Chapter 5 INTRODUCTION In 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 multiple 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 introduced 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. 65
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