Septocutaneous gluteal artery perforator (sc-GAP) flap for breast reconstruction: how we do it Actually, underneath the thin medial origin of the gluteus maximus muscle, it is very easy to develop in a blunt way a dissectional plane between the gluteus maximus and medius muscles and, introducing the finger into this plane, sometimes the pulsation of the perforator can be felt: this offers the opportunity to identify the exact location where the perforator emerges from the tight cranial fascial border between the gluteus maximus and medius muscles. The dissection continues in a retrograde way from medial to lateral, paying attention not to damage perforators emerging from the septum between the gluteus maximus and medius. The fascia of the gluteal muscles is very tight in this region and the approach of the septal plane between the gluteus maximus and medius is sometimes not easy: therefore this approach is a key point in the dissection. When the perforator(s) are identified the complete flap is incised and isolated. The dissection continues, lifting the gluteus maximus muscle (fig 6.14 A, B) with the aid of a light hook. When the muscle is very tight it is difficult to lift it enough. In that case the gluteus maximus can partially be dissected at its origin on the sacrum and later on be sutured back. The perforator is followed between the gluteus maximus and medius paying attention to ligate every muscular or musculocutaneous branch. In the intermuscular septal plane the perforators join the superficial branch of the SGA (see anatomy). Near the sacrum the perforator continues retrogradely, running deep from the gluteus medius to reach its origin at the SGA. There the caput medusae of veins is present. These veins have usually a caliber above the 3 mm and are very fragile, having a very thin wall. To avoid problems the dissection is finished just before the caput medusae. The flap is then removed from the gluteal region and the ischemia time starts. The donor site is closed, 2 drains are po- sitioned and the patient is turned in supine position. The anastomosis to the internal mammary (thoracic) vessels proceeds in the same way as for a DIEP flap. Some preoperative pictures (fig 6.15 A, B) and postoperative results (fig 6.16 A, B) are shown. 104
5. lay-out phd DEFINITIEF_digitaal2
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