Composite Superior Gluteal Artery Perforator Flaps for Unilateral Breast Reconstruction: A Case Report.

Autogenous breast reconstruction methods offer excellent esthetic outcomes with minimal donor-site morbidity. The technique of “stacking” abdominal flaps, or using both abdominal flaps to reconstruct a single breast, has been described as a way of creating a breast of adequate volume and projection in a patient with a thin abdomen.1,2 When the abdomen is not an option, either for the sake of volume inadequacy or previous surgical damage to the desired donor site, the superior gluteal artery perforator (SGAP) flapmay be considered. Although a single SGAP flap is typically adequate to provide volume in the thin patient, those with larger volumetric requirements may have inadequate donor tissue for satisfactory reconstruction with a single flap.3 In such cases, a composite of two independent SGAP flaps may provide adequate soft tissue to occupy the dimensions of the breast pocket and provide desired projection. We present a patient who desired unilateral muscle sparing autogenous reconstruction and had previously received full abdominoplasty. This healthy 64-year-old woman was diagnosedwith breast cancer 3 years before presentation and was treated at that time with right mastectomy and immediate implant reconstruction. She subsequently developed grade 4 capsular contracture creating marked breast asymmetry with significant discomfort. Her right inframammary fold was elevated and the breast footprint narrowed by contracture (►Fig. 1). When evaluating the patient for potential perforator flap donor sites, it was noted that she carried a small amount of adiposity in her gluteal region (►Fig. 2). It was determined that a single SGAP flapwould not provide the volume needed to achieve her desired postoperative breast size and shape. Therefore, we elected to use two independent SGAP flaps to reconstruct her right breast. In the operating room, the breast pocket was developed, widely releasing the scarified tissue and the implant/capsule were removed. The internal mammary artery and vein (IMA/ V) were accessed as recipient vessels. As planned before her procedure to ensure adequate vessel length for tension free inset of both SGAP flaps, the left deep inferior epigastric vessels were harvested for use as interposition grafts. These vessels were accessed through a portion of her previous abdominoplasty incision. The left-sided vessels were chosen to preserve maximum retrograde perfusion in the right internal mammary artery. The patient was transferred to prone position for harvest of the SGAP flaps. A preoperative computed tomography angiogram had been reviewed to identify the vascular pattern of the superior gluteal arterial system and the dominant perforators had been identified and marked on the patient with a handheld Doppler. The flaps were designed to place the vascular supply centrally within the base of the flap to ensure adequate perfusion and minimize fat necrosis. As previously described, it is our preference to design the flap much higher on the buttock than the conventional SGAP pattern to allow for the ultimate scar line to rest at the junction of the esthetic units of the lower back and upper buttock.2 Because bilateral flaps were used, individual flap harvest was not overly aggressive minimizing donor-site morbidity and preserving the buttock contour. After evaluating our mastectomy defect it was determined that to best fill the breast pocket, one flap would be used to reconstruct the inferior aspect of the breast and the other would be used to reconstruct the superior aspect. In this way, the flaps were not stacked, per se, but independently arranged in the breast pocket to create a composite that made efficient use of each flap’s volume. By briefly placing the flaps in the breast pocket before anastomosing them allowed us to determine the most appropriate vessel arrangement for revascularization. The flaps were deepithelized, and the graft vessels anastomosed to the retrograde IMA/V. The superior