Fujino was the first to introduce gluteal tissue as a free flap for breast reconstruction. The use of the musculocutaneous flap from the buttock in breast reconstruction has been championed by Shaw. Despite the initial enthusiasm for this area as a donor site, few other large series exist on the subject. Two decades of experience with this region as a donor site led to recognition of advantages and drawbacks. Furthermore, use of both the superior and inferior gluteal musculocutaneous flap was associated with certain important donor site complications and the use of vein grafts to allow for microvascular anastomosis. The evolution of free tissue transfer has progressed to the level of the perforator flap. This reconstructive technique allows elevation of tissue from any region consisting only of fat and skin. This minimizes donor site morbidity by allowing preservation of the underlying muscle and coverage of important structures in the region such as nerves. The superior and inferior gluteal perforator flaps have been used at our institution for breast reconstruction since 1993. The superior gluteal artery perforator (S-GAP) flap is our preferred method of breast reconstruction when the abdomen is not available or preferable. We report the result of this flap over the past 9 years and point out important surgical refinements, advantages, disadvantages, and lessons learned during this time.

Bilateral prophylactic mastectomy can reduce the incidence of breast cancer by 87 to 93% in high-risk individuals and is an appealing option for many patients if reconstruction can be provided with acceptable morbidity and outstanding esthetic results. Autogenous breast reconstruction techniques have evolved over the last 20 years to meet this goal. Familiarity with the deep inferior epigastric perforator (DIEP) flap led us to carry out simultaneous bilateral breast reconstruction with acceptable morbidity and superior esthetic outcome in 3 patient groups: (1) after bilateral prophylactic mastectomy, (2) after therapeutic and contralateral prophylactic mastectomy, and (3) after explantation of bilateral implant failures. A retrospective review of our experience with 280 flaps in 140 patients was performed. Average operating times, including time for implant removal or mastectomy and reconstruction, was 7.3 hours. Average hospitalization was 3.9 days. Significant perioperative complications occurred in 9 patients (6.4%); all returned to the operating room. This included 7 microvascular complications, 1 hematoma, 1 seroma, and 1 DVT. Less significant complications were divided into early and late. The early complications included 1.8% partial flap necrosis, 4.2% abdominal apron necrosis greater than 5 cm2, 2.9% seromas that required intervention, and 5.7% partial breast flap dehiscence. Late complications included 12.5% fat necrosis of any size and 2.1% hernia formation. Smoking, obesity, age, history of chest wall radiation, and flap size were evaluated as risk factors for increased morbidity.

The superior gluteal artery perforator (SGAP) flap is a useful technique for restoration of the breast after mastectomy. If appropriately planned, the soft-tissue envelope supplied by the superior gluteal artery perforator vessels can be harvested with minimal donor site morbidity and often results in a highly esthetic restoration of the breasts. Dissection of the flap is performed with complete preservation of gluteus maximus muscle function. The resulting vascular pedicle obtained via dissection through the muscle is longer than that of gluteal musculocutaneous flaps and affords the surgeon the luxury of avoiding vein grafts in the anastomotic phase of surgery. Despite these advantages, use of the SGAP flap is not popular among reconstructive surgeons. Many practitioners are not familiar with the vascular anatomy of the gluteal area and may not be comfortable with the dissection of the parent vessels or lack the desire to practice microsurgery. On the other hand, our group has reported the largest experience to date with this method of breast reconstruction and has found the SGAP flap to be a reliable and safe method of autologous breast restoration in unilateral absence of the breast. Although the indications to perform single-stage gluteal tissue transplantation for bilateral breast restoration are uncommon, they do occasionally arise in clinical practice. We have carried out concurrent bilateral breast reconstruction using SGAP flaps on 6 patients with acceptable overall morbidity. All flaps went on to survive and resulted in highly esthetic restorations of the breast. Though a challenging undertaking, in-unison transfer of bilateral SGAP flaps serves as a useful option for a subset of patients desiring 1-stage bilateral breast reconstruction.

The subcutaneous temporal brow lift is an effective, reproducible, and inexpensive technique that can be performed safely under local anesthesia.