Introducing the septocutaneous gluteal artery perforator flap: a simplified approach to microsurgical breast reconstruction.

BACKGROUND: Consistent septocutaneous perforators exist between the gluteus maximus and medius muscles. The existence of these septocutaneous perforators obviates the need for any intramuscular dissection when elevating a gluteal artery perforator flap. In this study, the authors present their experience with the septocutaneous gluteal artery perforator (sc-GAP) flap for microsurgical breast reconstruction. METHODS: The authors retrospectively reviewed 11 consecutive sc-GAP flaps performed for postmastectomy breast reconstruction in nine patients between February and July of 2008. Patient demographics, risk factors, perforator characteristics, operative technique, operative time, and outcome were analyzed. Preoperative imaging was used for all patients. RESULTS: Mean patient age was 52 years (range, 44 to 60 years). Mean body mass index was 22.2 (range, 17.2 to 29.1). Of the 11 flaps, five sc-GAP flaps were immediate (45 percent) and six were delayed reconstruction (55 percent); seven were unilateral (64 percent) and four were bilateral (36 percent). Mean operative time was 8.2 hours (range, 6.5 to 11 hours). All patients stayed in the hospital for 5 days. Mean pedicle length was 7.9 cm (range, 5 to 10 cm) and mean flap weight was 499 g (range, 360 to 640 g). Vessel size ranged from 1.8 to 3 mm. Complications included one take-back, one axillary seroma, one donor-site seroma, and one donor-site hematoma. There were no flap losses. CONCLUSIONS: The sc-GAP flap is a viable technique for microsurgical breast reconstruction that may be easier to master than traditional musculocutaneous gluteal artery perforator flap procedures. The authors recommend the sc-GAP flap as a simplified approach to gluteal artery perforator flaps for microsurgical breast reconstruction.

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions.

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

The effects of systemic phenylephrine and epinephrine on pedicle artery and microvascular perfusion in a pig model of myoadipocutaneous rotational flaps.

BACKGROUND: Anesthesiologists and reconstructive surgeons have differing views regarding the control of rotational flap perfusion. Anesthesiologists view the entire body as having flow that is dependent on systemic perfusion pressure, whereas plastic surgeons conjure that systemic administration of vasoactive agents causes vasoconstriction of the pedicle artery and the microvasculature. The aim of this study was to investigate the effects of systemically administered phenylephrine and epinephrine on rotational myocutaneous flap perfusion. METHODS: After institutional animal care and use committee approval, seven vertical rectus abdominal myocutaneous (VRAM) flaps were created in six pigs. Under 1.0 minimum alveolar concentration isoflurane anesthesia, pedicle artery blood flow (transit time flow probe) and microvascular perfusion (laser Doppler flow probe) were recorded at baseline and after achieving steady hemodynamics with the systemic intravenous administration of phenylephrine (20, 40, and 80 microg/minute) and epinephrine (0.5, 1, and 2 microg/kg/minute). RESULTS: Under stable physiologic conditions, phenylephrine consistently decreased the pedicle artery blood flow and the microvascular perfusion of porcine VRAM rotational flaps, whereas epinephrine consistently increased both flows across the entire dose range studied. Furthermore, epinephrine-induced increases in cardiac output correlated well with the observed increases in pedicle artery blood flow and microvascular perfusion. CONCLUSIONS: With the systemic delivery of phenylephrine, rotational myocutaneous flaps react in a manner described by the surgeon. In contrast, the anesthesiologist's model of the hemodynamics is correct for low to moderate doses of epinephrine. Therefore, epinephrine may be the vasoactive agent of choice for treating perioperative hypotension without harming the rotational flap blood flow.