Chapter 6 INTRODUCTION In 1976 the first free flap for breast reconstruction was reported bij Fujino: he used the gluteus maximus myocutaneous flap. A skin-fat-muscle flap, including the superior gluteal artery and veins, was dissected and anastomosed to the thoracoacromial artery and vein.1 In 1983 Shaw published a series of 10 patients undergoing the superior gluteal myocutanous free flap:2 technical refinements were added to the work of Fujino. Only in 1993 Allen introduced the superior gluteal artery perforator (S-GAP) flap for breast reconstruction.3 The pedicle of the flap was longer than that of the gluteus maximus myocutaneous flap because of the intramuscular dissection: as a consequence a vein graft was not necessary to perform the microanastomosis: moreover no muscle was sacrified giving less donor site morbidity. In 2010 LoTempio and Allen published a review of the latest 17 years with gluteal flaps:4 over the years the donor site is just improved, positioning the scar in the upper buttock superior from medial to lateral and beveling superior to reduce the contour deformity. Their experience showed a complication rate of 2% of flap loss. The improvement in technique and results is also due to the introduction of new technologies such as MRA (magnetic resonance angiography) en CTA (computed tomo- graphy angiography) supporting the identification of the best perforator. Within the first years of development of perforator flaps confusion arose about the nomenclature: for example the flap based on paraumbilical perforators, originating from the deep inferior epigastric artery, was called PUP (paraumbilical perforator flap) by Koshima5 and DIEP (deep inferior epigastric perforator) flap by Allen and Treece.6 Attempts were made to unify the perforator flap nomenclature: -In 2001, during the fifth international course on perforator flaps in Gent, Belgium.7 -The Canadian proposal, summarized in an article by Geddes et al.8 -The Asian microsurgical community proposal, with a tendency to use a more complex terminology.9 Discussion however is still open regarding the nomenclature of perforator flaps and the last proposal is published in 2010 by Sinna et al.10 In 2012 Taylor commented that with the advent of modern imaging techniques, the true subcutaneous course of a perforator has to be considered in the classification and in the flap design.11 Clinically it is really important to distinguish perforators running through the muscle (in this chapter indicated as musculocutaneous) and perforators running between two muscles (septocutaneous) because they have 83
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