BREAST
Introducing the Septocutaneous Gluteal Artery
Perforator Flap: A Simplified Approach to
Microsurgical Breast Reconstruction
Stefania Tuinder, M.D.
Constance M. Chen, M.D.,
M.P.H.
Marga F. Massey, M.D.
Robert J. Allen, Sr., M.D.
Rene Van Der Huist, M.D.
Maastricht, The Netherlands; New York,
N.Y.; and Charleston, S.C.

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. (Plast. Reconstr. Surg. 127: 489, 2011.)

I

n 1975, breast reconstruction entered a new era
when microsurgical techniques were first used
to create a breast mound in a patient with Poland syndrome.1 The landmark case, reported by
Fujino et al., was performed successfully by using
a gluteus maximus myocutaneous flap. The following year, the same team again reported using
a gluteus maximus myocutaneous flap to perform
the first microsurgical breast reconstruction in a
patient after a mastectomy.2 The gluteus maximus
myocutaneous free flap went on to undergo mulFrom the Department of Plastic and Reconstructive Surgery,
University Hospital Maastricht; the Institute of Reconstructive Plastic Surgery, New York University Medical Center;
and the Center for Microsurgical Breast Reconstruction.
Received for publication March 12, 2010; accepted July 15,
2010.
Copyright ©2011 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181fed4d6

tiple modifications in its use for breast reconstruction, most notably by Shaw in 1983.3–7 At the same
time, however, breast reconstruction was further
transformed by the use of the abdomen as a donor
site, which provided the surgeon with tissue that
was easier and more convenient to use.8 –10 In comparison with the abdomen, it became evident that
the buttock as a donor site had multiple disadvantages, most notably a short vascular pedicle, a
deforming donor-site defect, and the long operative time that was needed to reposition the patient for harvest and inset.
Not until 1995 were the first two problems
with the gluteal flap solved by Allen, who intro-

Disclosure: The authors have no financial interest
or commercial associations with regard to information presented in this article.

www.PRSJournal.com

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Plastic and Reconstructive Surgery • February 2011
duced the superior gluteal artery perforator
(S-GAP) flap.11,12 As a muscle-sparing method of
microsurgical breast reconstruction, the S-GAP
flap was significant for preserving the gluteus
maximus muscle at the donor site and leaving a
longer vascular pedicle with the flap. The technique essentially eliminated the donor-site deformity and made the microsurgical anastomosis and flap inset much more straightforward.
The improvements seen in the S-GAP flap led to
the development of the inferior gluteal artery
perforator (I-GAP) flap.13,14 With the establishment of the S-GAP and I-GAP flaps, the buttock
became a much more viable donor site for microvascular breast reconstruction.
Today, many critics of the S-GAP or I-GAP superior flap voice skepticism about the meticulous
intramuscular dissection of the perforators to the
vascular pedicle. The dissection must be carried out
all the way to the superior or inferior gluteal vessels
to harvest a donor artery with favorable size match
characteristics.15 At this level, the vein is usually 2 to
3 mm, a factor that has become less important now
that vascular coupling devices have entered routine
use. To address the concerns of skeptics, preoperative imaging with magnetic resonance angiography
and computed tomographic angiography has allowed us to define the intramuscular course of the
perforators before flap elevation.16 –20 This has allowed us to quickly and accurately identify the size,
location, and route of target perforators before the
operative procedure.
To further simplify the use of gluteal flaps for
microsurgical breast reconstruction, we have recently published an anatomical study demonstrating
the consistent presence of septocutaneous perforators between the gluteus maximus and medius
muscles.21 These septocutaneous perforators originate from the superior gluteal artery and are not
usually included in a conventional S-GAP flap
design.21 The existence of these septocutaneous perforators obviates the need for any intramuscular dissection when elevating the S-GAP or I-GAP flap. We
have named this simplified gluteal artery perforator
flap the septocutaneous gluteal artery perforator (scGAP) flap. In this study, we present our experience
with the sc-GAP flap for microsurgical breast reconstruction. We have found the sc-GAP flap to be
straightforward to use, and we introduce it as a simplified approach to gluteal artery perforator flaps for
microsurgical breast reconstruction.

PATIENTS AND METHODS
This was a retrospective review of 11 consecutive sc-GAP flaps performed for postmastectomy

490

breast reconstruction in nine patients between
February and July of 2008 at three institutions in
Maastricht, The Netherlands; Charleston, South
Carolina; and New York, New York. A detailed
chart review was performed for each patient. We
evaluated patient demographics, perforator characteristics, operative technique, operative time,
length of hospital stay, and outcome. Risk factors
analyzed included age, body mass index, smoking
status, timing of reconstruction, and vessel size.
Information was compiled regarding the incidence of intraoperative and postoperative flap
complications. Preoperative imaging was used for
all patients.
Operative Technique
All candidates for a breast reconstruction from
the gluteal region underwent preoperative imaging before surgery. In 75 percent of the cases, an
acceptable septocutaneous gluteal perforator was
identified, and for all these patients, a plan for an
sc-GAP flap was made. Preoperative markings consist of an elliptical skin island centered on one
perforator within the ipsilateral gluteal region,
with marks above the margin of the gluteus maximus muscle (Fig. 1). On average, the perforator is
located 12.9 cm from the midline (range, 9.6 to 16
cm) and 5.1 cm from the iliac crest (range, 3.4 to
11 cm). The design of the skin island is more
cephalad and lateral than that used in a conventional musculocutaneous S-GAP flap (Fig. 2). In
cases of primary reconstruction, the oncologic surgeon performs the mastectomy, after which the
reconstructive surgeon prepares the recipient vessels. The patient is then flipped to the prone position to elevate the gluteal artery perforator flap.
In cases of secondary reconstruction, patients are
placed in the prone position at the start of the
procedure for flap harvest.
Dissection starts from the cephalad side of the
skin island and continues caudally until the margin of the gluteus maximus muscle is identified
and the fascia incised (Fig. 3). The key point of the
dissection is the identification of the superior margin of the gluteus maximus. Once the superior
edge of the gluteus maximus is identified and the
fascia incised, the septocutaneous perforator(s)
may be palpated at the inferior edge of the gluteus
maximus. The plane between the gluteus maximus and medius muscles is very loose, and if the
surgeon puts his or her finger in this plane, it can
be moved and the pulsation of the perforators
running in the same plane can be felt. A small cuff
of fascia around the perforator can be included in

Volume 127, Number 2 • Microsurgical Breast Reconstruction

Fig. 1. Drawings show the relationship of the septocutaneous gluteal artery
perforator (Sc-GAP) to the tensor fasciae latae muscle (TFL), the gluteus maximus muscle (G. Max.), and the gluteus medius muscle (G. Med.). (Left) Frontal
view; (right) lateral view.

Fig. 2. Preoperative markings for the septocutaneous gluteal artery perforator flap (right) consist of an elliptical skin island centered
on one perforator within the ipsilateral gluteal region, with marks
cephalad to the margin of the gluteus maximus muscle. The design
of the septocutaneous gluteal artery perforator skin island is more
cephalad and lateral than that used in a conventional musculocutaneous superior gluteal artery perforator flap (left).

the flap (Fig. 4). The gluteus maximus and gluteus
medius are then separated to expose the septocutaneous perforator (Fig. 5). If more than one
septocutaneous perforator exists, all of them may

Fig. 3. Dissection starts from the cephalad side of the skin island
and continues caudally until the margin of the gluteus maximus
muscle and the perforators are identified and the fascia is incised.
G. Max., gluteus maximus muscle; G. Med., gluteus medius muscle; TFL, tensor fasciae latae; Perf., septocutaneous perforator
pedicle of the septocutaneous gluteal artery perforator.

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Plastic and Reconstructive Surgery • February 2011

Fig. 4. A small cuff of fascia around the perforator can be
included in the flap.
Fig. 6. Drawing depicts the dissection of septocutaneous perforators between the gluteus maximus and medius muscle until
the superior gluteal artery. Sc-GAP, septocutaneous gluteal artery perforator; G. Max, gluteus maximus muscle; G. Med., gluteus
medius muscle; TFL, tensor fasciae latae muscle; Perf., septocutaneous perforator pedicle of the septocutaneous gluteal artery
perforator; SGA, superior gluteal artery.

Fig. 5. The septocutaneous perforator is identified between the
gluteus maximus and the gluteus medius.

be preserved if possible; otherwise, the most lateral one may be preserved and dissected underneath the gluteus maximus to the origin of the
superior gluteal artery (Figs. 6 and 7). Once the
vessels are identified and the flap is harvested,
the donor site is closed primarily. The patient is
then turned supine for inset. In this series, the
internal mammary artery and vein were used for
the microsurgical anastomoses in all patients.

RESULTS
From February to July of 2008, 11 consecutive
sc-GAP flaps were performed for postmastectomy
breast reconstruction in nine patients. Mean patient age was 52 years (range, 44 to 60 years). Mean
body mass index was 22.2 (range, 17.2 to 29.1).
One patient was a smoker. All patients underwent
preoperative imaging. Of the nine patients, four
underwent computed tomographic angiography
(44 percent) and five underwent magnetic reso-

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Fig. 7. The septocutaneous perforator was dissected underneath the gluteus maximus to the origin of the superior gluteal artery.

nance angiography (56 percent). One patient underwent prophylactic mastectomy and bilateral scGAP reconstruction because of testing positive for
the BRCA2 gene (Fig. 8). Of the 11 sc-GAP flaps,
five were performed as immediate reconstruction
(45 percent) and six were performed as delayed
reconstruction (55 percent); seven were unilateral
(64 percent) and four were bilateral (36 percent);
six were from the right buttock (55 percent) and
five were from the left buttock (45 percent). The
buttock was selected as a donor site in 10 flaps

Volume 127, Number 2 • Microsurgical Breast Reconstruction

Fig. 8. One patient underwent prophylactic mastectomy and bilateral septocutaneous gluteal artery
perforator reconstruction because she tested positive for the BRCA2 gene. (Left) Preoperative view; (right)
postoperative view.

because of low body mass index and insufficient
abdominal adipose tissue above the rectus abdominis muscle (91 percent); one patient had undergone previous abdominal surgery (9 percent).
Patient and flap characteristics are listed in Table
1.
The mean operative time was 8.2 hours
(range, 6.5 to 11 hours). All patients stayed in the
hospital for 5 days. The mean pedicle length was
7.9 cm (range, 5 to 10 cm) and the mean flap
weight was 499 g (range, 360 to 640 g). Vessel size
ranged from 1.8 to 3 mm; 9-0 or 10-0 Ethilon
(Ethicon, Inc., Somerville, N.J.) was used for arterial anastomosis, and couplers were used for veTable 1. Patient and Flap Characteristics
Characteristic
No. of patients
Age, yr
Mean
Range
BMI
Mean
Range
Tobacco use
CT angiography
MR angiography
sc-GAP flaps (n ⫽ 11)
Immediate reconstruction
Delayed reconstruction
Unilateral sc-GAP
Bilateral sc-GAP
Right sc-GAP
Left sc-GAP
Internal mammary recipient

nous anastomosis. When two or more septal perforators were located, the branches were dissected
until they joined in the septum and followed until
they reached adequate pedicle length and caliber.
There were no flap losses. One intraoperative
complication occurred (9 percent) in which the
venous anastomosis had to be performed a second
time as a result of venous kinking. There was one
take-back because of arterial occlusion (9 percent), in which the arterial and venous anastomoses had to be redone. There was also one axillary
seroma (9 percent), one seroma at the gluteal
donor site (9 percent), and one hematoma at the
gluteal donor site (9 percent) that was aspirated in
the clinic. Major and minor complications are
summarized in Table 2.

Value (%)

DISCUSSION

9

Most microsurgeons who perform autologous
tissue breast reconstruction select the abdomen as
their first choice for the donor site. We agree with
this preference; we also prefer the abdomen as our

52
44–60
22.2
17.2–29.1
1 (9)
4 (44)
5 (55)
5 (45)
6 (55)
7 (64)
4 (36)
6 (55)
5 (45)
11 (100)

BMI, body mass index; CT, computed tomographic; MR, magnetic
resonance; sc-GAP, septocutaneous gluteal artery perforator.

Table 2. Complications
Complications
Total
Major
Flap loss
Take-back (arterial occlusion)
Intraoperative venous reoperation
Minor
Axillary seroma
Donor-site seroma
Donor-site hematoma

No. (%)
11
0 (0)
1 (9)
1 (9)
1 (9)
1 (9)
1 (9)

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Plastic and Reconstructive Surgery • February 2011
primary donor site for autologous tissue breast
reconstruction. Furthermore, our second-choice
donor site for microsurgical breast reconstruction
is the medial thigh. Like the abdomen, the medial
thigh donor site does not require positioning
changes during the operative procedure. The patient can remain supine for both flap harvest and
inset, which minimizes the anesthesia time for the
patient. Despite the advances that have been made
with the S-GAP and I-GAP flaps, the buttock remains our third-choice donor site for microsurgical breast reconstruction. Unlike the abdomen
and medial thigh, the buttock as a donor site for
microsurgical breast reconstruction requires positioning changes for flap harvest and inset. Furthermore, the intramuscular dissection of the gluteal artery perforator can be difficult, and a
significant size mismatch between the superior
gluteal artery and the internal mammary artery is
always a concern.
As microsurgeons, however, we are committed
to performing microsurgical breast reconstruction, and there are inevitably times when our first
two donor-site choices are unavailable. At this
time, our preference is to use the sc-GAP flap as
described in this series. We find the harvest of the
sc-GAP flap to be simpler and faster than a conventional S-GAP or I-GAP harvest, because the
intramuscular dissection is avoided. In addition,
when the most lateral septocutaneous perforator
is used, the pedicle is longer than a traditional
S-GAP or I-GAP flap. The septocutaneous perforator flap does have one potential drawback in that
the vessels are often surrounded by adipose tissue,
which can make the perforators appear stiffer
than conventional intramuscular vessels. We hypothesize that the less flexible vessels may make
the septocutaneous vessels more prone to kinking
than an intramuscular perforator.
As described in this series, the sc-GAP flap also
has other advantages. The skin island is positioned
higher and more lateral than in a conventional
S-GAP or I-GAP flap. Although the scar itself may
be more visible in low-cut pants or a bathing suit,
it is more easily camouflaged in other types of
clothing because the higher positioning minimizes contour changes in the buttock, particularly
with regard to projection (Fig. 9). This results in
a postoperative appearance that is comparable to
a gluteal lift: the contour of the gluteal region is
nice, but the infragluteal fold is a little bit higher
than the contralateral one. Finally, patients report
minimal pain at the donor site. Anecdotally, they
seem to ambulate and mobilize earlier than patients who undergo abdominal flap harvest.

494

Fig. 9. The higher donor-site scar minimizes contour changes in
the buttock, particularly with regard to projection.

The introduction of the sc-GAP flap has been
made possible by the improvement of preoperative
imaging techniques. Developments in radiographic
imaging have supported preoperative flap design
and planning. The ability to identify septocutaneous
perforators preoperatively has decreased the level of
difficulty for perforator flaps. Intraoperative flap elevation is now more predictable and straightforward, which makes dissection faster and easier. Hypothetically, easier perforator flap dissection should
also lead to a lower complication rate. We feel that
the sc-GAP flap is a viable technique for autologous
tissue breast reconstruction that may be easier to
master than the traditional S-GAP and I-GAP procedures. In conclusion, we recommend the sc-GAP
flap as a simple and reliable approach to gluteal
artery perforator flaps for microsurgical breast
reconstruction.
Stefania Tuinder, M.D.
Department of Plastic and Reconstructive Surgery
University Hospital Maastricht
Maastricht, The Netherlands
nervofaciale@yahoo.it

ACKNOWLEDGMENT

This work was supported by the Building Interdisciplinary Research Careers in Women’s Health
Scholars Program (National Institutes of Health grant
1K12HD43449-01).
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