Septal perforators for an S-GAP flap: Preliminary study. DISCUSSION The S-GAP flap was initially popular to cover big defects in the lumbosacral region: still it is commonly used with the same purpose.10 In 1988 Allen and Tucker used this flap for the first time for breast reconstruction.3 Perforators usually used as pedicle for the S-GAP flap run through the gluteus maximus muscle (indirect perforators according to the “Gent consensus”).9 This preliminary study shows the presence of septal perforators originating from the anterior branch of the superficial branch of the superior gluteal artery: they run between the gluteus maximus and medius muscle. The “Gent consensus” on perforator flaps in 2003 clarified the definition of perforator flaps and underlined that direct and septal perforators are easier to identify and to dissect then indirect.9 According to our data all septal perforators for an S-GAP flap lie cranial from the mentioned line through the natal cleft (line B). As a consequence, to include septal perforators in an S-GAP flap the bounderies of the flap should be a little more cranial than conventionally (fig 4.9, number 1), that is above line B (fig 4.9, number 2). In addition we have to underline that in our study a number of septal perforators is situated laterally and therefore provides a long pedicle (range: 7.8 to 9.5 cm in the anatomical study): according to the anatomical study 40% (4/10) of the septal perforators is situated between 14 and 16 cm from line A and according to the Color Doppler study 26% (9/34). In our opinion these perforators are very suitable: in case of a pedicled flap the arc of rotation should be improved and in case of a free flap the pedicle of the flap should be anyway longer then in a usual S-GAP flap reducing problems for the anastomosis, when the recipient vessels are very deep or faraway from the defect. Data are not yet sufficient for a statistical analysis, but we think that the presence of septal perforators should be considered when an S-GAP flap has to be performed. The presence of septal perforator has to be tested preoperatively with a Color Doppler analysis. This preliminary study only wants to underline the presence of septal perforator in the gluteal region, a region where a lot of perforators are always present and an analysis of direct and indirect perforators has not yet been performed. A patient study will follow. 60
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