Autologous reconstruction satisfies the plastic surgery dictum “replace like with like” to create a breast with a natural appearance and feel. The use of a patient’s own tissue results in a reconstructed breast that improves with time as postoperative swelling subsides, scars fade, gravity pulls naturally on the tissue, and nerves and blood vessels grow into the transferred tissue. Sensation can develop in the reconstructed breast as sensory nerves grow into the transferred tissue (1) and/or with direct coaptation of sensory nerves (2). The abdomen is our first choice of donor tissue for breast reconstruction. However, gluteal tissue is an excellent alternative for patients who are not a candidate for an abdominal flap breast reconstruction.

Fujino et al. were the first to use the gluteal area, in the form of a myocutaneous free flap, to reconstruct a breast in 1975 (3). The gluteus maximus myocutaneous flap for breast reconstruction was further developed and popularized by Shaw in 1983 (4). In 1993, Koshima et al. were the first to describe local transposition of gluteal flaps, based on perforating vessels without the underlying gluteus muscle, to heal sacral decubitus wounds (5). Allen and Tucker first described the use of free gluteal artery perforator flaps to transfer gluteal tissue without sacrificing the gluteus muscle for breast reconstruction in 1995 (6).

Determining whether a patient is a candidate for gluteal artery perforator flap breast reconstruction begins with a preoperative consultation that includes a focused history and physical. Common indications for gluteal flap breast reconstruction are insufficient abdominal tissue, prior abdominoplasty, extensive abdominal liposuction, failed abdominal flap, and patient preference. The buttock is a natural area of fat deposition in everyone and can usually be used to make reasonable-sized breasts in even the most athletic patient. Liposuction is considered a contraindication to perforator flap surgery because it can disrupt the fine vascular connections at the capillary level. If the area of liposuction was confined to only a portion of the buttock, sometimes a gluteal flap can be designed on a vessel in the nonoperated area. Copies of previous operative reports and preoperative imaging can be helpful in this regard (7).

A 10-year review of perforator flap breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps clearly showed that chemotherapy, abdominal scars, diabetes, and advanced age alone did not affect the surgical outcome of perforator flap breast reconstruction (8). The results of this study are also applicable to gluteal perforator flap breast reconstruction. Obesity increases wound-healing complications but is not a contraindication if the patient understands the risks. However, morbid obesity is a contraindication because of increased pulmonary complications. Smoking is a contraindication to all flap procedures, and we recommend to patients a 3-month period of abstinence from tobacco, but this period can be shortened in select cases. Radiation can cause fibrosis and damage to any type of breast reconstruction. We recommend postponing breast reconstruction until 6 months after radiation is completed. Hypertension can be associated with increased complications, and we recommend medical consultation for good blood pressure control before surgery. Hematologic disturbances in a patient’s clotting cascade require consultation with a hematologist for advice on perioperative management strategies and close follow-up in the postoperative period and may not be a contraindication.

Gluteal tissue can be harvested from the superior or inferior portions of the buttock and are usually based on branches from the superior or inferior gluteal artery, respectively. Occasionally, we have based gluteal flaps on branches from the lumbar artery and deep femoral artery. Gluteal artery perforator (GAP) flaps are nourished by arteries that “perforate” through the gluteal muscles and are harvested with preservation of the muscle and function (6,9,10). The superior gluteal artery exits the pelvis superior to the piriformis muscle, and its branches perforate through the gluteus maximus and gluteus medius muscles. The superior gluteal artery perforators are located in a large zone extending along the superior two thirds of a line from the posterior superior iliac spine to the greater trochanter (11). The inferior gluteal artery exits the pelvis inferior to the piriformis muscle, and its branches perforate through the gluteus maximus muscle (10,11). The inferior gluteal artery perforators are located in a large zone extending along the middle third of the lower buttock (11).

The decision to choose a superior or inferior gluteal flap is based on each patient’s preference and anatomy. A patient’s preference toward a superior or inferior flap is influenced by the tradeoffs of each gluteal flap procedure. The scar from a
superior gluteal flap can be covered by a bathing suit, but the scar is located in a more prominent position on the buttock. In addition, harvesting a superior gluteal flap can disturb the superior fullness of the buttock, which is considered the aesthetic unit of the buttock. The scar from an inferior gluteal flap can be located in a less prominent area of the buttock in the inferior gluteal crease, but the lateral portion of the scar can be visible in a bathing suit, and sometimes the inferior gluteal crease can be shifted cephalad or caudal. Harvesting an inferior gluteal flap removes the “saddle bags,” commonly an area of abundant fat deposition in women, and does not disturb the aesthetic unit of the buttock (10). Contrary to what we previously published, the sciatic nerve has never been injured with an inferior gluteal flap and is never exposed during dissection of the flap (9). Rarely, temporary paresthesias can occur if the posterior femoral cutaneous nerve is stretched during harvest of an inferior gluteal flap (12).

Anatomic considerations on the decision to choose a superior or inferior gluteal flap are based on a patient’s distribution of fat on the buttock and location of the most favorable vessels in the buttock. Cross-sectional preoperative gluteal imaging with intravenous contrast has been immensely helpful with the latter. We use magnetic resonance imaging angiography (MRA) preoperatively to view the gluteal vessels because of the lack of radiation exposure and iodinated contrast. Table 66.1 gives the characteristics of large gluteal vessels identified in 32 buttocks on MRA. Of the gluteal vessels large enough to support a flap, 57% originated from the superior gluteal artery and 35% from the inferior gluteal artery. An average of 3 (range 1 to 5) large vessels branched from the superior gluteal artery, and an average of 2 (range 0 to 7) large vessels branched from the inferior gluteal artery. On occasion, we have switched the preoperative plan from a superior gluteal flap to an inferior gluteal flap, and vice versa, based on the lack of a large vessel in the planned donor site.

We request patients to stop taking all herbal supplements, aspirin, and nonsteroidal anti-inflammatory drugs 2 weeks before the procedure. We only recently developed an MRA protocol for high-resolution imaging of gluteal artery perforating vessels, but already MRA has been of enormous benefit for us. Preoperatively, all surgical candidates for perforator flap breast reconstruction are imaged with MRA. The radiologist identifies the diameter, course, and location of all large gluteal vessels. The locations of the vessels at the fascia level are determined at a perpendicular point on the skin surface in relation to a marker placed on the superior point of the gluteal crease on an x, y axis. X denotes the distance in centimeters left or right from the marker. Y denotes the distance in centimeters above or below the marker. The x, y measurements are taken along the curved surface of the buttock skin using three-dimensional (3D) reconstructed MRA images of patients in the prone position. Figure 66.1 demonstrates an example of how location measurements are determined of an identified gluteal artery perforator on an MRA.

From the radiology report and MRA images, we choose the optimal vessels on each buttock. We consider the foremost factors in determining the optimal vessel on which to base a flap in order of importance to be vessel diameter, length of pedicle, location at which a vessel enters the planned flap, and vessel arborization pattern within the subcutaneous fat. In this regard, a larger vessel diameter, pedicle of sufficient length for insetting, central location of the vessel on the flap, and a pattern of arborization that suggests perfusion of the tissue to be transferred are all considered favorable. Vessels located laterally on the buttock produce longer pedicles, but if a vessel is located too laterally, it will be at the edge of the designed flap. An ideal vessel for insetting is one that will produce a pedicle length of between 8 and 10 cm. Special consideration in the selection of vessels is taken with bilateral gluteal flap procedures. To create symmetric scars on the buttock, we try to select vessels that are located at a similar position on each buttock.

The course of a vessel is a secondary factor that influences vessel selection. If two vessels appear to be of similar size and both have equivalent vascular arborization patterns within the subcutaneous fat of the planned flap, then the vessel that can be dissected more easily or with the least trauma to the muscle is selected. Provided there is adequate length for insetting, a perforator with a more direct intramuscular course is favored because the dissection is usually technically easier, proceeds more quickly, and reduces trauma to the gluteal muscle. A septocutaneous branch of the superior gluteal artery, which travels around the gluteus muscles or between the gluteus maximus and medius muscles, may also be advantageous. However, sometimes the dissection can be tedious with gluteal septocutaneous vessels that are enveloped by thick fascia (e.g., deep femoral artery branches).