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Inferior gluteal artery perforator flap breast reconstruction
The American Journal of Surgery (2008) 195, 651– 653
North Pacific Surgical Association
Inferior gluteal artery perforator flap breast reconstruction Kevin M. Beshlian, M.D.*, Keith T. Paige, M.D. Section of Plastic and Reconstructive Surgery, Virginia Mason Medical Center, Seattle, WA, USA KEYWORDS: Breast reconstruction; Gluteal; Free flap
Abstract 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. © 2008 Elsevier Inc. All rights reserved.
Autologous tissue breast reconstruction generally uses lower abdominal skin and subcutaneous fat, perfused by the deep or superficial inferior epigastric arteries. In the majority of patients, these methods provide sufficient tissue to create an aesthetic breast. In patients with an inadequate abdominal donor site, whether because of a thin body habitus or prior surgical procedures, alternative methods of autologous reconstruction are sought. These include the use of tissue from the back in the extended latissimus dorsi flap, flank tissue in the deep circumflex iliac artery (Reuben’s) flap, thigh tissue in tensor fascia lata, transverse gracilis and anterolateral thigh flaps, and gluteal tissue based on the superior and inferior gluteal arteries. The inferior gluteal artery myocutaneous flap for breast reconstruction was introduced by Paleta et al1 and Le* Corresponding author. Tel.: ⫹1-206-223-6751; fax: ⫹1-206-625-7259. E-mail address: [email protected] Manuscript received October 31, 2007; revised manuscript December 24, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.12.041
Quang.2 This method uses skin and fat from the lower buttock, and includes harvesting a portion of the gluteus maximus muscle. A criticism of this method is that the loss of soft-tissue protection over the sciatic nerve may result in chronic pain. Allen et al3 described harvest of gluteal tissue, but as a perforator flap without muscle harvest,4 and later placed the donor site scar in the lower buttock crease. The inferior gluteal artery perforator flap has become our first alternative for autologous breast reconstruction when an abdominal donor site is not suitable. This article summarizes our experience with this method.
Methods The records of all patients undergoing breast reconstruction based on the inferior gluteal artery performed at Virginia Mason Medical Center between July 2001 and March 2007 were reviewed. Data were collected retrospectively on
652
The American Journal of Surgery, Vol 195, No 5, May 2008
Table 1
Results of gluteal flap breast reconstructions
Flap Patient/ number side Age, y BMI
Cancer stage Radiation Timing
1
1/left
47
19.3
2 3 4 5 6
2/left 3/left 3/right 4/right 4/left
46 49
18.6 0 19.8 0
56
7 8 9 10
5/left 6/right 7/right 8/right
11 12 13
9/right 9/left 10/left
14 15 16 17 18 19
10/right 11/left 12/left 13/left 13/right 14/right
Operating room time, Hospital hours:minutes stay, d Complications
No
Primary
9:34
9
20.1 0 P
No No No No No
Primary Lack of tissue 5:35 Primary Lack of tissue 8:48 Primary 9:27 Secondary Abdominoplasty 12:09 Secondary 9:22
4 4 7 4 4
53 43 46 53
22.5 II 22.7 I 28.3 II 28.4 0
Yes No Yes No
Tertiary Tertiary Secondary Secondary
4 4 4 4
51
21.8
II P 24.3 I
Yes No Yes
Secondary Lack of tissue Secondary Tertiary Patient choice
8:20 9:01 8:35
4 4 4
II 29.3 III 23.2 0 21.5 I P 19.4 0
Yes Yes No Yes Yes No
Primary Secondary Secondary Secondary Primary Secondary
8:51 7:31 8:45 8:45 8:31 7:50
4 4 4 3 3 3
36
61 54 42 46
I
Indication Lack of tissue
Lack of tissue 15:00 Lack of tissue 9:40 Abdominoplasty 13:00 Abdominoplasty 5:42
Abdominoplasty Lack of tissue Lack of tissue Lack of tissue
Donor site seroma None None Thrombocytosis None Donor dehiscence Flap loss None Flap loss Donor site seroma None None Donor and breast seroma Breast seroma None Breast seroma None Breast seroma Delayed healing of donor site
P ⫽ prophylactic.
patients who underwent surgery before December 2006, and prospectively thereafter. Our Institutional Review Board approved this study. Patient information recorded included body mass index (BMI), cancer stage and treatment, indications for use of gluteal tissue, and timing of reconstruction. Surgical data included choice of recipient vessels, use of vein grafts, and duration of surgery. Postoperatively, length of hospitalization and complications were recorded.
Results Nineteen reconstructions were performed on 14 patients (4 bilateral reconstructions). Our findings are summarized in Table 1. The average patient age was 49 years, with an early stage breast cancer. The most common indication for the use of a gluteal flap was a low BMI, and consequently minimal redundant skin and fat in the lower abdomen. A typical patient is illustrated in Fig. 1. Reconstruction was performed most frequently as a secondary procedure after healing of the mastectomy site, followed by primary reconstruction performed at or near the time of mastectomy, and tertiary reconstruction performed after failure of a prior method. The surgical time averaged 9 hours and 7 minutes. In contrast to this long mean surgical time, hospitalization was brief, averaging 4 days, and 7 or more days in only 2 patients.
Complications were frequent, with 8 of 19 (42%) procedures associated with a healing complication, including seromas, delayed healing, and wound dehiscence. In general, these wound complications were minor, and were treated expectantly with percutaneous drainage and local wound care. Two patients required a second surgery to achieve wound healing. Two cases resulted in complete flap failure. Both patients were irradiated previously, one had a prior failed implant reconstruction. In both of these cases, vein grafts were used in attempts to salvage the flaps after primary revascularization failed).
Comments The first 4 flaps included harvest of a small (approximately 2 ⫻ 2 cm) cuff of muscle surrounding the perforating vessels. All subsequent flaps were developed as perforator flaps with no muscle harvest. In these same 4 flaps, the thoracodorsal artery and its associated vena comitantes were chosen as recipient vessels, a reflection of our usual protocol for free-flap breast reconstruction at that time. In all subsequent flaps, the internal mammary vessels were used. The long surgical time for these cases is a product of numerous factors, and includes a positioning change from lateral (for flap harvest and recipient site preparation), to supine (for microvascular anastomoses and insetting). The
K.M. Beshlian and K.T. Paige
Inferior gluteal artery perforator flap
653
longest surgical times occurred early in our series, and included 2 very lengthy cases with complete flap failure, reflecting repeated unsuccessful attempts to establish flow. In the last 10 procedures, with no flap failures, the average surgical time was 8 hours and 10 minutes, versus 10 hours and 17 minutes for the first 9 procedures. The most significant complication was 2 complete flap failures. In both of these cases, vein grafts were used in attempts to create patent arterial anastomoses after primary revascularization failed. Both flaps failed intraoperatively; there were no returns to the operating room for arterial or venous thrombosis. Aesthetic outcomes and patient satisfaction were not examined specifically in this study. Our impression is that most patients were very satisfied with the result of their reconstruction (Figs. 1 and 2). We believe this method is better suited to patients with a low BMI versus patients with a higher BMI. In the latter group, the reconstructed breasts were not always proportionate to the patient’s body habitus. In addition, we noted greater difficulty correcting infracla-
Figure 2 (A) Preoperative and (B) postoperative photographs of bilateral flap donor sites, illustrating placement of the scar in the inferior gluteal crease.
vicular tissue defects with the gluteal flaps than with abdominal flaps, a consequence of the more fibrous nature of the gluteal fat. We believe this study shows that inferior gluteal artery perforator flaps represent a useful method of autologous breast reconstruction in patients with inadequate abdominal donor tissue. Complications, although frequent, usually are self-limiting.
References
Figure 1 (A) Preoperative and (B) postoperative photographs of a patient with inferior gluteal artery perforator flap breast reconstruction, before nipple reconstruction.
1. Paleta CE, Bostwick J III, Nahai F. The inferior gluteal free flap in breast reconstruction. Plast Reconstr Surg 1989;84:875– 83. 2. Le-Quang C. Secondary microsurgical reconstruction of the breast and free inferior gluteal flap. Ann Chir Plast Esthet 1992;37:723– 41. 3. Allen RJ, Levine JL, Graznow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006;118:333–9. 4. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Ann Plast Surg 2004;52:118 –25.
North Pacific Surgical Association
Inferior gluteal artery perforator flap breast reconstruction Kevin M. Beshlian, M.D.*, Keith T. Paige, M.D. Section of Plastic and Reconstructive Surgery, Virginia Mason Medical Center, Seattle, WA, USA KEYWORDS: Breast reconstruction; Gluteal; Free flap
Abstract 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. © 2008 Elsevier Inc. All rights reserved.
Autologous tissue breast reconstruction generally uses lower abdominal skin and subcutaneous fat, perfused by the deep or superficial inferior epigastric arteries. In the majority of patients, these methods provide sufficient tissue to create an aesthetic breast. In patients with an inadequate abdominal donor site, whether because of a thin body habitus or prior surgical procedures, alternative methods of autologous reconstruction are sought. These include the use of tissue from the back in the extended latissimus dorsi flap, flank tissue in the deep circumflex iliac artery (Reuben’s) flap, thigh tissue in tensor fascia lata, transverse gracilis and anterolateral thigh flaps, and gluteal tissue based on the superior and inferior gluteal arteries. The inferior gluteal artery myocutaneous flap for breast reconstruction was introduced by Paleta et al1 and Le* Corresponding author. Tel.: ⫹1-206-223-6751; fax: ⫹1-206-625-7259. E-mail address: [email protected] Manuscript received October 31, 2007; revised manuscript December 24, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.12.041
Quang.2 This method uses skin and fat from the lower buttock, and includes harvesting a portion of the gluteus maximus muscle. A criticism of this method is that the loss of soft-tissue protection over the sciatic nerve may result in chronic pain. Allen et al3 described harvest of gluteal tissue, but as a perforator flap without muscle harvest,4 and later placed the donor site scar in the lower buttock crease. The inferior gluteal artery perforator flap has become our first alternative for autologous breast reconstruction when an abdominal donor site is not suitable. This article summarizes our experience with this method.
Methods The records of all patients undergoing breast reconstruction based on the inferior gluteal artery performed at Virginia Mason Medical Center between July 2001 and March 2007 were reviewed. Data were collected retrospectively on
652
The American Journal of Surgery, Vol 195, No 5, May 2008
Table 1
Results of gluteal flap breast reconstructions
Flap Patient/ number side Age, y BMI
Cancer stage Radiation Timing
1
1/left
47
19.3
2 3 4 5 6
2/left 3/left 3/right 4/right 4/left
46 49
18.6 0 19.8 0
56
7 8 9 10
5/left 6/right 7/right 8/right
11 12 13
9/right 9/left 10/left
14 15 16 17 18 19
10/right 11/left 12/left 13/left 13/right 14/right
Operating room time, Hospital hours:minutes stay, d Complications
No
Primary
9:34
9
20.1 0 P
No No No No No
Primary Lack of tissue 5:35 Primary Lack of tissue 8:48 Primary 9:27 Secondary Abdominoplasty 12:09 Secondary 9:22
4 4 7 4 4
53 43 46 53
22.5 II 22.7 I 28.3 II 28.4 0
Yes No Yes No
Tertiary Tertiary Secondary Secondary
4 4 4 4
51
21.8
II P 24.3 I
Yes No Yes
Secondary Lack of tissue Secondary Tertiary Patient choice
8:20 9:01 8:35
4 4 4
II 29.3 III 23.2 0 21.5 I P 19.4 0
Yes Yes No Yes Yes No
Primary Secondary Secondary Secondary Primary Secondary
8:51 7:31 8:45 8:45 8:31 7:50
4 4 4 3 3 3
36
61 54 42 46
I
Indication Lack of tissue
Lack of tissue 15:00 Lack of tissue 9:40 Abdominoplasty 13:00 Abdominoplasty 5:42
Abdominoplasty Lack of tissue Lack of tissue Lack of tissue
Donor site seroma None None Thrombocytosis None Donor dehiscence Flap loss None Flap loss Donor site seroma None None Donor and breast seroma Breast seroma None Breast seroma None Breast seroma Delayed healing of donor site
P ⫽ prophylactic.
patients who underwent surgery before December 2006, and prospectively thereafter. Our Institutional Review Board approved this study. Patient information recorded included body mass index (BMI), cancer stage and treatment, indications for use of gluteal tissue, and timing of reconstruction. Surgical data included choice of recipient vessels, use of vein grafts, and duration of surgery. Postoperatively, length of hospitalization and complications were recorded.
Results Nineteen reconstructions were performed on 14 patients (4 bilateral reconstructions). Our findings are summarized in Table 1. The average patient age was 49 years, with an early stage breast cancer. The most common indication for the use of a gluteal flap was a low BMI, and consequently minimal redundant skin and fat in the lower abdomen. A typical patient is illustrated in Fig. 1. Reconstruction was performed most frequently as a secondary procedure after healing of the mastectomy site, followed by primary reconstruction performed at or near the time of mastectomy, and tertiary reconstruction performed after failure of a prior method. The surgical time averaged 9 hours and 7 minutes. In contrast to this long mean surgical time, hospitalization was brief, averaging 4 days, and 7 or more days in only 2 patients.
Complications were frequent, with 8 of 19 (42%) procedures associated with a healing complication, including seromas, delayed healing, and wound dehiscence. In general, these wound complications were minor, and were treated expectantly with percutaneous drainage and local wound care. Two patients required a second surgery to achieve wound healing. Two cases resulted in complete flap failure. Both patients were irradiated previously, one had a prior failed implant reconstruction. In both of these cases, vein grafts were used in attempts to salvage the flaps after primary revascularization failed).
Comments The first 4 flaps included harvest of a small (approximately 2 ⫻ 2 cm) cuff of muscle surrounding the perforating vessels. All subsequent flaps were developed as perforator flaps with no muscle harvest. In these same 4 flaps, the thoracodorsal artery and its associated vena comitantes were chosen as recipient vessels, a reflection of our usual protocol for free-flap breast reconstruction at that time. In all subsequent flaps, the internal mammary vessels were used. The long surgical time for these cases is a product of numerous factors, and includes a positioning change from lateral (for flap harvest and recipient site preparation), to supine (for microvascular anastomoses and insetting). The
K.M. Beshlian and K.T. Paige
Inferior gluteal artery perforator flap
653
longest surgical times occurred early in our series, and included 2 very lengthy cases with complete flap failure, reflecting repeated unsuccessful attempts to establish flow. In the last 10 procedures, with no flap failures, the average surgical time was 8 hours and 10 minutes, versus 10 hours and 17 minutes for the first 9 procedures. The most significant complication was 2 complete flap failures. In both of these cases, vein grafts were used in attempts to create patent arterial anastomoses after primary revascularization failed. Both flaps failed intraoperatively; there were no returns to the operating room for arterial or venous thrombosis. Aesthetic outcomes and patient satisfaction were not examined specifically in this study. Our impression is that most patients were very satisfied with the result of their reconstruction (Figs. 1 and 2). We believe this method is better suited to patients with a low BMI versus patients with a higher BMI. In the latter group, the reconstructed breasts were not always proportionate to the patient’s body habitus. In addition, we noted greater difficulty correcting infracla-
Figure 2 (A) Preoperative and (B) postoperative photographs of bilateral flap donor sites, illustrating placement of the scar in the inferior gluteal crease.
vicular tissue defects with the gluteal flaps than with abdominal flaps, a consequence of the more fibrous nature of the gluteal fat. We believe this study shows that inferior gluteal artery perforator flaps represent a useful method of autologous breast reconstruction in patients with inadequate abdominal donor tissue. Complications, although frequent, usually are self-limiting.
References
Figure 1 (A) Preoperative and (B) postoperative photographs of a patient with inferior gluteal artery perforator flap breast reconstruction, before nipple reconstruction.
1. Paleta CE, Bostwick J III, Nahai F. The inferior gluteal free flap in breast reconstruction. Plast Reconstr Surg 1989;84:875– 83. 2. Le-Quang C. Secondary microsurgical reconstruction of the breast and free inferior gluteal flap. Ann Chir Plast Esthet 1992;37:723– 41. 3. Allen RJ, Levine JL, Graznow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006;118:333–9. 4. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Ann Plast Surg 2004;52:118 –25.