Introducing the sc-GAP Flap: A New Approach to Microsurgical Breast Reconstruction To further simplify the use of gluteal flaps for microsurgical breast reconstruction, we have recently published an anatomical study demonstrating the consistent presence of septocutaneous perforators between the gluteus maximus and medius muscles.21 These septocutaneous perforators originate from the superior gluteal artery and are not usually included in a conventional S-GAP flap design.21 The existence of these septocutaneous perforators obviates the need for any intramuscular dissection when elevating the S-GAP or I-GAP flap. We have named this simplified gluteal artery perforator flap the septocutaneous gluteal artery perforator (sc-GAP) flap. In this study, we present our experience with the sc-GAP flap for microsurgical breast reconstruction. We have found the sc-GAP flap to be straightforward to use, and we introduce it as a simplified approach to gluteal artery perforator flaps for microsurgical breast reconstruction. PATIENTS AND METHODS This was a retrospective review of 11 consecutive sc-GAP flaps performed for postmastectomy breast reconstruction in nine patients between February and July of 2008 at three institutions in Maastricht, The Netherlands; Charleston, South Carolina; and New York, New York. A detailed chart review was performed for each patient. We evaluated patient demographics, perforator characteristics, operative technique, operative time, length of hospital stay, and outcome. Risk factors analyzed included age, body mass index, smoking status, timing of reconstruction, and vessel size. Information was compiled regarding the incidence of intra- operative and postoperative flap complications. Preoperative imaging was used for all patients. Operative Technique All candidates for a breast reconstruction from the gluteal region under- went preoperative imaging before surgery. In 75 percent of the cases, an acceptable septocutaneous gluteal perforator was identified, and for all these patients, a plan for an sc-GAP flap was made. Preoperative markings consist of an elliptical skin island centered on one perforator within the ipsilateral gluteal region, with marks above the margin of the gluteus maximus muscle (Fig. 5.1). On average, the perforator is located 12.9 cm from the midline (range, 9.6 to 16 cm) and 5.1 cm from the iliac crest (range, 3.4 to 11 cm). The design of the skin island is more cephalad and lateral than that used in a conventional musculocutaneous S-GAP flap (Fig. 5.2). 66
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