Inferior gluteal artery perforator flap breast reconstruction

BACKGROUND: In thin patients or in those with prior surgery that precludes the use of abdominal tissue for autologous breast reconstruction, the skin and fat of the lower buttock, perfused by perforating branches of the inferior gluteal artery, has been proposed as an alternative. METHODS: This study reviewed 19 reconstructions based on the inferior gluteal artery that were performed between July 2001 and March 2007. Patient characteristics, cancer stage and treatment, indications for use of gluteal tissue, surgical time, length of hospitalization, and complications were recorded. RESULTS: Our average patient age was 49 years, with early stage breast cancer, and low body mass index. The average surgical time was 9 hours and 7 minutes, and the average hospitalization time was 4 days. Complications included 2 complete flap losses, seromas, and delayed donor site healing. CONCLUSIONS: We conclude that tissue from the lower buttock, perfused by branches of the inferior gluteal artery, is a useful alternative for autologous breast reconstruction.     

Arteriovenous fistula complicating an inferior gluteal artery perforator flap donor site

We report the case of a 59-year-old woman who developed an arteriovenous fistula in her right buttock following a right inferior gluteal artery perforator flap for breast reconstruction.     

Donor-site morbidity of the inferior gluteal artery perforator flap for breast reconstruction in teenagers

BACKGROUND/OBJECTIVE:

Few options, apart from the buttock area, are available for autologous breast reconstruction in thin teenagers. The aim of the present study was to objectively evaluate and compare donor-site morbidity of the inferior gluteal artery perforator (IGAP) flap with that of the previously described inferior gluteal musculocutaneous flap.

METHOD:

A retrospective review of all IGAP flaps for breast reconstruction performed in teenagers between June 2006 and April 2011 at the Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, was performed. Patients were invited to undergo a specific physical evaluation and complete a questionnaire on aesthetic and functional outcomes.

RESULTS:

Thirteen records and 11 photographic charts were reviewed. Lateral buttock flattening was noticeable in nine of 11 cases. Three patients experienced some degree of inferior displacement of the gluteal crease. All six patients available for the appointment presented with a zone of dysesthesia or hypoesthesia in the territory of the operated buttock and/or posterior thigh. No motor impairment was found. The questionnaire, completed by eight patients, revealed that six were satisfied or very satisfied with the surgery. Appearance of the operated buttock was rated 3.4 on a scale from 1 to 5 (5 = normal) compared with the normal side.

CONCLUSIONS:

The IGAP flap remains a suitable option for breast reconstruction in slim teenagers. Similar to the myocutaneous flap, the major donor-site morbidity of the IGAP flap remains sensory impairment involving the posterior femoral cutaneous nerve. There is, however, less visible lateral depression when it is harvested as a perforator flap.     

臀上、臀下动脉穿支皮瓣的解剖学研究

目的 为了克服传统臀大肌肌皮瓣切取肌肉所带来的缺点，继承其血运好、组织量大的优点，寻找改进手术操作的解剖学基础。方法 采用5具10侧成人尸体，对臀上动脉、臀下动脉及其相应区域皮肤的穿支血管分布情况，包括主干血管、穿支血管的走行层次、数量、管径及分布、穿出位置及体表投影、相应区域神经分布情况进行大体解剖学研究。另对6例12侧成年女性双侧臀上动脉穿支分布区，应用多普勒超声血流探测仪进行穿支定位。结果 臀上动脉、臀下动脉起于髂内动脉，臀上动脉穿支分布区域集中在坐骨旁及臀大肌中部，数量约为10～15支，穿支血管的长度3～8cm，其外径约为1～1．5mm。这些穿支血管穿过臀大肌及筋膜直接供应相应区皮肤。来自腰神经背支的臀上皮神经越过髂棘在髂后上嵴外侧穿出深筋膜，向臀部走行，与血管穿支密切相邻．支配臀部皮肤感觉。在皮瓣上缘切口处注意分离直径合适的神经，与皮瓣一同切取，可与受区相应神经(如为乳房再造可与第4肋问神经)相吻合。在成人6例12侧女性患者，用多普勒超声血流探测仪进行定位，每侧可明确定位3～5支，均集中于由髂后上嵴、股骨大转子及坐骨结节所形成的三角区内，此为穿支血管的体表投影区域。结论 臀上动脉穿支血管分布区域恒定，管径粗细合适，切取该区域皮瓣，完全可以不携带肌肉，既包含了肌皮瓣血运好、组织量大的优点，又克服了切取肌肉所带来的缺点，临床应用多普勒血流探测仪进行穿支血管定位，简单可靠。切取皮瓣可同时携带臀上神经，为与受区神经吻合成为可能。由于臀下动脉穿支分布区为臀部负重部位，且臀下动脉主干与坐骨神经毗邻，因此，建议临床上尽量不采用臀下动脉穿支皮瓣。臀上动脉穿支皮瓣预期可行带蒂移植用于修复骶尾部褥疮等创面，也可成为乳房再造又一供区。     

Soft tissue reconstruction with the superior gluteal artery perforator flap

The development of the perforator flap technique revolutionized the practice of soft tissue transfer. The main goal of this technique is muscle sparing at the donor site for function and strength. Meanwhile, this concept is being widely applied for reconstruction of tissues throughout the entire body. Perforator flaps are the ultimate upgrade of the well-known myocutaneous flaps. Theoretically, any myocutaneous flap can be harvested as a perforator flap if skin resurfacing is needed. Although the DIEP flap, the anterolateral thigh flap, and the TAP flap are probably more frequently used for breast, trunk, and upper and lower limb reconstruction, as well as head and neck reconstruction, the SGAP flap takes its own position in the large group of perforator flaps and has its own specific indications.     

利用腹壁下动脉穿支皮瓣阴茎再造的临床研究

目的 探讨腹壁下动脉穿支(DIEP)皮瓣阴茎再造手术方法的临床疗效.方法 2003年12月至2006年11月收治体外热疗致阴茎严重烧伤2例、假两性畸形1例、动物咬伤致阴茎大部缺损1例.患者平均年龄31岁.术前残余阴茎常态下长度0.5～1.5 cm.应用DIEP皮瓣及第12肋骨植入行一期阴茎再造术.结果 4例手术均成功,皮瓣完全成活,术后未发生感染、尿道狭窄等并发症.3例术后随访5～32个月,再造阴茎外形逼真,阴茎定型长度7.5～11.0 cm,排尿正常,未发生严重感染及尿道狭窄,皮肤感觉与勃起功能良好.1例近期手术者随访3个月阴茎感觉仍在恢复中.结论 该手术方法设计合理,手术一期完成,术后再造阴茎形态功能良好,能满足患者及配偶性生活的要求.供区损伤小,是比较理想的阴茎再造方法.     

Breast reconstruction with gluteal artery perforator flaps.

BACKGROUND: Several alternatives exist for breast cancer reconstruction with perforator flaps. For those patients in whom the buttock is the best choice as a source for autologous tissue, the IGAP and SGAP flaps are an excellent option. These flaps allow the reliable transfer of skin and soft tissue from the buttock without the associated donor site morbidity of a muscle flap. INDICATIONS: Most women requiring tissue transfer to the chest from the buttock for breast reconstruction or other reasons are candidates for IGAP or SGAP flaps. Do to an improved donor site contour and scar, we now prefer to use the IGAP to the SGAP flap. Absolute contraindications specific to perforator flap breast reconstruction in our practice include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: IGAP and SGAP flaps are based on perforators from either the superior or inferior gluteal artery. These perforators are carefully dissected free from the surrounding gluteus maximus muscle, which is spread in the direction of the muscle fibres and safely preserved. The vascular pedicle is anastomosed to recipient vessels in the chest and the donor site closed primarily. CONCLUSIONS: IGAP and SGAP flaps allow the safe and reliable transfer of tissue from the buttock for breast reconstruction as an alternative to soft tissue transfer from an abdominal donor site or even as a first choice in selected patients.     

Sacral osteoradionecrosis treated via gluteal artery perforator (GAP) flap

Radiation is an important tool in curative or adjuvant therapy for a wide range of malignancies. With the increasing application of radiation, a number of patients display complications, e.g., hypoxic ulcers. When a radiation-induced skin ulcer does occur, the injury tends to be much deeper. If the ulcer involves the underlying skeleton, osteoradionecrosis and subsequent osteomyelitis result. Standard surgical dictum for the treatment of radiation-induced tissue damage follows two basic tenets: (1) removal of all altered tissues to the level of satisfactory blood supply; and (2) provision of suitable coverage. Vascular- and volume-rich flaps are essential to ensure adequate blood supply, fill dead space, and provide soft tissue coverage. Several flaps consistent with these requirements have been documented; however, most are technically challenging and relatively invasive for elderly patients. This report describes the utility of the gluteal artery-based perforator flap to treat a radiation-induced, infected sacral non-healing ulcer.     

A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction

Background: Perforator‐based fasciocutaneous flaps for reconstructing pressure sores can achieve good functional results with acceptable donor site complications in the short‐term. Recurrence is a difficult issue and a major concern in plastic surgery. In this study, we introduce a reusable perforator‐preserving gluteal artery‐based rotation flap for reconstruction of pressure sores, which can be also elevated from the same incision to accommodate pressure sore recurrence. Methods: The study included 23 men and 13 women with a mean age of 59.3 (range 24–89) years. There were 24 sacral ulcers, 11 ischial ulcers, and one trochanteric ulcer. The defects ranged in size from 4 × 3 to 12 × 10 cm². Thirty‐six consecutive pressure sore patients underwent gluteal artery‐based rotation flap reconstruction. An inferior gluteal artery‐based rotation fasciocutaneous flap was raised, and the superior gluteal artery perforator was preserved in sacral sores; alternatively, a superior gluteal artery‐based rotation fasciocutaneous flap was elevated, and the inferior gluteal artery perforator was identified and dissected in ischial ulcers. Results: The mean follow‐up was 20.8 (range 0–30) months in this study. Complications included four cases of tip necrosis, three wound dehiscences, two recurrences reusing the same flap for pressure sore reconstruction, one seroma, and one patient who died on the fourth postoperative day. The complication rate was 20.8% for sacral ulcers, 54.5% for ischial wounds, and none for trochanteric ulcer. After secondary repair and reconstruction of the compromised wounds, all of the wounds healed uneventfully. Conclusions: The perforator‐preserving gluteal artery‐based rotation fasciocutaneous flap is a reliable, reusable flap that provides rich vascularity facilitating wound healing and accommodating the difficulties of pressure sore reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

臀下动脉穿支皮瓣修复臀部压疮的临床应用

目的目的探讨臀下动脉穿支皮瓣修复臀部压疮的临床疗效。方法自2016年1月至2018年12月河池市人民医院创伤手足外科对收治的106例臀部压疮患者于术前常规采用彩色超声多普勒血流仪探测穿支点并标计,设计将包括穿支点在内的臀下动脉穿支皮瓣修复压疮创面。结果本组共106例患者,皮瓣大小为4.5 cm×8.0 cm~8.5 cm×15.0 cm;其中2例术后压疮复发引起全身感染,经积极局部引流和应用抗生素治疗后,感染控制;其余患者术后皮瓣均完全成活。随访3~12个月,压疮无复发,修复效果较满意。结论采用臀下动脉穿支皮瓣修复臀部压疮,创伤性较小,血运可靠,修复效果较好,值得临床推广。     

Emerging trends in microsurgical breast reconstruction: deep inferior epigastric artery perforator (DIEP) and the superior gluteal artery perforator (SGAP) flaps

Breast reconstruction is an important adjunct in the treatment of breast cancer. Many reconstructive options exist, however autologous tissue remains the gold standard. One drawback to autologous reconstruction methods is the potential for flap donor site morbidity. Recent advances in microsurgical techniques include the development of perforator flaps, including the Deep Inferior Epigastric Artery Perforator flap (DIEP) and the Superior Gluteal Artery Perforator (SGAP) flaps. Harvest of these flaps attempt to minimize the impact on the donor site and thereby reduce the incidence of donor site complications. This article will review of the indications, advantages and drawbacks to the use of perforator flaps in breast reconstruction surgery.     

Deep inferior epigastric perforator flap for foot reconstruction using an external pedicle

When it is necessary to apply free flaps for foot reconstruction, the choices are limited. Conventionally, split-thickness skin-grafted muscle flaps and fasciocutaneous flaps from the back or thigh have been two major options, but these methods take substantial time to wearing normal shoes. As an alternative, the authors use the deep inferior epigastric perforator (DIEP) flap with an external pedicle. After elevation and thinning of the flap, the vascular pedicle is anastomosed at a site distant from the skin defect of the foot. About 20 days after that, the pedicle is severed, and the skin island is trimmed and sutured. This method provides thin and wide coverage within a limited time, and donor-site morbidity is minimal both functionally and aesthetically.     

Reconstruction of ischial pressure sore using an inferior rectus abdominis myocutaneous flap

Summary In this article, a reconstructive method for ischial pressure sores using an inferior rectus abdominis myocutaneous flap, is reported. Results obtained with two paraplegic patients with recurrent ischial pressure sores were excellent, and they were free from recurrence over two years after this operation. This technique is one of the methods of choice in cases of recurrent ischial pressure sore where conventional methods have been tried.