Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 24:
Superior Gluteal Free Flap for Breast Reconstruction
  Occasionally, internal mammary arteries are not suitable; and alternative recipient arteries are the transverse cervical, thoracoacromial arterial, or thoracodorsal artery. If these vessels are not available, or if the pedicle is too short for proper breast wound position, an end-to-side vein graft from the axillary artery and vein should be used. Occasionally, a single long vein graft can be used to create a temporary arteriovenous fistula to allow blood to flow through the graft while awaiting completion of the flap dissection. Later, when the flap is ready for anastomosis, the final length of graft can be determined and the graft fistula divided. This saves time because the vein graft anastomosis can be performed with the blood flow through the fistula allowing a disparity in operating times of the donor and recipient sites.

To prepare for the flap dissection, the position of the superficial gluteal vessels is determined. These vessels lie approximately 5 to 6 cm below the posterior iliac spine, about 4 cm lateral to the midline of the sacrum. The paddle is designed with a slightly oblique central axis, with its most lateral extent just above the greater trochanter. This positions the skin paddle over the upper medial quarter of the gluteus maximus muscle with a somewhat horizontal orientation that allows a cosmetically acceptable primary closure. The flap may be safely extended beyond the borders of the muscle for a few centimeters in each direction. The flap dimensions range from 9 cm x 25 cm to 13 cm x 35 cm with the average flap about 10 cm x 27 cm. The flap is a wedge of myocutaneous tissue. The skin paddle of 10 cm x 27 cm has a subcutaneous tissue thickness of 8 cm, a muscle thickness of 4 cm, and a total volume of approximately 820 cc.


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