Septocutaneous gluteal artery perforator (sc-GAP) flap for breast reconstruction: how we do it PITFALLS -Do not consider suitable for surgery a perforator with a pedicle length measured on MRA less than 6 cm: the anastomosis with the mammary vessels will be very difficult. -Draw your patient in the exact same position as she will have during the operation (in our practice patients will have a pillow underneath the abdomen in the operative theatre): the skin of the gluteal region can move very easily with respect to the muscles because of the presence of a lot of subcutaneous tissue. A different position during drawing and operation can lead to a shift in the position of the septal plane and the perforator. -The identification of the septal plane between the gluteus maximus and medius muscles is essential: actually it is the key point of the dissection. -Lift the gluteus maximus muscle carefully because you can damage muscu- lar or musculocutaneous branches of the superficial branch of the SGA. -If a clear visualization of the perforator is not possible, the gluteus maximus can partially detached from his origin from the sacral bone and at the end be reattached. -To be sure to include the perforator, chosen with the MRA, the flap is oriented just cranial to the edge of the gluteus maximus muscle: getting more experienced in the exact identification of the perforator offers the opportunity to change the flap orientation to improve aesthetic results. Because of the large number of perforators in this area it is not difficult to identify one of them with a standard Doppler, but you still don’t know if it is a septocutaneous or a musculocutaneous one. The dissection especially will be very difficult when you accidentally have chosen a musculocutaneous perforator running into the gluteus medius muscles (see fig 6.3). -Septocutaneous perforators, compared to musculocutaneous ones, are surrounded by a greater amount of fat and connective tissue. Therefore they are more compact than musculocutaneous ones and, as a consequence, less flexible: the plastic surgeon has to pay more attention to maintain the original orientation of the pedicle to avoid torsion or kinking during positioning of the flap on the breast. The orientation can be maintained visually by marking the upper surface of the pedicle with ink. 106
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