Bilateral Simultaneous Laterally Placed Superior Gluteal Artery Flap for Unilateral Breast Reconstruction

Abstract

Sir: The superior gluteal artery perforator (SGAP) flap has become an important alternative donor site for breast reconstruction, especially if abdominal tissue is inadequate or unavailable.1 Although a few centers have reported the performance of bilateral simultaneous SGAP flaps for bilateral breast reconstruction,2,3 and bilateral simultaneous deep inferior epigastric artery perforator flaps have been used for unilateral breast reconstruction,4 to our knowledge, the use of bilateral simultaneous SGAP flaps has not been reported for reconstruction of a single breast. The patient (body mass index, 18.6 kg m2) was first diagnosed with left-sided breast cancer in 2004. She underwent bilateral mastectomies with immediate implant reconstruction (the right mastectomy was prophylactic because of a strong family history of breast cancer). She then developed two local recurrences (in 2005 and 2007) and underwent left axillary lymph node dissection, and irradiation and further chemotherapy of the left side of the chest wall. Given her history of chest irradiation and obvious abdominal tissue inadequacy, we felt that the best option for her left breast reconstruction was bilateral simultaneous SGAP flaps. To ensure blood flow and adequate length to the recipient vessels (internal mammary), we created an arteriovenous fistula to the internal mammary artery and internal mammary vein using a saphenous vein (arteriovenous) graft (Fig. 1, above). In the second stage, the bilateral lateral SGAP flaps were transferred for single-breast reconstruction 4 days after the creation of the arteriovenous fistula.Fig. 1.: (Above) Saphenous vein graft anastomosed to the ipsilateral internal mammary vessels to create a temporary arteriovenous fistula. (Center) The “superior” SGAP flap pedicle is anastomosed to a side branch off the main pedicle of the “inferior” SGAP flap. In turn, the main pedicle of the “inferior” SGAP flap is then anastomosed to the two ends of the divided saphenous vein graft. (Below) Two new saphenous vein grafts are then anastomosed to the contralateral internal mammary vein and one of its intercostal perforators during the emergent flap take-back on postoperative day 1. The arterial anastomosis to the ipsilateral internal mammary artery is not shown because it remained patent and was not revised.The procedure began in the supine position by first ensuring patency of the arteriovenous fistula. The lateral septal SGAP dissection was performed in the septum between the gluteus maximus and medius toward the medusa head, as described previously.5 On the back table, the pedicle of one flap was sutured to large side branches of the other flap, leaving only one superior gluteal artery and vein pedicle for the internal mammary artery and internal mammary vein anastomoses (by means of the saphenous vein graft arteriovenous fistula). The flaps were then transferred to the chest and their pedicles were anastomosed to the existing saphenous vein graft loop (Fig. 1, center). Because of signs of venous congestion, the patient returned to the operating room on postoperative day 1. The initial vein graft appeared thrombosed and thus new vein grafts were used to the contralateral internal mammary vein and a contralateral, medial, intercostal perforator vein branch (Fig. 1, below). The patient was discharged on postoperative day 5 and had a nice result at 6-month follow-up (Fig. 2).Fig. 2.: The patient at 6-month postoperative follow-up after bilateral SGAP flap surgery for unilateral breast reconstruction. Note the incision on the medial aspect of the right breast that was used to access the contralateral internal mammary vein during the take-back.Given this patient's abdominal tissue inadequacy and her irradiated chest wall, the best potential donor site was her lateral gluteal tissue from both sides to accomplish projection and adequate skin coverage over her irradiated skin. To further support this approach, one must also consider that using bilateral SGAP flaps, as opposed to unilateral flaps, in a low-weight patient provides better donor-site symmetry. This case report exemplifies a safe, viable expansion of the previously reported surgical technique using the SGAP flap for breast reconstruction. With the successful use of bilateral simultaneous SGAP flaps for the reconstruction of a single breast, the authors of this article report an approach that proved to be a useful alternative for breast reconstruction in this patient with insufficient abdominal, back, inner thigh, and gluteal tissue. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Michael Magarakis, M.D. Jaime I. Flores, M.D. Sachin M. Shridharani, M.D. Philip S. Brazio, M.D. Raghunandan Venkat, M.D. Gedge D. Rosson, M.D. Division of Plastic, Reconstructive, and Maxillofacial Surgery Department of Surgery The Johns Hopkins University Baltimore, Md.