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21.8 Pearls andPitfalls 21.9 Selected Readings
H. Yoshimatsu et al.
Pearls
• When an adequate pedicle is found, the elevation of
the SIEA is rather simple since it does not involve
intramuscular dissection of the pedicle.
• A relatively thin skin paddle can be expected even
in obese patients because the SIEA runs in a supercial layer.
• When the SIEA and the SCIA do not share a common trunk, either the supercial or the deep branch
of the SCIA can be used for the recipient artery for
the SIEA.
• The DIEP can serve as the backup ap for the SIEA
in the SIEA-SCIP combined ap.
• Because the anatomy can be complicated at times,
the dissection of the proximal portion of the SIEA
and the SCIA should be done under a surgical
microscope.
Pitfalls
• Conversion to other aps (e.g., DIEP ap or SCIP
ap) should be considered when the exposed SIEA
is not pulsating or its diameter is smaller than
1.0mm at its takeoff from the femoral artery.
• The SIEA runs in a supercial layer as it goes
supercially. When performing a vertical SIEA
ap, the initial incision for the pedicle dissection
should not be placed too high.
• The superior region of the SIEA ap can go higher
than the umbilicus, but its perfusion should always
be conrmed with ICG angiography when
available.
• Damage to the lymph nodes and the lymphatic vessels can result in postoperative lymphorrhea or
seroma. Meticulous coagulation of the lymphatic
vessels, along with hemostasis, should be performed before donor site closure.
• Non-pulsating SIEA should not be used as the pedicle of the ap. Conversion to the SCIP ap or the
DIEP ap should be considered.
• Hester TR Jr., Nahai F, Beegle PE, Bostwick J 3rd. Blood
supply of the abdomen revisited, with emphasis on the
supercial inferior epigastric artery. Plast Reconstr Surg.
1984;74(5):657–70.
• Rozen WM, Chubb D, Grinsell D, Ashton MW.The variability of the Supercial Inferior Epigastric Artery (SIEA)
and its angiosome: a clinical anatomical study.
Microsurgery. 2010;30(5):386–91.
• Kita Y, Fukunaga Y, Arikawa M, Kagaya Y, Miyamoto
S. Anatomy of the arterial and venous systems of the
supercial inferior epigastric artery ap: a retrospective
study based on computed tomographic angiography. J
Plast Reconstr Aesthet Surg. 2020;73(5):870–5.
• Yoshimatsu H, Hayashi A, Karakawa R, Yano
T.Combining the supercial circumex iliac artery perforator ap with the supercial inferior epigastric artery ap
or the deep inferior epigastric artery perforator ap for
coverage of large soft tissue defects in the extremities and
the trunk. Microsurgery. 2020.
• Coroneos CJ, Heller AM, Voineskos SH, Avram R.SIEA
versus DIEP arterial complications: a cohort study. Plast
Reconstr Surg. 2015;135(5):802e–7e.
• Zhang YX, Hayakawa TJ, Levin LS, Hallock GG, Lazzeri
D.The economy in autologous tissue transfer: part 1. The
kiss ap technique. Plast Reconstr Surg.
2016;137(3):1018–30.
• Zhang YX, Messmer C, Pang FK, Ong YS, Feng SQ,
Qian Y, Spinelli G, Agostini T, Levin LS, Lazzeri D. A
novel design of the multilobed latissimus dorsi myocutaneous ap to achieve primary donor-site closure in the
reconstruction of large defects. Plast Reconstr Surg.
2013;132(5):886e–7e.
Superior Gluteal Artery Perforator Flap
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MohammedFarid andMohamedShibu
22
22.1 Introduction
The superior gluteal artery perforator (SGAP) ap evolved in its
composition and application over the past four decades. A myocutaneous SGAP free ap was rst used in breast reconstruction
by Fujino in 1975 [1]. In 1984, Remirez then described the use
of sliding myocutaneous gluteal aps for sacral defect reconstruction [2]. The evolution of perforator aps happened with
the introduction of fasciocutaneous ap concept in reconstructive microsurgery. This led to reduced morbidity associated with
SGAP muscle aps. The turning point was when Koshima in
1993 described up to 25 perforators in the gluteal region and the
rst to use gluteal fasciocutaneous pedicled aps in sacral
reconstruction [3]. Verpaele and Blondeel etal. modication led
to the selection of a single-perforator superior gluteal artery to
be the choice for sacral reconstruction in 1999 [4]. Within the
same period in 1995, Allen etal. utilised SGAP fasciocutaneous
ap in breast reconstruction [5]. The current state is the use of
predominately SGAP as a fasciocutaneous pedicled ap for
sacral reconstruction and a free ap in breast reconstruction.
The use of gluteal muscle should be reserved to patients with
extensive sacral defects for dead space obliteration.
22.2 Anatomy
The superior gluteal artery (SGA) is one of the terminal branches
of the internal iliac artery [6, 7]. A continuation of the posterior
trunk of this vessel appears complete in the majority of cases,
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978- 3- 031- 07678- 7_22.
M. Farid (*)
Department of Plastic Surgery, Royal Stoke University Hospital,
Stoke-on-Trent, UK
M. Shibu
Department of Plastic Surgery, The Royal London Hospital,
London, UK
but can arise from a common stem (truncus glutealis) with the
inferior gluteal artery [8]. The SGA courses posteriorly between
the lumbosacral trunk and the rst sacral ventral ramus and then
exits through the greater sciatic foramen [9]. It leaves the pelvis
above the upper border of the piriformis muscle, to divide into
supercial and deep branches [6]. The supercial branch of
SGA passes between gluteus maximus and medius in a septal
plane. It gives off three branches either muscular (supplies gluteus maximus), septocutaneous (skin and subcutis) and musculocutaneous (run through the gluteus muscle to reach skin) [9].
Cormack and Lamberty described a posterior, intermediate and
anterior branch (synonymous to septocutaneous) for the supercial part of SGA [8]. The deep branch gives off superior (supplies gluteus medius) and inferior (supplies gluteus medius and
minimus). Musculocutaneous perforators for the deep branch
are difcult to dissect and should not be used as a pedicle for
SGA.A large venous network (caput medusa) is found where
supercial and deep branches of SGA branch superior to the
piriformis [9].
Particular anatomical landmarks are described to locate
the SGAP topographically. With the hip exed and internally rotated, the SGAP exit from the pelvis corresponds to
the junction of the upper and middle third between the posterior superior iliac spine (PSIS) and greater trochanter [6].
The exit point corresponds anatomically to 6cm below the
posterior superior iliac spine and 4.5cm lateral to the midline of the sacrum [10]. The piriformis is located half-way
between the greater trochanter and the sacrum. Perforators
are located lateral to SGA and above the piriformis. An
average of three perforators are found to supply the skin
(Fig.22.1) [6, 7, 11]. A more detailed anatomical study by
Ahmadzadeh etal. [12] described a mean of 5±2 myocutaneous perforators from SGA in the gluteal region. He
described that the average cutaneous SGA vascular area was
69±56cm2 which corresponds to the angiosome territory.
The diameter of the SGA ranges from 0.6 to 3.5mm [11, 13,
14]. The pedicle length is short with an average of 3 to 7cm
(range 2–10 cm) [6, 13]. Venous drainage is through the
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_22
219
220
Perforator
Fig. 22.1 Bilateral SGAP aps to reconstruct a perineal defect from
pelvic exenteration (anal SCC)
superior gluteal vein (SGV) (venae comitantes) with many
tributaries from pelvic veins. The average length of SGV is
2.5cm and diameter of 3mm [13].
M. Farid and M. Shibu
22.4 Flap Design andMarkings
The SGA perforator is identied at the junction between the
proximal and middle third of a line drawn from PSIS and
greater trochanter of the femur. Flap design is in a fusiform
shape, oriented from 0° to 90°, on the area surrounding the
perforator (Fig.22.2). Flap dimension is based on the defect
size and location in the gluteal region or the desired size for
free ap breast reconstruction. The maximum ap size by
one SGAP perforator can be 14cm wide and up to 30 cm
long [11, 16]. The length of the ap is based on reverse planning for defect size. The skin paddle length should be made
a few centimetres longer than the defect size to reach the
distal end of defect once rotated. Bilateral SGAP aps can be
planned based on the clinical indication in terms of defect
dimensions (Fig.22.3).
22.3 Preoperative Investigation
Preoperative imaging is one of the crucial steps to allow safe
surgical planning prior to raising the SGAP ap. The perforators for SGA can be localised using either a handheld
Doppler ultrasound (US), duplex US, computed tomography
angiography (CTA) or magnetic resonance angiography
(MRA) imaging. All imaging should be performed while the
patient is in the prone position.
Handheld Doppler US is routinely used in the immediate preoperative period and determines location and number of SGA perforators. Angiography combined with CT
or MR identifies the perforator pathway (musculocutaneous or septocutaneous), location and calibre of vessels [6,
10, 15]. MRA imaging identifies perforator branches, has
no ionising radiation compared to CT and offers excellent soft tissue detail. CTA also allows 3-D reconstruction of the images to add more detail into the course of
perforator [9].
The investigation of choice is based on the resources
available, surgeon’s preference and intended operation
whether pedicle or free SGA ap. The choice we propose is
the use of handheld Doppler for pedicled SGAP aps to be
combined with MRA or CTA if a free SGAP ap is planned.
The ultimate goal is to safely identify and isolate the perforator without ap compromise at any point during the
operation.
Right SGAP
based on one
perforator
Fig. 22.2 Right SGAP ap islanded based on a single perforator
Perineal Defect
Left SGAP
Fig. 22.3 Bilateral SGAP islanded and perineal defect post
debridement
Right SGAP
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22.5 Flap Raise/Elevation: AStep-by-Step
Guide
Step 1: Incision. An incision is made through the marked
area for ap skin paddle. The depth of the incision is down to
gluteal subfascial plane. Dissection can be beveled at an
angle to recruit more subcutaneous tissue and volume.
Step 2: Raising Flap. The ap is raised supero-laterally
and then inferiorly in the gluteal subfascial plane. Once the
correct plane is identied, the ap is raised lateral to medial
towards the SGA perforator (Fig.22.4). When the perforator
is visualised, the dissection is moved superomedially towards
the perforator towards the perforator. Intraoperative Doppler
is used to conrm the ow of the perforator and can be palpated for pulsatile ow.
Right SGAP Flap
Step 3: Islanding the Flap (propeller). Once the perforator is identied from all angles, the pedicle is traced by gluteal muscle dissection. The ap is mobilised and would
rotate on a perforator axis as a propeller ap (Fig.22.5).
The following steps would depend on the size and the
depth of the defect. Two SGAP aps are raised in large perineal defects as in the case demonstrated.
Step 4: Flap De-epithelialised. The contralateral SGAP
ap to the defect side is de-epithelialised and inset deep into
the defect (Figs.22.6 and 22.7).
Step 5: Second SGAP Flap Raised. The ipsilateral
SGAP ap to defect is raised similar to Steps 1–3. This ap
is inset on top of de-epithelialised SGAP ap (Figs. 22.8,
22.9, 22.10, and 22.11). This is followed by insertion of two
suction drains prior to closure.
SGA Perforator
Fig. 22.4 Right SGAP ap demonstrating the perforator once ap
islanded
Right SGA Perforator
Right SGAP
De-epithelialised
Fig. 22.6 Right SGAP ap de-epithelialised to ll in deep into the
defect
Right SGAP flap islanded on
perforator and rotated 90 degrees
Gluteus Maximus Muscle
Fig. 22.5 Right SGA perforator close-up and underlying gluteus maximus muscle
Fig. 22.7 Right SGAP ap islanded on a single perforator, deepithelialised and rotated 90 degrees
222
Left SGAP
Defect
Right SGAP
De-epithelialised
Left SGAP placed over deepithelialised Right SGAP to
cover perineal defect
M. Farid and M. Shibu
Fig. 22.8 Bilateral SGAP ap to reconstruct perineal defect
Right SGAP
De-epithelialised
and rotated to fill
perineal defect
Fig. 22.9 Right SGAP ap rotated to ll perineal defect
Right SGAP de-epithelialised
and rotated to fill perineal defect
Fig. 22.10 Right SGAP ap rotated and mobilised to ll perineal
defect
Step 6: Closure Post Inset. Three-layer closure from
deep to supercial. The deepest layer would be above the
gluteal fascial planes (3/0 PDS suture), deep dermal layer
(3/0 Monocryl) and skin (3/0 Nylon Interrupted) (Fig.22.12).
Fig. 22.11 Left SGAP ap over de-epithelialised right SGAP to cover
perineal defect
Left SGAP donor site closure
Left SGAP over Right
SGAP closure for
perineal defect
Left SGAP donor site closure
Fig. 22.12 Bilateral SGAP closure of donor and recipient site
22.6 Core Surgical Techniques inFlap
Dissection
Step 1: Perforator Checkpoint: The ap relies on one main
SGAP perforator. Adequate attention and step-by-step
approach when raising ap. Regular checkpoint throughout
dissection using handheld Doppler to ensure pedicle is not
compromised at any point.
Step 2: Perforator Dissection: Careful gluteal muscle
dissection to obtain longer SGAP pedicle which can reach up
to 10–12 cm [14]. This is important for free ap cases to
reduce the tension on the pedicle and ensure adequate length
to reach the recipient site. The SGAP pedicle length can be
further extended with the use of a vein graft [16]. The length
of the pedicle would increase the arc of rotation to reach the
defect.
Step 3: Perforator Torsion: Perforator to be isolated
from surrounding tissue to allow ap rotation. Perforator torsion or kinking would cause ap venous congestion. This is
22 Superior Gluteal Artery Perforator Flap
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223
commonly seen in SGAP aps with poor planning related to
perforator dissection. The pedicle is dissected down without
any kink on rotation to adhere to the principles of the propeller ap concept [17].
Step 4: Flap Inset: Pedicled SGAP ap, inset should be
tensionless without any pull or traction on the pedicle. This
may lead to vessel spasm and ap compromise.
Step 5: Closure: The aim is to close the donor site primarily. This is dependent on the laxity of surrounding soft
tissue and the width of the ap harvest (less than 10cm).
Instrumentation: A number of smaller vessel branches
along the SGAP pedicle should be Ligaclipped safely. Lone
stars can be used to retract the tissue margins either side of
the ap which facilitate dissection. Safe use of bipolar diathermy when dissecting the pedicle is advised. The setting
we recommend is 6–8 watts. DeBakey forceps are placed
2 mm from the pedicle when cauterising small vessel
branches off the pedicle (heat-sink principle) [18].
22.7 Clinical Scenario
Scenario A: M Shibu and D Nikkhah A 53-year-old man
with Crohn’s disease underwent a pelvic exenteration for
anal SCC (Fig.22.13). He had had multiple previous abdominal operations and was not a suitable candidate for an
abdominal-based ap. Decision was made to perform an
SGAP ap to obliterate the dead space (Figs. 22.1, 22.2,
22.3, 22.4, 22.5, 22.6, 22.7, 22.8, 22.9, 22.10, 22.11, 22.12,
and 22.13). This ap was raised in the standard fashion and
the perforator isolated and the skin de-epithelialised and
placed into the perineal defect. A second ap was designed
on the contralateral side. An IGAP ap with its leading edge
de-epithelialised was advanced to cover the rst ap. The
patient had an uneventful recovery and was discharged at
1week.
Scenario B: M Shibu and D Nikkhah A 26-year-old
woman underwent a pelvic exenteration for rectal cancer.
Decision was made to perform bilateral SGAP aps, one to
obliterate the dead space and the second to cover the soft tissue defect (Figs.22.14, 22.15, 22.16, 22.17, and 22.18 and
Video 22.1).
Left IGAP Flap
Fig. 22.14 A 26-year-old woman underwent a pelvic exenteration for
rectal cancer
Right SGAP Flap
Perineal defect
Fig. 22.13 A 53-year-old man with Crohn’s disease underwent a pelvic exenteration for anal SCC
Fig. 22.15 Right SGAP ap islanded
Right SGAP Flap
224
Right SGAP Flap
Fig. 22.16 Right SGAP ap rotated into perineal defect
Right SGAP Flap de-epithelialised
and rotated into defect
Fig. 22.17 Right SGAP ap de-epithelialised, rotated and placed in
perineal defect
M. Farid and M. Shibu
22.8 Pearls andPitfalls
• Venous congestion: Linked mainly to perforator
kinking or twisting. This risk is reduced with raising the ap as a propeller, hence freeing the pedicle.
The other technical tip is to rotate the ap on pedicle in a clockwise/anticlockwise based on visualising the pedicle to rule out kinking (Video 22.2).
• Flap tip necrosis: Based on the angiosome concept,
the distal end of the ap may suffer necrosis. The perforator branches may not reach the distal end of the
ap. Intraoperative mapping with indocyanine green
uorescence (ICG) angiography may help in viewing
under-perfused ap areas which can then be excised.
• Flap wound dehiscence: Wound edges of the SGAP
ap may break down with pressure or swelling postoperatively. Removal of continuous undissolved
sutures for 2–3 weeks, nurse laterally or prone,
wound care and regular reviews all reduce this risk.
• Intraoperative pedicle/ap compromise:
Meticulous attention to ap dissection and perforator identication is crucial to prevent immediate
complications. Using intraoperative handheld
Doppler, careful muscle dissection and appropriate
inset all help in minimising complications.
• Breast reconstruction: The SGAP is used as a free
ap in breast reconstruction. Preoperatively, patients
ideally are made aware that gluteal fat is thicker and
less malleable than normal breast tissue.
Intraoperatively, patient positioning is variable either
lateral decubitus or then changed to supine depending whether unilateral or bilateral breast reconstruction. The short pedicle length can be a limiting factor
to being rst choice in breast reconstruction. Shaping
of SGAP to breast form is challenging due to the
nature of the tissue. Postoperatively, secondary surgery to re- contour gluteal regions may be indicated
as patients report unaesthetic look of their buttocks.
Left IGAP flap over Right SGAP Flap
de-epithelialised to cover perineal defect
Fig. 22.18 Left IGAP ap over de-epithelialised right SGAP ap and
closure of donor sites
22.9 Selected Readings
• Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The
superior and inferior gluteal artery perforator aps. Plast
Reconstr Surg. 2007.
This paper is a cadaveric anatomical study specic to
SGAP and IGAP perforators. It gives an accurate description of the perforator landmarks and maps their territory
based on the angiosome principle. This information provides the basis for safe surgical dissection and planning
to minimise ap compromise.
• Blondeel PN, Beyens G, Verhaeghe R, Van Landuyt K,
Tonnard P, Monstrey SJ, etal. Doppler owmetry in the
planning of perforator aps. Br J Plast Surg. 1998.
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The authors support this paper to describe the use of
handheld Doppler and duplex US in perforator planning.
Preoperative and intraoperative US help reduce operating time and decision-making for suitable perforators.
SGAP perforator anatomy is consistent, and identication using handheld Doppler US has a high positive predictive value (91.9%) which conrms its reliability in
perforator planning.
• Gagnon A, Blondeel P.Superior gluteal artery perforator
ap. Semin Plast Surg. 2006.
This paper offered a comprehensive and specic
encounter for SGAP aps. It highlighted the anatomical
landmarks, marking, perforator dissections and indications. There was a clear distinction for the use as pedicled
ap for loco-regional defects or free ap in breast
reconstruction.
• Verpaele AM, Blondeel PN, Van Landuyt K, Tonnard PL,
Decordier B, Monstrey SJ, et al. The superior gluteal
artery perforator ap: An additional tool in the treatment
of sacral pressure sores. Br J Plast Surg. 1999.
The paper highlighted the known concepts introduced
previously by Koshima (rst SGAP) and Ramirez (sliding
SGAP ap). The main recommendation is the dissection of
the pedicle from the muscle to allow longer pedicle length
and ap translation without perforator torsion. Another
technical tip was the avoidance of tunnelling SGAP ap
and utilising of ipsilateral SGAP for sacral defects.
• Acartürk TO, Parsak CK, Sakman G, Demircan O.Superior
gluteal artery perforator ap in the reconstruction of pilonidal sinus. J Plast Reconstr Aesthetic Surg. 2010.
The paper showed the detailed planning for SGAP ap
in pilonidal sinus surgery. This was based on transposing
the ap without perforator dissection, visualisation or
skeletonisation from the gluteal muscle. No complications
reported by the author based on their technique.
• Zeng A, Jia Y, Wang X, Liu Z.The superior gluteal artery
perforator ap for lumbosacral defect repair: A unied
approach. J Plast Reconstr Aesthetic Surg. 2013.
This is interesting short correspondence describing a
new technique in raising pedicled SGAP ap. The perforator was not identied with handheld Doppler but based
on an exploratory incision. This incision was 2cm below
and parallel to middle of a line between the PSIS and
greater trochanter. The technique applied ap tunnelling
to reach lumbosacral defect without any suggested complications. A long pedicled SGAP advancement ap
would help reach a distant defect site.
• Zoccali G, Mughal M, Giwa L, Roblin P, Farhadi J.Breast
reconstruction with Superior Gluteal Artery Perforator
free ap: 8years of experience J Plast Reconstr Aesthetic
Surg. 2019.
This is one of the largest studies in the literature for the
use of free SGAP aps in breast reconstruction. It
addresses the indications, complications and outcomes
for SGAP breast reconstruction. The paper also looked at
re-operation rates and reasons behind it. It describes ap
inset prior to anastomosis to prevent vessel avulsion considering the short pedicle length. For immediate breast
reconstruction, ap was harvested on lateral position at
the same time as mastectomy. One of the main recommendations is appropriate patients’ selection and takes into
account cultural belief about aesthetics.
References
1. Fujino T, Harashina T, Aoyagi F.Reconstruction for aplasia of the
breast and pectoral region by microvascular transfer of a free ap
from the buttock. Plast Reconstr Surg. 1975;56:178–81.
2. Ramirez OM, Swartz WM, Futrell JW.The gluteus maximus muscle: experimental and clinical considerations relevant to reconstruction in ambulatory patients. Br J Plast Surg. 1987;40(1):1–10.
3. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforatorbased ap for repair of sacral pressure sores. Plast Reconstr Surg.
1993;91(4):678–83.
4. Verpaele AM, Blondeel PN, Van Landuyt K, Tonnard PL, Decordier
B, Monstrey SJ, etal. The superior gluteal artery perforator ap: an
additional tool in the treatment of sacral pressure sores. Br J Plast
Surg. 1999;52:385–91.
5. Allen RJ, Tucker C.Superior gluteal artery perforator free ap for
breast reconstruction. Plast Reconstr Surg. 1995;95:1207–12.
6. Samir M, Fu-Chen W. Chapter:58: Superior and inferior gluteal
artery perforator aps. In: Levine J, Allen R, editors. Flaps and
reconstructive surgery. 2nd ed; 2016. p.687–99.
7. Lin C-T, Dai N-T, Chang S-C, Chen S-G, Chen T-M, Wang H-J,
Tzeng Y-S.Ten-year experience of superior gluteal artery perforator ap for reconstruction of sacral defects in tri-service general
hospital. J Med Sci (Taiwan). 2014;34(2):66–71.
8. Cormack G, Lamberty B.Chapter 6: Buttock. In: The arterial anatomy of skin aps. 2nd ed; 1996. p.220–6.
9. Spiegel A. Chapter 9: Septocutaneous gluteal artery perforator
(Sc-GAP) ap for breast reconstruction: how we do it. In: Tuinder
S, Van Der Hulst R, Lobbes M, Versluis B, Lataster A, editors.
Breast reconstruction- current perspectives and state of the art techniques. 1st ed; 2013. p.135–50.
10. Pu L, Karp N.Chapter 5: free gluteal perforator ap breast reconstruction. In: Levine J, Conde-Green A, Andrade P, editors. Atlas of
reconstructive breast surgery. 1st ed; 2019. p.61–72.
11. Lin CT, etal. Modication of the superior gluteal artery perforator
ap for reconstruction of sacral sores. J Plast Reconstr Aesthet Surg.
2014;67(4):526–32. https://doi.org/10.1016/j.bjps.2013.12.031.
12. Ahmadzadeh R, etal. The superior and inferior gluteal artery perforator aps. Plast Reconstr Surg. 2007;120(6):1551–6. https://doi.
org/10.1097/01.prs.0000282098.61498.ee.
13. Samir M, Fu-Chen W. Chapter: 28: Gluteus ap. In: Hamdi M,
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14. Elizabeth Hall-Findlay E, Evans G.Chapter 11: Gluteal ap breast
reconstruction. In: Cheng M-H, Huang J-J, editors. Aesthetic and
reconstructive surgery of the breast. 1st ed; 2010. p.161–70.
15. Sakuraba M, Asano T, Yano T, Yamamoto S, Moriya
Y. Reconstruction of an enterocutaneous stula using a superior gluteal artery perforator ap. J Plast Reconstr Aesthet Surg.
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AF.Infrared evaluation of the heat-sink bipolar diathermy dissection technique. J Plast Reconstr Aesthet Surg. 2015;68(8):1145–51.
Inferior Gluteal Artery Perforator Flap
MaleehaMughal andPaulRoblin
23
23.1 Introduction
The inferior gluteal artery perforator (IGAP) ap was rst
described for use in ischial pressure sores by Higgins etal. in
2002 [1]. It has since gained in popularity for perineal reconstructions due to its technical simplicity and reliability.
In clinical practice the IGAP ap is a workhorse ap for
sacral and pelvic defects following pelvic oncological resections, pressure sores, and traumatic injuries [2].
The perforators in the lower gluteal region are relatively
constant; therefore, preoperative and even intraoperative
identication (for a number of cases) of perforators is unnecessary. If extensive mobility is required (more than can be
achieved with the myocutaneous ap), this ap can be completely isolated on a single or two perforators only. In a
majority of cases, sufcient mobility can be achieved with
the retention of multiple perforators. This robust vascular
supply allows larger aps to be harvested reliably, and it can
also be elevated with sensory innervation from the posterior
cutaneous nerve of the thigh.
It is also important to note that in suitable patients, for
disease involving the vaginal vault, the IGAP ap (uni- or
bilateral) can reliably be used for simultaneous closure of the
perineal defect and vaginal reconstruction, thus permitting
earlier discharge, return to daily living, and sexual activity in
a single-stage operation.
nerve, the greater sciatic nerve, and the posterior cutaneous
nerve of the thigh. The perforators from the inferior gluteal
artery traverse the caudal half of the gluteus maximus muscle, in a more oblique fashion than the course of the superior
gluteal vessels. Cutaneous perforators ultimately reach the
external border of the gluteal musculature. Therefore, the
length of the IGAP pedicle is typically longer than that of the
SGAP. Between two and four perforating vessels from the
inferior gluteal artery will be located in the lower half of
each gluteal muscle.
23.3 Preoperative Investigation
Due to constant anatomy of the perforators in the region, preoperative imaging is not essential when using the IGAP for
perineal reconstruction. However magnetic resonance imaging (MRI) of the gluteal perforators is preferred by the
authors when utilizing the ap for breast reconstruction. In
that instance our ap of choice is the superior gluteal artery
perforator (SGAP) ap which has been discussed further in
the remit of this book.
23.4 Flap Design andMarkings
23.4.1 Markings
23.2 Anatomy
Both the inferior gluteal artery and superior gluteal artery are
terminal branches of the internal iliac artery. They exit the
pelvis through the greater sciatic foramen. The inferior gluteal artery travels inferior to the piriformis muscle and is
accompanied by the internal pudendal vessels, the pudendal
M. Mughal (*) · P. Roblin
Guy’s and St. Thomas Hospital, London, UK
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_23
The patient is positioned prone as the specimen is delivered
through the wound. The IGAP ap is designed in a V -Y
fashion, with the lower border placed in the buttock crease
and the lateral extension medial to the greater trochanter. A
line is drawn from the greater trochanter to the posterior
superior iliac spine; the inferior gluteal artery perforators are
inferior to this line; these can be mapped with a Doppler
probe if required, but with more experience this step is not
necessary (Fig.23.1). Bilateral IGAPs mirror each other.
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Fig. 23.1 Bilateral IGAP ap markings. The inferior edge is kept
above the gluteal crease
23.5 Flap Raise/Elevation: AStep-by-Step
Guide
M. Mughal and P. Roblin
Fig. 23.2 Subfascial raise of both IGAP aps, medial edge of the right
IGAP elevated to show medial dissection
1. The ap is raised from lateral to medial in a subfascial
plane using a monopolar diathermy. This approach allows
identication of the perforating vessels passing through
the gluteal muscle into the ap (Fig.23.2). A consistent
perforating vessel is usually identied at the junction
between the lateral and middle third of the ap. This
perforator is isolated and can be traced down through the
muscle to allow adequate mobilization.
2. Once the perforator has been isolated and dissected, the
medial border of the ap is raised in a subfascial plane.
Perforators from the medial and central areas can then be
isolated and dissected dependent on the degree of medial
transposition required.
3. The ap is advanced medially; the medial edge is de-
epithelialized and buried to ll the dead space in the pelvis (Fig.23.3).
4. In cases where bilateral aps are required, the rst ap is
inset as mentioned above, the second ap is advanced
medially and de-epithelialized, and this is then closed in
a double-breasted fashion (Fig.23.4).
5. Two lateral suction drains are placed under the upper and
lower borders of the ap. The wound is closed in layers
with absorbable sutures.
Fig. 23.3 Medial edge of ap de-epithelialized to allow inset into pelvic cavity
Fig. 23.4 Closure of bilateral IGAPs
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