Download Superior and inferior gluteal artery perforator flaps

RECONSTRUCTIVE
The Superior and Inferior Gluteal Artery
Perforator Flaps
Reza Ahmadzadeh, B.Sc.
Leonard Bergeron, M.D.,
C.M., M.Sc.
Maolin Tang, M.D.
Steven F. Morris, M.D., M.Sc.
Halifax, Nova Scotia, Canada
Background: Perforator flaps have allowed reconstruction of soft-tissue defects
throughout the body. The superior and inferior gluteal artery perforator flaps
have been used clinically, yet the published anatomical studies describing the
blood supply to the gluteal skin are inadequate. This study comprehensively
evaluated the anatomical basis of these flaps to present anatomical landmarks
to facilitate flap dissection.
Methods: In six fresh cadavers, the integument of the gluteal region was dissected. Cutaneous perforators of the superior and inferior gluteal arteries were
identified. Their course, size, location, and type (septocutaneous versus musculocutaneous) were recorded based on dissection, angiography, and photography. The surface areas of cutaneous territories and perforator zones were
measured and calculated.
Results: The average number of superior and inferior cutaneous perforators
greater than or equal to 0.5 mm in the gluteal region was 5 ⫾ 2 and 8 ⫾ 4,
respectively, with all of the superior and 99 percent of the inferior gluteal artery
perforators being musculocutaneous. Their average perforator internal diameter was 0.6 ⫾ 0.1 mm. The average superior and inferior gluteal artery cutaneous vascular territory was 69 ⫾ 56 cm2 and 177 ⫾ 38 cm2, respectively. The
superior gluteal perforators were found adjacent to the medial two-thirds of a
line drawn from the posterior superior iliac spine to the greater trochanter. The
inferior gluteal artery perforators were concentrated along a line in the middle
third of the gluteal region above the gluteal crease.
Conclusion: The reliable size and consistency of the superior and inferior
gluteal artery perforators allow the use of pedicled and free superior and inferior
gluteal artery perforator flaps in a variety of clinical situations. (Plast. Reconstr.
Surg. 120: 1551, 2007.)
O
ne of the main goals in reconstructive
surgery of soft-tissue defects is to replace
“like with like.” During the evolution of
flap design and transfer over the past 50 years,
surgeons have gradually improved the results of
reconstructive surgical procedures by selecting
the best flap for a specific reconstructive challenge. Perforator flaps have become well accepted
and are useful alternatives to historical reconstructive techniques.1 The musculocutaneous superior
and inferior gluteal artery flaps have been previously described and may have a role in certain
From the Departments of Anatomy and Neurobiology and
Surgery, Dalhousie University.
Received for publication December 13, 2005; accepted June
7, 2006.
Presented at the 51st Annual Meeting of the Research Council
of Plastic Surgery, in Dana Beach, California, May 20, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000282098.61498.ee
procedures. However, the sacrifice of muscle in the
region and the potentially difficult dissection have
limited their acceptance. The superior gluteal artery perforator (SGAP) and inferior gluteal artery
perforator (IGAP) flaps have been well described
clinically and are reliable flap procedures. A more
detailed description of the vascular anatomy will
aid surgeons in the customized design of perforator flaps in this region.2
Fujino et al.3 first used the gluteal region as a
donor site in 1975. Since then, gluteal flaps based
on the superior gluteal artery have advanced, as
shown in the works of Blondeel4 and Allen and
Tucker.5 The inferior gluteal artery free flap was
first reported by Le-Quang6 in 1979 and later was
used as a perforator flap by Higgins et al.7 in 2002.
Potential donor sites for breast reconstruction
are few. In the thin patient, the buttocks region
offers a substantial amount of soft tissue that can
be microsurgically transferred. Clinical works
have documented the use of the superior gluteal
www.PRSJournal.com
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Plastic and Reconstructive Surgery • November 2007
artery and the inferior gluteal artery musculocutaneous flaps. More recently, enthusiasm for perforator flaps has led to many reports of SGAP
and IGAP perforator flaps.4,7–9 Although the
SGAP flap has been extensively used, the IGAP
flap has been used less widely. There is a lack of
detailed anatomical information regarding the
location and properties of gluteal artery perforators, which has slowed the adoption of perforator flaps in the area. The goal of this study was
to objectively and comprehensively document
the surgical anatomy of the superior and inferior
gluteal artery perforator flaps with regard to vessel diameter, length, and cutaneous territory.
MATERIALS AND METHODS
Whole-body lead oxide and gelatin arterial injection studies were carried out in six fresh human
cadavers (12 specimens) using the technique described by Tang et al.10 For the purpose of this
study, the gluteal area is defined superiorly by the
iliac crest, inferiorly by the inferior gluteal fold,
laterally by the trochanter, and medially by the
midline. These landmarks were identified and the
integument was dissected. Cutaneous perforators
were labeled with radiopaque markers. Radiographs, photographs, and dissection notes were
used to document the dissection at each stage. By
means of angiography, photography, and dissection notes, the exact course and source artery of
individual perforators were described.
The length, diameter, type (musculocutaneous or septocutaneous), and source artery of each
perforator were identified. Vessel measurements
were obtained directly on the original angiogram.
The radiographs were assembled using Adobe
Photoshop CS (Adobe Systems, Inc., San Jose,
Calif.), and the cutaneous territories of specific
perforators were determined. The cutaneous vascular territory of a specific perforating cutaneous
blood vessel was defined as the region supplied by
a specific vessel between adjacent territories separated by choke anastomotic vessels. Scion Image
Beta 4.02 (Scion Corporation, Frederick, Md.) was
used to measure cutaneous vascular territories
and average perforator zones (the cutaneous territory of a single cutaneous perforator). Average
perforator zones were determined by dividing the
area of each vascular territory by the number of its
cutaneous perforators.
RESULTS
Regional Vascular Anatomy
The superior and inferior gluteal arteries are
both terminal branches of the internal iliac artery
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Fig. 1. Medial view of the left pelvic region of a human cadaver
injected with lead oxide and gelatin. The superior and inferior
gluteal arties are terminal branches of the internal iliac artery. 1,
external iliac artery; 2, internal iliac artery; 3, lateral sacral artery;
4, umbilical artery; 5, obturator nerve; 6, obturator artery; 7, superior gluteal artery; 8, inferior gluteal artery; 9, internal pudendal
artery; S1 through S4, anterior rami of sacral spinal nerves.
(Fig. 1). They both exit the pelvis through the
greater sciatic foramen. The superior gluteal artery passes superior to the piriformis muscle. It
then gives off a deep branch that runs laterally in
between the gluteus medius muscle and the iliac
bone. The superior gluteal artery enters the gluteus maximus muscle to supply its upper portion
and to send perforators to the overlying skin. The
inferior gluteal artery travels inferior to the piriformis muscle. It is accompanied by the internal
pudendal vessels, the pudendal nerve, the posterior femoral cutaneous nerve (posterior cutaneous nerve of the thigh), and the sciatic nerve. The
inferior gluteal artery supplies the lower half of the
gluteus maximus and also provides perforators to
the overlying gluteal skin. The descending branch
of the inferior gluteal artery, when present, accompanies the posterior femoral cutaneous nerve.
Local Vascular Anatomy
Both the superior and inferior gluteal arteries
are major contributors to the blood supply of the
skin in the gluteal region (Fig. 2). Other source
arteries such as the lumbar artery, deep circumflex
iliac artery, lateral sacral arteries, obturator artery,
internal pudendal artery, femoral artery, profunda femoris artery, and medial and lateral circumflex femoral arteries also contribute to the
blood supply of the gluteal region (Fig. 2). How-
Volume 120, Number 6 • Gluteal Artery Perforator Flaps
Table 1. Properties of the Superior and Inferior
Gluteal Arteries
Regional blood
supply
No. of cutaneous
perforators
Average perforator
size, mm
Cutaneous vascular
territory, cm2
Perforator zone, cm2
Fig. 2. Angiogram of the integument of the left side of the cadaver from the L3 level to the midthigh region, dissected after
medial incision. The gluteal region is outlined in red. Note that the
superior and inferior gluteal artery vascular territories occupy
most of the gluteal region. G, greater trochanter; P, posterior superior iliac spine; LA, lumbar artery; DCIA, deep circumflex iliac
artery; LSA, lateral sacral arteries; SGA, superior gluteal artery; IGA,
inferior gluteal artery; IPA, internal pudendal artery; LCFA, lateral
circumflex femoral artery; PFA, profunda femoris artery.
ever, the frequency of their contribution, their
cutaneous territory, and the number of their perforators in the region is minor when compared
with the major contribution of superior and inferior gluteal arteries.
On average, we found 5 ⫾ 2 cutaneous perforators arising from the superior gluteal artery
and 8 ⫾ 4 cutaneous perforators arising from the
inferior gluteal artery. All of the superior gluteal
artery perforators and 99 percent of the inferior
gluteal artery perforators were musculocutaneous. All of the inferior gluteal musculocutaneous
perforators and 50 percent of the superior gluteal
musculocutaneous perforators passed through
the gluteus maximus muscle, and the remaining
50 percent of the superior gluteal musculocutaneous perforators passed through the gluteus medius muscle. The average diameter of the perforators arising from the superior and inferior
gluteal artery was similar at 0.6 ⫾ 0.1 mm.
The average pedicle length from the deep fascia was 23 ⫾ 11 mm and 21 ⫾ 11 mm for perforators arising from the superior and inferior glu-
Superior Gluteal
Artery
Inferior Gluteal
Artery
Internal iliac
artery
Internal iliac
artery
5⫾2
8⫾4
0.6 ⫾ 1
0.6 ⫾ 1
69 ⫾ 56
21 ⫾ 8
177 ⫾ 38
24 ⫾ 13
teal arteries, respectively. The average cutaneous
vascular territory for the superior gluteal artery
and the inferior gluteal artery in the gluteal region
was found to be 69 ⫾ 56 cm2 and 177 ⫾ 38 cm2,
respectively. Each perforator of the superior gluteal artery supplies an area (perforator zone) of
21 ⫾ 8 cm2, and each perforator of the inferior
gluteal artery supplies 24 ⫾ 13 cm2 (Table 1). The
superior gluteal artery perforators were generally
more vertical and the inferior gluteal artery perforators were generally more horizontal or
oblique as they passed through the muscle. Most
of the superior gluteal artery perforators were located adjacent to the medial two-thirds of a line
drawn from the posterior superior iliac spine to
the greater trochanter. The inferior gluteal artery
perforators were mostly located in the horizontal
middle third of the gluteal region parallel to the
gluteal crease. Inferior gluteal artery perforators
were also found at approximately 5 cm superior to
the lateral third of the gluteal crease (Fig. 3).
Landmarks for SGAP Dissection
Based on our study, the following landmarks
could be used to locate the SGAP and IGAP perforators and design a viable skin paddle (Figs. 4
and 5). To locate SGAP perforators, a line is drawn
from the posterior superior iliac spine to the
greater trochanter. Perforators are usually found
adjacent to the medial two-thirds of the drawn
line. A skin paddle is positioned over the most
suitable perforator. In general, the more lateral
the perforator, the longer the pedicle.
Landmarks for IGAP Dissection
A line is drawn from the greater trochanter to
the middle of the distance between the posterior
superior iliac spine and the medial border of the
gluteal crease (Figs. 4 and 5). Perforators are located on the marked areas. A skin paddle is positioned over a desirable (size and position-wise)
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Plastic and Reconstructive Surgery • November 2007
100 years, including the impressive works of
Manchot11 and Salmon.12 As surgery evolves, the
need for specific anatomical information continually changes. Thus, with the recent enthusiasm
for perforator flaps, precise anatomical studies are
required to carefully document cutaneous perforators suitable for flap harvest. In this study, we
have described the cutaneous territories supplying the gluteal region. We specifically looked at
the superior and inferior gluteal arteries and
provided landmarks to perforators arising from
these arteries.
Fig. 3. Angiogram of the integument of the left gluteal region.
The superior and inferior gluteal artery vascular territories are
outlined in blue and red, respectively. The yellow line indicates the
glutealcrease.Superiorglutealarteryperforatorsareusuallylocated
along the superior two-thirds of a line drawn from the posterior superior iliac spine (P) to the greater trochanter (G). The inferior gluteal
artery perforators are usually located in the middle third of the gluteal region above the gluteal crease, and also at approximately 5 cm
superior to the lateral third of the gluteal crease.
Fig. 4. Landmarks to locate inferior (a) or superior (b) gluteal artery perforators. Cross marks (x) are at the posterior superior iliac
spine and the greater trochanter.
perforator and dissection proceeds as for a standard perforator flap.
DISCUSSION
The study of the blood supply of the skin of
the human body has been carried out for over
1554
SGAP
The SGAP flap5 is the most used gluteal artery
perforator flap. Fujino et al.3 reported in 1975 and
197613 the use of the gluteal region for breast
reconstruction. In 1988, Kroll and Rosenfield14
documented the first use of local skin flaps based
on unspecified perforators in the gluteal area. Koshima et al.15 showed that a flap in this area can be
nourished even by one perforator. SGAP flaps
have been used since for sacral pressure sores,8
breast reconstruction,4,5,9 breast augmentation,16
and closure of lumbosacral myelomeningoceles.17
Musculocutaneous flaps3,13,18 and perforators
flaps4,5,8,9,16,17,19 –22 based on the superior gluteal artery have been described. Nevertheless, clinical
studies of this region4,5,7–9,14,16,17,19 –23 far outnumber
the few anatomical studies15 documenting its cutaneous blood supply. In their clinical/anatomical
study, Koshima et al.15 described the perforators in
the gluteal region of five fresh cadavers after injecting barium into the internal iliac arteries using
the arterial embalming method. They found 20 to
25 perforators in each gluteal region but did not
specify the number of perforators based on each
source arteries. They reported that the main cutaneous vessels of the gluteal region arise from the
superior and inferior gluteal artery, which is consistent with our findings, and explained that the
perforators of the superior gluteal artery are located mostly in the superolateral gluteal region.
No previous anatomical study exists regarding the
size of the cutaneous vascular territory and perforator zones of the superior gluteal artery. Previous clinical reports have documented5 flap sizes
as large as 12 ⫻ 32 cm2, although donor sites larger
than 10 cm in diameter after harvesting flaps tend
to be more difficult to close primarily.
Our anatomical findings for the superior gluteal artery perforators support clinical reports in
terms of perforator and skin paddle location. The
ability to identify and trace back individual per-
Volume 120, Number 6 • Gluteal Artery Perforator Flaps
Fig. 5. Superior gluteal artery perforator flap (left) and inferior gluteal artery perforator flap (right) raised on respective perforators.
forators of the gluteal region with angiography has
allowed better demonstration of the relationship
of the SGAP with regards to other cutaneous vascular territories (Fig. 2). The total gluteal perforator count (Table 1) is lower than that found by
Koshima. This might be explained by more precise characterization of perforators with the lead
oxide technique10 or by anatomical variation.
IGAP
The inferior gluteal artery is the other dominant blood supply to the gluteal region. Surprisingly, very little clinical and anatomical information is available. Le-Quang6 was the first to
describe the use of an inferior gluteal musculocutaneous free flap in 1979. Pedicled IGAP flaps
have been used for ischial pressure sores,7
and free IGAP flaps have been used for breast
reconstruction.9 Despite these IGAP reports, no
comprehensive description of the number of perforators and their characteristics exists. In their
study, Koshima et al.15 reported that the perforators of the inferior gluteal artery are located in the
inferomedial and inferolateral areas of the gluteal
region. Our findings provide detailed anatomical
information concerning the characteristics (Table
1) and location of IGAPs (Fig. 2) that are relevant
to perforator flap design in this region.
The descending branch of the inferior gluteal
artery has been used clinically to perfuse flaps.24 –26
Its anatomy has been variably reported in the literature. Hurwitz et al.25 and Paletta et al.26 found
this branch to be consistently present. However,
Cormack and Lamberty27 found that it was present
in 25 percent of specimens and Rubin et al.28 did
not find this branch to be consistent. Windhofer
et al.29 documented the presence of the descending inferior gluteal artery branch to be 90 percent,
and they described its relationship to the posterior
femoral cutaneous nerve. They mentioned that
when this branch was absent, the cutaneous
branch came from either the lateral or medial
circumflex or profunda femoris artery. We found
the descending branch of the inferior gluteal artery to be present in 33 percent of cases. This
illustrates the variability of this branch and should
probably mandate the imaging of this branch before designing a flap on this pedicle.
SGAP versus IGAP
Table 1 demonstrates similar characteristics
between the SGAPs and IGAPs. Of interest is the
larger cutaneous territory of the inferior gluteal
artery. This might be of clinical significance when
a bulky flap needs to be raised in the gluteal region, such as for breast reconstruction. However,
Guerra et al.9 used the IGAP flap in six cases for
breast reconstruction but found that the exposure
of the sciatic nerve could cause prolonged postoperative dysesthesia when compared with the
SGAP flap.
The SGAP flap has been previously described
in the reconstruction of trochanteric and sacral
defects. Its short pedicle has prevented its use in
the repair of ischial defects. This shortcoming
prompted Higgins et al.7 to use an inferior gluteal
artery perforator flap to cover an ischial pressure
sore.
CONCLUSIONS
Both the inferior and superior gluteal arteries
supply cutaneous vascular territories that can be
harvested as valuable flaps. This study comprehensively describes the anatomy of the SGAPs and
IGAPs. Clinical studies will confirm the dynamic
cutaneous vascular territory of these arteries that
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Plastic and Reconstructive Surgery • November 2007
will predictably be larger than our observations,
because of the role of physiologic anastomoses.
The inferior gluteal artery has a more generous
cutaneous territory compared with the superior
gluteal artery. Dissection of the IGAP flap tends to
be easier; however, proximity to the sciatic and
femoral cutaneous nerves may result in painful
paresthesias postoperatively. Both of these flaps
are useful options for breast reconstruction and
for local reconstruction in the sacral, hip, and
perineal areas.
Steven F. Morris, M.D., M.Sc.
Division of Plastic Surgery, Room 4443
1796 Summer Street
Halifax, Nova Scotia B3H 3A7, Canada
[email protected]
DISCLOSURE
The authors have no financial interest in the products, devices, or drugs mentioned in this article.
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1556
11. Manchot, C. Die Hautarterien des Menschlichen Korpers. Leipzig:
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