Septocutaneous gluteal artery perforator (sc-GAP) flap for breast reconstruction: how we do it (1c) Musculocutaneous perforators which finally reach the subcutis and skin, running through the gluteus maximus muscle. The superficial branch of the SGA anastomizes with branches of the inferior gluteal artery (IGA), the medial circumflex femoral artery and the lateral sacral artery. Comark and Lamberty17 also described a super- ficial branch using the septal connective tissue plane between the gluteus maximus and the gluteus medius to devide into a posterior, intermediate and anterior branch. Anterior end branches pierce the deep fascia in the supero- lateral edge of the gluteus maximus muscle to supply the (sub)cutis there (septocutaneous perforators, as mentioned above). (2) The deep branch of the SGA runs between the gluteus medius muscle and the posterior pelvic surface (gluteus minimus and piriformis muscles). It divides into a (2a) superior and an (2b) inferior division. (2a) The superior division supplies the gluteus medius muscle, continues obliquely along the upper border of the gluteus minimus and supplies also the latter. Finally it runs along the ASIS and anatomizes with the deep circumflex iliac artery and the ascending branch of the lateral circumflex femoral artery. (2b) The inferior division also runs obliquely between the gluteus medius and minimus muscles, supplies them both and, like the superior division, anato- mizes with the lateral circumflex femoral artery. One branch of the inferior division, in the trochanteric fossa, joins the inferior gluteal artery (IGA) and the ascending branch of the medial circumflex artery. Other branches pierce the gluteus minimus muscle into the deep, to supply the hip joint. The deep branch also gives of musculocutaneous perforator, reaching the skin through gluteus medius and maximus muscles. Those branches have to be excluded as pedicle for the S-GAP, because of the difficult dissection through the two muscles. At the point where the superficial and the deep branch of the SGA meet, near the opening cranial to the piriformis muscle, a venous network of large, fragile bloodvessels is present forming a caput medusae. Clinically the dissection always should stop before reaching this caput medusae. The inferior gluteal artery The inferior gluteal artery (IGA) is the larger terminal branch of the anterior trunk of the internal iliac artery. It descends anterior from the sacral plexus and the piriformis muscle, behind the internal pudendal artery. Inside the pelvis it supplies piriformis, pelvic floor, perianal fat and branches to the fundus of the bladder and to the seminal vesicles and the prostate. It leaves the greater sciatic foramen below the piriformis muscle, supplying gluteus maximus, obturator internus, gemelli, quadratus femoris and upper 92
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