frommedial to lateral to ensure that a large perforatoris found. The muscle is then spread in the direc-tion of the muscle fibers and the perforating ves-sels are meticulously dissected free. The dissectioncontinues until both the artery and the vein are ofsufficient size to be anastomosed to the recipientvessels in the chest. The artery usually is the lim-iting factor in this dissection. The arterial perfo-rator is visualized and preserved as it enters themain superior or inferior gluteal artery. The pref-erable artery and vein diameter for anastomosis is2.0 to 2.5 mm and 3.0 to 4.5 mm, respectively.When using internal mammary vein perforators asrecipients, a shorter pedicle and smaller artery willsuffice.

Harvesting the in-the-crease IGAP flap allowsmore beveling superiorly and inferiorly because

soft-tissue deficiency in the crease is normal. Lat-erally, thicker fat from trochanteric area can betaken, increasing flap volume and decreasing asaddlebag deformity. When harvesting the IGAPflap, care must be taken to preserve the lightercolored medial fat pad that overlies the ischium.Preservation of the fat pad will prevent possibledonor-site discomfort when the patient is sitting.

When the recipient vessels are ready, the glu-teal artery and vein are divided and the flap isharvested and weighed. The skin and fat overlyingthe gluteus maximus muscle are elevated superi-orly and inferiorly to allow layered approximationof the fat of the donor site to prevent a contourdeformity and give a buttock lift. The donor siteis closed in layers over a suction drain with ab-sorbable suture. Adding a permanent removableskin suture increases the strength of the closure

Fig. 6. (Above) Preoperative markings of patient to undergo left breast reconstruction with a left IGAP flap. (Below) Views of thepatient 3 months after reconstruction of the left breast with the IGAP flap.

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(Fig. 5, below, left and right, above, right, and center,right).

The anastomosis is performed to the recipientvessels under the operating microscope. The flapis inset over a suction drain into the defect with caretaken not to twist or kink the pedicle. To create aspherical flap, the ends of the ellipse are excised.The flap may be inset horizontally, vertically, or ob-liquely, depending on the situation (Fig. 6).

Postoperative CareThe postoperative care is the same as with the

DIEP flap, and patients typically go home on thefourth postoperative day. The drain at the donorsite must usually be left in place for several dayslonger than with an abdominal donor site.

ComplicationsIn a review of 170 GAP flaps performed by our

unit for breast reconstruction, the incidence ofcomplications was low. The overall take-back ratewas approximately 8 percent, with a 6 percent rateof vascular complications. The total flap failurerate was approximately 2 percent. Donor-site se-roma occurred in 2 percent of patients, and ap-proximately 4 percent of patients required revi-sion of the donor site.15,16

SUMMARYPerforator 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 ofautogenous reconstruction. To make this optionmore available and desirable, there is plenty ofroom for improvement. The length of the proce-dure needs to be decreased, scars need to be im-proved, and complications need to be decreased.With improvements in technology and technique,these goals can be realized.

Robert Allen, M.D.Suite 180

1300 Hospital DriveMount Pleasant, S.C. 29464

DISCLOSURENone of the authors has a financial interest in any

medical device or product mentioned in this article.

REFERENCES1. Allen, R. J., and Treece, P. Deep inferior epigastric perforator

flap for breast reconstruction. Ann. Plast. Surg. 32: 32, 1994.2. Taylor, G. I., and Daniel, R. K. The anatomy of several free

flap donor sites. Plast. Reconstr. Surg. 56: 243, 1975.3. Koshima, I., and Soeda, S. Inferior epigastric artery skin flaps

without rectus abdominis muscle. Br. J. Plast. Surg. 42: 645, 1989.4. Allen, R., and Tucker, C., Jr. Superior gluteal artery perfo-

rator free flap for breast reconstruction. Plast. Reconstr. Surg.95: 1207, 1995.

5. Futter, C. M., Webster, M. H., Hagen, S., and Mitchell, S. L.A retrospective comparison of abdominus muscle strengthfollowing breast reconstruction with a free TRAM or DIEPflap. Br. J. Plast. Surg. 53: 578, 2000.

6. Kaplan, J., and Allen, R. Cost-based comparison betweenperforator flaps and TRAM flaps for breast reconstruction.Plast. Reconstr. Surg. 105: 943, 2000.

7. Kroll, S., Sharma, S., Koutz, C., et al. Postoperative morphinerequirements of free TRAM and DIEP flaps. Plast. Reconstr.Surg. 107: 338, 2001.

8. Allen, R., and Heitland, A. Autogenous augmentation mam-maplasty with microsurgical tissue transfer. Plast. Reconstr.Surg. 112: 91, 2003.

9. Rogers, N., and Allen, R. Radiation effects on breast recon-struction with the deep inferior epigastric perforator flap.Plast. Reconstr. Surg. 109: 1919, 2002.

10. Gill, P., Hunt, J., Guerra, A., et al. A 10-year retrospectivereview of 758 DIEP flaps for breast reconstruction. Plast.Reconstr. Surg. 113: 1153, 2004.

11. Reardon, C., O’Ceallaigh, S., and O’Sullivan, S. An anatom-ical study of the superficial inferior epigastric vessels in hu-mans. Br. J. Plast. Surg. 57: 515, 2004.

12. Allen, R. J. The superficial inferior epigastric artery free flap:An anatomic and clinical study for use in reconstruction ofthe breast. In Proceedings of the Annual Meeting of the South-eastern Society of Plastic and Reconstructive Surgeons, Kiawah,S.C., June 3–7, 1990.

13. Granzow, J. W., Levine, J. L., Chiu, E. S., et al. Breast recon-struction with the SIEA flap revisited: An 8-year review of 203cases (unpublished data).

14. Babineaux, K. L., Granzow, J. W., Bardin, E., et al. Micro-vascular breast reconstruction using buttock tissue: The pre-ferred scar location and shape. Plast. Reconstr. Surg. 116(Suppl.): 174, 2005.

15. Allen, R. J., Levine, J. L., and Granzow, J. W. The in-the-crease inferior gluteal artery perforator flap for breast re-construction. Plast. Reconstr. Surg. 118: 333, 2006.

16. Guerra, A., Metzinger, S., Bidros, R., Gill, P. S., Dupin, C. L.,and Allen, R. J. Breast reconstruction with gluteal arteryperforator (GAP) flaps: A critical analysis of 142 cases. Ann.Plast. Surg. 52: 118, 2004.

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