Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 24:
Superior Gluteal Free Flap for Breast Reconstruction
  Fear of failure looms as a major concern, but the patency rates of elective clinical microsurgery approach 95%, and this psychologic barrier should be recognized and dispelled. The indications for the use of the superior gluteal flap have increased, and the technique can now provide a safe, effective, and aesthetically superior breast reconstruction with autogenous tissue.


Free-flap reconstruction of the breast has been performed with groin flaps, tensor fascia lata, latissimus dorsi,25 rectus abdominis26,27 and gluteus maximus myocutaneous flaps.21-24 Indications for the superior gluteal free flap are many and have expanded from those enumerated previously.21-24 Free-flap reconstruction is required when no regional flaps are available, if the pedicles of the regional flaps have been divided by earlier surgeries, or if the rectus flap is unsuitable. Until recently, these salvage situations have been the main indications for the superior gluteal free flap. Now, however, other indications have been added. The patient's preference is important because she may have high aesthetic requirements; this is particularly true with younger patients. Also, with the emphasis on physical fitness, the patient may refuse certain techniques on the basis of muscle loss or because of the need for implants. Increasingly, implants have been subjected to significant stress during workouts and weightlifting that may cause temporary dynamic deformation of the reconstructed breast, prosthesis dislodgement, or potential rupture. In these cases, breast reconstruction may be best served by superior gluteal free flap techniques.


Technical Considerations


The superior gluteal flap is based on the superficial and deep branches of the superior gluteal vessels that compose its pedicle. The position of the superior gluteal vessels can be determined by drawing a line from the posterior superior iliac spine to the apex of the greater trochanter. At the juncture of the upper and middle thirds of this line (usually 6 cm below the spine), the superior gluteal vessels emerge from the pelvis and proceed between the more caudad piriformis muscle and the more cephalad gluteus medius muscle before branching into the more superficially positioned gluteus maximus. In the early descriptions of the superior gluteal free flap operation, this line marked the central axis of the ellipse of the skin paddle. Shaw27 modified this ellipse to a more horizontal orientation that extends to the midline of the sacrum. This keeps the scar more in the bikini-covered area and makes closure easier.

The sciatic nerve lies deep and caudad to the piriformis muscle. It is not visible, but it is away from the area of dissection.


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