Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 24:
Superior Gluteal Free Flap for Breast Reconstruction
  The dissection begins with the superior and lateral incisions, which are taken down to the deep fascia and developed medially to the lateral border of the gluteus maximus muscle. The skin incision should not be beveled because this may result in a depression deformity when the incision is closed. The upper third of the gluteus maximus is divided along the superior edge of the skin incision. The muscle is retracted inferiorly and medially. The plane between the gluteus maximus and gluteus medius muscles can be developed, and the distal branches of the vessels are seen under the gluteus maximus muscle. The dissection is continued medially bluntly with a scissor and to the point where the superior gluteal vessel pedicle is seen emerging between the gluteus medius and the piriformis muscle. The remainder of the inferior medial incision is then made, and the flap is raised in a lateral to medial fashion, with care taken to preserve the pedicle. The medial soft tissue muscle is then detached from the sacrum, preserving a small cuff of ligament and muscle attached to the sacrum so that the pedicle is protected during this phase of the dissection. The final dissection of the superior gluteal artery and vein is done by first separating the space between the gluteus medius superiorly and the piriformis muscle inferiorly. The vessels are usually 2 mm to 3 mm in diameter and fragile. A pedicle approximately 3 cm long can be dissected before multiple branches, which are distributed in a spoke-like fashion, are encountered. These should be clipped with vascular silver clips or tied with silk ligatures and divided to free up sufficient length of pedicle. The ligation and division of the superior gluteal vessels are done carefully with 2-0 silk when the recipient vessels are ready. With the flap on a side table, additional pedicle length can be gained by careful intramuscular dissection of the pedicle. Hemostasis is achieved, and the donor wound is closed in layers over a hemovac drain. The patient is then placed in a supine position to facilitate the thoracic part of the operation.

  The flap is temporarily placed on the chest wall with its skin surface facing inferiorly and muscle surface superomedially, but left mobile to provide exposure for the microanastomosis. Anastomosis is performed with 9-0 nylon sutures in simple interrupted microsurgical fashion. Depending on the exposure, either the artery or the vein may be done first. The muscle cuff around the pedicle is sutured onto the chest wall to prevent motion of the pedicle during skin closure. The gluteal flap is inset after completing the anastomosis. The lateral (distal) end of the gluteal flap is positioned toward the axilla, where it is used to fill in the infraclavicular hollow. The skin surface faces inferolaterally, and when the flap is secured along the curvilinear incision of the inframammary fold, it takes on the shape of a projecting breast mound. The superior chest flap is then draped over the cephalad surface of the gluteal flap. The flap is secured with tacking sutures, it is tailored and full-thickness skin excised as needed to allow the final contouring of the breast mound. The skin is excised rather than de-epithelialized as the presence of the dermis impairs molding. A hemovac drain is brought out from under the flap laterally, and the skin is closed. The flap is dressed with a bacitracin ointment and telfa strips to provide a nonconstricting dressing and also to allow the flap to be visible.

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