BREAST

Breast Reconstruction with Perforator Flaps

Jay W. Granzow, M.D.,
Background: Perforator flaps represent the latest in the evolution of soft-tissue
M.P.H. flaps. They allow the transfer of the patient’s own skin and fat in a reliable
Joshua L. Levine, M.D. manner, with minimal donor-site morbidity. The powerful perforator flap con-
Ernest S. Chiu, M.D. cept allows transfer of tissue from numerous, well-described donor sites to
Maria M. LoTempio, M.D. almost any distant site with suitable recipient vessels. Large-volume flaps can be
Robert J. Allen, M.D. supported reliably with perforators from areas such as the abdomen, buttock,
New Orleans, La.; Charleston, S.C.; or flank and transferred microsurgically for breast reconstruction.
and Torrance, Calif. Indications: The ideal tissue for breast reconstruction is fat with or without skin,
not implants or muscle. Absolute contraindications specific to perforator flaps
in the authors’ practice include history of previous liposuction of the donor site,
some previous donor-site surgery, or active smoking (within 1 month before
surgery).
Technique: 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 per-
forators are meticulously dissected free from the surrounding muscle, which is
spread in the direction of the muscle fibers and preserved intact. The pedicle
is anastomosed to recipient vessels in the chest, and the donor site is closed
without the use of 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. 120: 1, 2007.)

T
he most common type of breast reconstruc- Over time, the magnitude of the donor-site mor-
tion involves the use of saline or silicone gel bidity became more apparent. As plastic sur-
implants. This technique has the advan- geons, we are always looking for better ways to do
tages of simplicity and the absence of a donor things. The deep inferior epigastric perforator
site. Aesthetic results can be quite good, al- (DIEP) and superficial inferior epigastric artery
though in the senior author’s experience these (SIEA) flaps have certainly decreased donor-site
patients have consistently reported that the re- morbidity. However, these techniques have
sult never feels natural and always feels like an brought new difficulties and problems that must
implant under the chest muscle. Approximately be addressed. First and foremost, these tech-
25 percent of the women seen for breast recon- niques require microsurgical expertise. Bill Shaw
struction in the senior author’s practice have once said that the super specialist might perform
undergone previous attempted implant recon- certain types of free flaps beyond the realm of
struction. the occasional microsurgeon. What is the learn-
The transverse rectus abdominis musculocuta- ing curve for perforator flap breast reconstruc-
neous (TRAM) flap in the early 1980s ushered in tion? Perhaps 50 to 100 procedures.
The variability of vascular anatomy contributes
the new era of autogenous reconstruction. Every
to the difficulties with these procedures. Judg-
plastic surgeon set out to learn this technique.
ment as to how many and what size and location
From the Section of Plastic Surgery, Louisiana State Uni- of perforators to select affect factors such as
versity Health Sciences Center; Division of Plastic Surgery, length of operation and incidence of fat necro-
Medical University of South Carolina; and Division of Plas- sis. Vascular territory depends on the above fac-
tic Surgery, Harbor-UCLA Medical Center. tors. It is amazing how little blood supply is
A Master Series article from Plastic Surgery 2004. actually necessary to adequately perfuse skin and
Received for publication May 18, 2005; accepted February fat. Flap insetting also affects flap circulation.
15, 2006. Perforator flaps have allowed the transfer of
Copyright ©2007 by the American Society of Plastic Surgeons the patient’s own skin and fat in a reliable man-
DOI: 10.1097/01.prs.0000256044.66107.a6 ner, with minimal donor-site morbidity, for more

www.PRSJournal.com 1
 Plastic and Reconstructive Surgery • July 2007

than a decade.1 They represent the most recent TRAM flap could have been used to carry reliably
development in the evolution of flaps for breast the abdominal skin and fat at the expense of sac-
reconstruction. Flaps that relied on a random rificing the abdominal rectus muscle and fascia.
pattern blood supply were soon supplanted by The DIEP flap can carry the same tissue without
pedicled, axial pattern flaps that could reliably the sacrifice of the rectus muscle or fascia, thereby
transfer greater amounts of tissue. The advent of minimizing donor-site morbidity and pain and
free tissue transfer allowed an even greater range shortening recovery time.5–7
of possibilities to appropriately match donor and
recipient sites.2 Indications
In 1989, the quest to further reduce donor-site
Most women who have had or will have mas-
morbidity and flap bulk was led by Koshima and
tectomies for breast cancer are possible candi-
Soeda.3 They succeeded in transferring skin ter-
dates for the DIEP flap. In addition, DIEP flap
ritory above the rectus abdominis muscle based
reconstruction may be used for women requiring
off a perforator vessel to reconstruct a floor-of-
additional breast tissue for defects such as a con-
mouth and groin defect. In 1992, breast recon-
genital deficiency or lumpectomy defect.8 In most
struction using the same principles was devel-
patients, DIEP flaps may also be used for head and
oped by Allen and Treece and Allen and
neck reconstruction or extremity wounds.
Tucker.1,4 Abdominal tissue supplied by perfora-
Absolute contraindications specific to DIEP
tors to the rectus abdominis muscle was trans-
flap breast reconstruction in our practice include
ferred with the deep inferior epigastric perfora-
history of previous abdominoplasty or abdominal
tor flap, buttock tissue overlying the gluteus
liposuction, and active smoking (within 1 month
maximus muscle was transferred with the gluteal
before surgery). Relative contraindications in-
artery perforator flap, back tissue overlying the
clude large transverse or oblique abdominal
latissimus dorsi muscle was rotated with the tho-
incisions.
racodorsal artery perforator flap, and lateral
In the case of breast reconstruction, we prefer
thigh skin and fat overlying the tensor fasciae
to have the patient complete any radiation therapy
latae muscle were transferred as the lateral
and a delay of 6 months before placement of the
thigh perforator flap as new options for breast
free flap. Although the perforator flaps usually
reconstruction.
tolerate radiation well, a superior long-term result
The flow of a noncompressible liquid through
is typically obtained in reconstructions performed
a tube is governed by Poiseuille’s law according
after rather than before chest wall irradiation.
to the following equation:
This spares the flap the damaging effects of radi-
r4 p* ation and typically results in a better long-term
V
8 l result. It also allows the removal of any thick, stiff
The flow of a volume of liquid, V, is propor- irradiated chest wall skin and its replacement with
tional to the fourth power of the radius of the soft and nonirradiated abdominal skin and soft
tube through which it is carried. Thus, a single tissue.9
large perforating vessel that is 2.0 mm in diam-
eter will carry approximately 16 times the blood Anatomy
flow of an otherwise similar vessel that is only 1.0 Like the free TRAM flap, the DIEP flap is
mm in diameter. Therefore, it is preferable to based on the deep inferior epigastric artery and
use a single large perforator than multiple, vein. Two rows of perforating arteries and veins
smaller perforators when choosing among ves- penetrate the rectus muscle on each side of the
sels to carry a perforator flap. abdomen to provide the blood supply for the over-
Relative contraindications for perforator flaps lying skin and fat. The deep inferior epigastric
include active nicotine use, obesity with a body artery is typically between 2 and 3 mm in diameter
mass index greater than 30, and previous lipo- and the accompanying veins are between 2 and 3.5
suction. Immediate perforator breast reconstruc- mm in size.
tion is not recommended in patients scheduled Unlike a TRAM flap, the rectus muscle and
to have radiation therapy after mastectomy.9 fascia are spared. Instead, the perforating vessels
that supply the overlying skin and fat are carefully
DIEP FLAP followed through the rectus muscle to their ori-
A good source of this soft tissue for a free flap gins from the deep inferior epigastric vessels. Dur-
is the patient’s own lower abdomen. Previously, a ing the dissection, the rectus muscle itself is spared

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Volume 120, Number 1 • Breast Reconstruction

and atraumatically separated in the direction of cipient vessels. The vein is often 3 mm in diameter.
the muscle fibers. The artery varies from 1 to 2 mm.
The internal mammary recipient vessels are
Preoperative Evaluation particularly suited to a shorter DIEP pedicle, an
SIEA flap, or a gluteal artery perforator (GAP) flap
The patient is usually seen in the office on the
where the flap artery match is better. We use the
day before surgery for preoperative markings and
thoracodorsal vessels when the internal mammary
Doppler studies. The surgical plan again is re-
vessels prevent proper flap insetting and geome-
viewed with the patient, and remaining questions
try, such as in cases of partial breast reconstruction
are also answered at this time.
where lateral placement of tissue is required. The
Standard abdominoplasty markings are made
thoracodorsal vessels are also used with nipple/
in the sitting or standing position. The side of the
areola-sparing mastectomy through an axillary
abdomen contralateral to the side to be recon-
incision.
structed is preferred, as this provides for easier
After the superior and inferior skin incisions
insetting at the time of surgery. Flaps are typically
are made, the superficial inferior epigastric vessels
marked approximately 12 cm high at the midline
are identified. If these are found to be of sufficient
and extend approximately 22 to 24 cm laterally
size and quality, they are followed down to their
from the midline. Then, with the patient in the
origin from the common femoral artery and an
supine position, a Doppler probe is used to iden-
SIEA flap is performed instead. Often, only the
tify the main perforators of the medial and lateral
superficial inferior epigastric vein is present of
branches of the deep inferior epigastric artery.
sufficient size, and this is dissected free for several
The superficial inferior epigastric artery and vein
centimeters. This can be used as a backup for the
are likewise found with the Doppler probe and
venous drainage of the flap if venous congestion
marked.
is present after the anastomosis is performed in
the chest.
Surgical Technique The abdominal skin island is carefully elevated
A two-team approach is used, with simulta- from lateral to medial until the lateral row of per-
neous raising of the flap and preparation of the forators is encountered. The lateral perforators
recipient vessels. The deep inferior epigastric ar- are carefully inspected. If a large lateral perforator
tery usually is between 2.0 and 2.5 mm in diameter, is found, the flap may be based on this vessel.
and the accompanying vein usually is between Additional perforators in the same row may also be
2.5 and 3.0 mm in diameter. Careful prepara- dissected and included with the flap for additional
tion of recipient vessels with similar diameters is perfusion. If no large lateral row perforators are
preferred. found, the medial row is approached in a similar
For breast reconstruction, the internal mam- fashion. If no dominant single perforators are
mary artery and vein are the recipient vessels of found, two or even three smaller perforators in the
choice and are used in over 90 percent of our same lateral or medial row may be taken to carry
cases. The internal mammary vessels are of con- the flap. In cases where more than one large per-
sistent location and diameter in the majority of the forator is present, the perforator with a more cen-
cases. They are not damaged during axillary dis- tral location to the proposed flap is used. In our
section and typically not negatively affected by experience, approximately 25 percent of flaps are
radiation therapy. Their central position in the based on one perforator, 50 percent are based on
chest makes medial placement of the flap easier two perforators, and 25 percent are based on three
on insetting. The vessels are dissected in the sec- or more perforators. We prefer a flap to be based
ond or third intercostal space. A working field with on a single large perforator. As described above,
a width of 2 to 3 cm makes the anastomosis to the one large perforator can carry more blood flow
recipient vessels easier. If the rib space is less than than several smaller perforators and is associated
3 cm in width, the removal of a portion the lower with a lower incidence of fat necrosis in the flap.10
rib is performed. The advantage is to gain length In the case of a unilateral DIEP flap reconstruc-
on the recipient vessels, prevent a contour defi- tion, if the medial and lateral row perforators on
ciency superior on the chest wall, and prevent the initially approached side of the abdomen are
injury to the vessels by dissecting more distally. found to be less than optimal, the perforators on
The longer pedicle allows for greater ease of vessel the opposite side of the abdomen are investigated,
orientation. In approximately 10 percent of cases, as the contralateral side often yields a perforator
we use the internal mammary perforators as re- of better quality.

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 Plastic and Reconstructive Surgery • July 2007

cases of venous compromise can be traced to a

kinked pedicle. Temporary stay sutures are placed
in the flap with the orientation of the 180 degrees
with the umbilicus inferiorly. This allows for the
thicker part of the flap to lie medially on the chest
wall. The operating microscope is brought into
position.
Under magnification, the anterior surface of
the recipient artery and vein are also labeled with
a surgical marker and the larger vein is ligated
distally. An anastomotic coupling device typically
is used to connect the recipient and flap veins. The
coupling device makes the anastomosis easier and
faster, and has the additional benefit of stenting
Fig. 1. Perforating vessels of the lateral branch of the deep in-
the vein open after the vessels are joined. The
ferior epigastric artery are visible coursing through the rectus
sheath.
arterial anastomosis is typically performed with a
nylon 9-0 suture with a 100- m needle. In the case
of a good size match between the flap and recip-
ient arteries, a running suture is used. Otherwise,
Once the appropriate perforators are chosen, interrupted sutures are used with a 10-0 suture and
the anterior rectus sheath is opened around the a 75- m needle. If a size mismatch is observed,
perforators and the vessels are carefully dissected identification of a side branch of the artery allows
down through the rectus muscle to the deep in- creation of a larger lumen when cut in a plane
ferior epigastric artery and vein (Fig. 1). The mus- parallel to the side branch. Other techniques to
cle is spread apart in the direction of the fibers, adjust for the size mismatch are to cut obliquely on
and care is taken to identify and preserve any the smaller artery or to obtain a vein graft to in-
intercostal nerves innervating the medial aspect of
terpose between the donor and recipient artery. In
the muscle that might cross the pedicle. Dissection
the literature, reports of telescoping the small re-
continues until the pedicle is of sufficient length,
cipient artery into the donor artery and also end-
typically 8 to 10 cm long, and the vessels are a
to-side anastomosis have been reported.
sufficient caliber to match the recipient vessels in
the chest. High-power, 4.5 or greater loupe mag- After completion of the anastomosis, there
nification and careful microsurgical techniques should be a palpable pulse in the pedicle. We call
are essential during this dissection. Pure sensory this the Khoobehi sign after one of our associates,
nerves that innervate the flap skin paddle typically Dr. Kamran Khoobehi, who pointed out its im-
run with the perforators and may also be dissected portance. Roger Khoury’s prospective study on
free for anastomosis into divided recipient sensory centers of microsurgical excellence revealed that
nerves in the chest. 20 percent of all microanastomoses have to be
When the recipient vessels are prepared, the redone. Thus, if excellent flow is not present de-
anterior surfaces of the pedicle vessels at their spite adequate blood pressure, one should not
origin are marked with a surgical marker for vessel hesitate to revise the anastomosis.
orientation in the chest to prevent possible kink- Donor-site closure proceeds either during the
ing or twisting. The artery and then veins of the microanastomosis or concurrent with flap inset-
pedicle are ligated and the pedicle slid out un- ting. The abdominal fascia is closed and tied se-
derneath any crossing intercostal nerves. Some- curely with running size 0 absorbable sutures.
times, it is necessary to divide a crossing motor Mesh or other synthetic materials are not used in
intercostal nerve to release the vascular pedicle. In abdominal wall closures. The edges of the umbi-
these cases, the nerve is repaired with two inter- licus are tacked down to the fascia with 2-0 Vicryl
rupted 8-0 nylon sutures before closure of the suture (Ethicon, Inc., Somerville, N.J.). The upper
abdominal fascia. The flap is then weighed and abdominal flap is elevated, the patient flexed, and
transferred to the recipient site. Great care is the wound closed in layers over two closed suction
taken to lay the donor pedicle to the recipient drains. Care is taken to approximate Scarpa’s fas-
vessels without any twists or kinks in the vessels. cia with 2-0 interrupted Vicryl sutures. As in an
Although the overall incidence of vascular com- abdominoplasty, the umbilicus is brought out
plications is low, experience has shown that many through the abdominal flap and secured in place.

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Volume 120, Number 1 • Breast Reconstruction

The insetting and closure are performed nous congestion as well. The external Doppler
over a suction drain, and great care is used to probe is used to identify the locations on the flap
monitor the integrity of the pedicle during the with good arterial and venous signals, and these
insetting of the flap at all times. If a contralateral locations are marked for postoperative monitor-
flap is used, the flap is turned between approx- ing in the intensive care unit and on the floor with
imately 90 and 120 degrees such that the medial the handheld Doppler probe.
portion of the abdominal flap becomes the base An implantable Doppler probe may be used
of the reconstructed breast. The apex of the on the vein and/or artery to facilitate postopera-
triangular flap becomes the “tail” of the re- tive monitoring. This is especially useful in cases
constructed breast. The lateral portion of fat where a smaller skin paddle is left or no dominant
flap may be stabilized with absorbable sutures point can be found on the exposed skin portion
to the lateral aspect of the pectoralis major mus- of an otherwise healthy flap to allow easy moni-
cle to keep the flap from falling out into the toring with the handheld Doppler. Care must be
axilla and creating additional tension on the taken with placement of these probes. A Doppler
anastomosis. sleeve placed too loosely around the vessel may
Excess skin is deepithelialized superiorly and result in loss of signal despite the presence of good
inferiorly and the flap inset with a visible skin blood flow, whereas a tight sleeve or wire connec-
paddle left in place. A large skin paddle allows tion may kink or otherwise compromise the ves-
easier postoperative monitoring for signs of ve- 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.

5
 Plastic and Reconstructive Surgery • July 2007

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.

Postoperative Care venous anastomosis were almost eight times more

Postoperatively, the patient is observed in the likely than problems with the artery or arterial
surgical intensive care unit overnight and trans- anastomosis. Fat necrosis appeared in 13 percent
ferred to the floor in the morning of the first of flaps. Seroma formation at the abdominal do-
postoperative day. As the postoperative pain is nor site was approximately 5 percent and abdom-
significantly less than with TRAM flap reconstruc- inal hernia occurred in 0.7 percent of cases.10
tion, oral pain medications are given also begin-
ning on postoperative day 1. Typically, the patient SIEA FLAP
ambulates on postoperative day 1 and is dis- The SIEA flap provides the same abdominal
charged to home on postoperative day 4. skin and fat for reconstruction as the DIEP flap. Of
the two flaps, the SIEA causes less donor-site mor-
bidity, as no incision must be made in the abdom-
Complications inal fascia and no vessel dissection is performed
Complications are infrequent. In our pub- through the rectus abdominis muscle. There is
lished series of over 750 DIEP flap reconstructions minimal to no risk of a new abdominal hernia and
and in subsequent work, 6 percent of patients were even less abdominal pain than with other abdom-
returned to the operating room for flap-related inal flaps.
problems, but partial flap loss occurred in 2.5 However, the SIEA flap is limited by variability
percent and total flap loss occurred in less than 1 in its vascular anatomy and skin territory. The
percent of all cases. Problems with the vein or superficial inferior epigastric artery and vein are

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Volume 120, Number 1 • Breast Reconstruction

only inconsistently present in sufficient caliber to Preparation of the recipient site is the same as
reliably support sufficient tissue for a breast re- described above for the DIEP flap. However, as the
construction. The superficial inferior epigastric artery of the SIEA flap pedicle is typically smaller
artery and the superficial circumflex iliac artery than that of a DIEP flap, the procurement of
enter into the common femoral as a common smaller recipient vessels is preferable. If obtain-
trunk only 60 percent of the time. Therefore, time able, the internal mammary artery perforators
and energy may be invested in a dissection that have a better size match than the internal mam-
yields only an artery of insignificant caliber at the mary artery itself. The thoracodorsal vessels offer
end of the dissection. A common trunk usually an advantage also, as they provide a greater range
means a better size match with the internal mam- of arterial sizes to better match the SIEA.
mary artery. The microsurgical anastomosis, flap insetting,
The amount of skin and fat that may be safely and abdominal closure proceed as described
carried by an SIEA flap is limited to zones I and II above. Abdominal fascial closure is unnecessary
(the ipsilateral side). Of course, this varies de- (Fig. 4). An SIEA flap may be harder to inset
pending on the particular vascular anatomy, because of the location of the pedicle, which exits
which is quite variable. Because the course of the at the edge of the flap. Also, a pedicle that is too
SIEA is lateral to the anterior rectus sheath, one long may kink when using the internal mammary
would expect the vascular territory to be different vein unless the flap is rotated.
from the DIEP flap. Because the vascular pedicle
extends from one side of the flap, insetting at the Postoperative Care
recipient site may be more difficult as compared The postoperative care is the same as with the
with the DIEP flap. The flap often needs to be DIEP flap, and patients typically go home on the
rotated counterclockwise to avoid kinking and re- fourth postoperative day.
dundancy of the pedicle.
Complications
Indications
Complications for the SIEA flap are similar to
The indications for the SIEA flap are the same those for the DIEP flap. In a review of over 200
as those for the DIEP flap. SIEA flap breast reconstructions, rates of return to
the operating room and arterial and venous in-
Anatomy sufficiency are similar to those found with DIEP
The SIEA flap is based on the superficial in- flap reconstructions. Only one flap loss occurred
ferior epigastric artery and vein. The anatomy of in our series. The rate of abdominal seroma for-
these vessels is quite variable. In two series, the mation was slightly higher; approximately 9 per-
superficial inferior epigastric artery was present in cent versus 3.5 percent for the DIEP flap, possibly
65 to 72 percent of cases.2,11 In the series by Allen because of the increased dissection causing dis-
et al., the average diameter at the point the artery ruption around the inguinal lymphatics as re-
crossed the inguinal ligament was 1.66 mm. The quired by this procedure.13 It is necessary to con-
artery was present in 58 percent of both groins and tinue drain placement until the drainage is less
absent in 9 percent of both groins.12 The veins can than 40 cc in a 24-hour period.
also be variable. The venae comitantes may be ad-
equate to drain the flap, or the separate, more me- GAP FLAPS
dial superficial inferior epigastric vein may be nec- The GAP flap for breast reconstruction was
essary to drain the flap. first introduced by our group in 1993.4 It is a good
choice for breast reconstruction when the abdo-
Surgical Technique men is not. In patients we see for breast recon-
The markings, preoperative preparation, and struction, the buttock is the donor site in 22
operating room setup are the same for the SIEA percent and the abdomen in 78 percent. As with
flap as with the DIEP flap. During flap harvest, the the DIEP and SIEA flaps, donor-site morbidity is
superficial inferior epigastric vessels are ap- minimal and no sacrifice of muscle is required.
proached first. If these vessels are found to have Various locations, orientations, and dimensions of
sufficient caliber (approximately 1.0 to 1.5 mm) at the skin island have been attempted over the years.
the level of the inferior flap incision, they are Each has advantages and disadvantages. Initially,
followed down to their origin from the common we used an oblique ellipse totally over the muscle
femoral artery and saphenous vein. oriented in the direction of the muscle. This gives

7
 Plastic and Reconstructive Surgery • July 2007

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.

the greatest chance of finding an adequate per- mosis easier and negating the need to remove
forator under the flap. With better appreciation of rib cartilage because less length was required on
the vascular anatomy and confidence in the hand- the recipient vessels. However, sitting directly on
held Doppler, there is more freedom is designing the healing incision causes more pain than the
the skin island. An oblique ellipse extending su- SGAP flap, and the rate of dehiscence increases.
perior from medial to lateral has the advantage This is particularly true in bilateral simultaneous
of concealing the scar in swimwear and under- reconstructions, where the patient cannot shift
garments. By beveling superiorly, a nicely shaped weight bearing to the side that was not operated
flap with less contour deformity can be obtained. on. The sciatic nerve has never been a problem
We have used both the superior GAP (SGAP) and in my experience of 329 GAP flaps (approxi-
the inferior GAP (IGAP) flap since 1993. In 2004, mately 100 IGAP flaps). The ideal candidate is
we began designing the IGAP flap so that the scar someone with a large buttock (pear shape) and
would be in the natural inferior crease.14 By har- a B size breast. In the right candidate, the in-
vesting tissue from the lowest part of the buttock, the-crease IGAP flap can provide for excellent
the shape of the rounded upper buttock was breast reconstruction, with a hardly noticeable
preserved. The pedicle length was also longer donor site. After initial overenthusiasm with the
than that of the SGAP flap, making the anasto- in-the-crease IGAP flap, we are now back to the

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Volume 120, Number 1 • Breast Reconstruction

SGAP flap in slightly more than 50 percent of nourish the lateral portions of the overlying skin
patients. The women do their research and paddle must travel through the muscle in a more
come with their opinions about which GAP flap oblique manner. Therefore, pedicles based on
they prefer. perforators from the lateral aspects of the skin
paddle tend to be longer than those based on
Indications more medial perforators.
The buttock has a high fat-to-skin ratio,
whereas the abdomen has a high skin-to-fat ratio. Surgical Technique
Patients who require mostly fat and little skin may
The patient usually is seen in the office 1 day
be candidates for GAP flaps. Patients in whom the
before surgery. The surgical plan again is reviewed
abdomen cannot be used as a donor site or who
with the patient, and any remaining questions are
have more tissue in the buttock area than in the
answered.
abdomen are the best candidates. In our experi-
In SGAP flap marking for unilateral recon-
ence using GAP flaps for breast reconstruction,
struction, the patient is placed in lateral decubitus
the average final inset weights of our GAP flaps
position and the Doppler probe used to find per-
were slightly greater than weights of the mastec-
forating vessels from the superior gluteal artery.
tomy specimens removed.15,16
These are usually found approximately one-third
Absolute contraindications specific to GAP
of the distance on a line from the posterior supe-
flap breast reconstruction in our practice are sim-
rior iliac crest to the greater trochanter. Addi-
ilar to those mentioned above, and include history
tional perforators may be found slightly more lat-
of previous liposuction at the donor site or active
eral from above. The skin paddle is marked in an
smoking (within 1 month before surgery). Lipo-
oblique pattern from inferior medial to supero-
suction of the central buttock is rare, but liposuc-
lateral to include these perforators (Fig. 5, above,
tion of the saddlebag area can affect the IGAP flap
left, and center, left). The lateral third of the flap is
and liposuction of the hips can affect the SGAP
not over the gluteus muscle. In bilateral simulta-
flap.
neous reconstructions, the flaps are marked with
the patient prone because this is the position in
Anatomy which the flaps will be harvested simultaneously.
The SGAP and IGAP flaps are based on per- For the IGAP flap, the gluteal fold is noted
forators from the superior and inferior gluteal with the patient in the standing position. The in-
arteries and veins, respectively. The superior glu- ferior limit of the flap is marked 1 cm inferior and
teal artery arises from the internal iliac artery and parallel to the gluteal fold. The patient is then
exits the pelvis superior to the piriformis muscle. placed in the lateral position and the Doppler
It enters the gluteus maximus muscle approxi- probe is used to find perforating vessels from the
mately one-third of the distance along the line inferior gluteal artery. An ellipse is drawn for the
between the posterior superior iliac spine and the skin paddle to include these perforators, which
greater trochanter. roughly parallels the gluteal fold with dimensions
The inferior gluteal artery is a terminal branch of approximately 8 18 cm. As with the SGAP
of the internal iliac artery and leaves the pelvis flap, bilateral cases are marked with the patient in
through the greater sciatic foramen inferior to the the prone position.
piriformis muscle. The artery is accompanied by For unilateral procedures, the patient is
the greater sciatic nerve, the internal pudendal placed in the lateral decubitus position and a two-
vessels, and the posterior femoral cutaneous team approach is used. The recipient vessels are
nerve. The course of the inferior gluteal vessels is prepared as described above while the GAP flap is
more oblique through the gluteus maximus mus- harvested. For breast reconstruction, the internal
cle substance than the course of the superior glu- mammary vessels are preferred, as anastomosis to
teal vessels. Therefore, IGAP pedicle is typically these vessels allows easier medialization of the flap
longer than that of the SGAP. Between two and when it is inset. This is especially important for the
four perforating vessels from the inferior gluteal SGAP flap, which typically has a shorter pedicle
artery will be located in the lower half of each than the IGAP flap. However, the IGAP flap often
gluteal muscle. has a long enough pedicle to reach the thora-
Perforating vessels that nourish the medial codorsal vessels.
portions of the buttock have relatively short in- The skin incisions are made and Bovie elec-
tramuscular lengths, whereas perforators that trocautery is used to divide the flap down to the

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 Plastic and Reconstructive Surgery • July 2007

Fig. 5. (Above, left and center, left) Preoperative marking of patient to undergo left breast reconstruction with the SGAP flap. (Below,
left and right) Intraoperative views of the SGAP flap and pedicle. (Above, right, and center, right) Views of the patient 3 months following
second-stage surgery and nipple creation.

muscle of the gluteus maximus. Significant bevel- rators approached beginning from lateral to me-
ing is used as needed, particularly in the superior dial. It is preferred to use a single large perforator,
direction to harvest enough tissue for a good if it is present, but several perforators that lay in
breast reconstruction. The flap is elevated from the same plane and the direction of the gluteus
the muscle in the subfascial plane and the perfo- maximus muscle fibers can be taken together as

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Volume 120, Number 1 • Breast Reconstruction

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

well. Subfascial elevation is also performed from soft-tissue deficiency in the crease is normal. Lat-
medial to lateral to ensure that a large perforator erally, thicker fat from trochanteric area can be
is found. The muscle is then spread in the direc- taken, increasing flap volume and decreasing a
tion of the muscle fibers and the perforating ves- saddlebag deformity. When harvesting the IGAP
sels are meticulously dissected free. The dissection flap, care must be taken to preserve the lighter
continues until both the artery and the vein are of colored medial fat pad that overlies the ischium.
sufficient size to be anastomosed to the recipient Preservation of the fat pad will prevent possible
vessels in the chest. The artery usually is the lim- donor-site discomfort when the patient is sitting.
iting factor in this dissection. The arterial perfo- When the recipient vessels are ready, the glu-
rator is visualized and preserved as it enters the teal artery and vein are divided and the flap is
main superior or inferior gluteal artery. The pref- harvested and weighed. The skin and fat overlying
erable artery and vein diameter for anastomosis is the gluteus maximus muscle are elevated superi-
2.0 to 2.5 mm and 3.0 to 4.5 mm, respectively. orly and inferiorly to allow layered approximation
When using internal mammary vein perforators as of the fat of the donor site to prevent a contour
recipients, a shorter pedicle and smaller artery will deformity and give a buttock lift. The donor site
suffice. is closed in layers over a suction drain with ab-
Harvesting the in-the-crease IGAP flap allows sorbable suture. Adding a permanent removable
more beveling superiorly and inferiorly because skin suture increases the strength of the closure

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 Plastic and Reconstructive Surgery • July 2007

(Fig. 5, below, left and right, above, right, and center, DISCLOSURE
right). None of the authors has a financial interest in any
The anastomosis is performed to the recipient medical device or product mentioned in this article.
vessels under the operating microscope. The flap
is inset over a suction drain into the defect with care REFERENCES
taken not to twist or kink the pedicle. To create a 1. Allen, R. J., and Treece, P. Deep inferior epigastric perforator
flap for breast reconstruction. Ann. Plast. Surg. 32: 32, 1994.
spherical flap, the ends of the ellipse are excised. 2. Taylor, G. I., and Daniel, R. K. The anatomy of several free
The flap may be inset horizontally, vertically, or ob- flap donor sites. Plast. Reconstr. Surg. 56: 243, 1975.
liquely, depending on the situation (Fig. 6). 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-
Postoperative Care rator free flap for breast reconstruction. Plast. Reconstr. Surg.
The postoperative care is the same as with the 95: 1207, 1995.
DIEP flap, and patients typically go home on the 5. Futter, C. M., Webster, M. H., Hagen, S., and Mitchell, S. L.
A retrospective comparison of abdominus muscle strength
fourth postoperative day. The drain at the donor following breast reconstruction with a free TRAM or DIEP
site must usually be left in place for several days flap. Br. J. Plast. Surg. 53: 578, 2000.
longer than with an abdominal donor site. 6. Kaplan, J., and Allen, R. Cost-based comparison between
perforator flaps and TRAM flaps for breast reconstruction.
Complications Plast. Reconstr. Surg. 105: 943, 2000.
In a review of 170 GAP flaps performed by our 7. Kroll, S., Sharma, S., Koutz, C., et al. Postoperative morphine
requirements of free TRAM and DIEP flaps. Plast. Reconstr.
unit for breast reconstruction, the incidence of Surg. 107: 338, 2001.
complications was low. The overall take-back rate 8. Allen, R., and Heitland, A. Autogenous augmentation mam-
was approximately 8 percent, with a 6 percent rate maplasty with microsurgical tissue transfer. Plast. Reconstr.
of vascular complications. The total flap failure Surg. 112: 91, 2003.
rate was approximately 2 percent. Donor-site se- 9. Rogers, N., and Allen, R. Radiation effects on breast recon-
struction with the deep inferior epigastric perforator flap.
roma occurred in 2 percent of patients, and ap- Plast. Reconstr. Surg. 109: 1919, 2002.
proximately 4 percent of patients required revi- 10. Gill, P., Hunt, J., Guerra, A., et al. A 10-year retrospective
sion of the donor site.15,16 review of 758 DIEP flaps for breast reconstruction. Plast.
Reconstr. Surg. 113: 1153, 2004.
SUMMARY 11. Reardon, C., O’Ceallaigh, S., and O’Sullivan, S. An anatom-
ical study of the superficial inferior epigastric vessels in hu-
Perforator flaps have raised the standard in mans. Br. J. Plast. Surg. 57: 515, 2004.
breast reconstruction. By replacing like with like, 12. Allen, R. J. The superficial inferior epigastric artery free flap:
we can achieve permanent natural results, with An anatomic and clinical study for use in reconstruction of
minimal donor-site deformities. Being able to the breast. In Proceedings of the Annual Meeting of the South-
eastern Society of Plastic and Reconstructive Surgeons, Kiawah,
choose from many donor-site options makes vir- S.C., June 3–7, 1990.
tually all patients candidates for this method of 13. Granzow, J. W., Levine, J. L., Chiu, E. S., et al. Breast recon-
autogenous reconstruction. To make this option struction with the SIEA flap revisited: An 8-year review of 203
more available and desirable, there is plenty of cases (unpublished data).
room for improvement. The length of the proce- 14. Babineaux, K. L., Granzow, J. W., Bardin, E., et al. Micro-
vascular breast reconstruction using buttock tissue: The pre-
dure needs to be decreased, scars need to be im- ferred scar location and shape. Plast. Reconstr. Surg. 116
proved, and complications need to be decreased. (Suppl.): 174, 2005.
With improvements in technology and technique, 15. Allen, R. J., Levine, J. L., and Granzow, J. W. The in-the-
these goals can be realized. crease inferior gluteal artery perforator flap for breast re-
construction. Plast. Reconstr. Surg. 118: 333, 2006.
Robert Allen, M.D. 16. Guerra, A., Metzinger, S., Bidros, R., Gill, P. S., Dupin, C. L.,
Suite 180 and Allen, R. J. Breast reconstruction with gluteal artery
1300 Hospital Drive perforator (GAP) flaps: A critical analysis of 142 cases. Ann.
Mount Pleasant, S.C. 29464 Plast. Surg. 52: 118, 2004.

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