Inferior Gluteal Artery Perforator Flap Research Articles

Versatility of Gluteal Arteries Perforator Flaps for Local Coverage Relative to Defect Size, Site, and Different Pathological Conditions

Background: Superior and inferior gluteal artery perforator flaps have evolved in the last few decades for both free and local tissue transfer because of having the advantages of being voluminous with a relatively inconspicuous donor site. Therefore focusing on the details of such a reconstructive procedure would be of importance when thinking of skin defect coverage in the lower back, gluteal, and upper thigh areas. Patients and methods: This study was done on 14 cases, 10 of them had defects due to pressure sores, and 4 cases due to other inflammatory and neoplastic conditions. All cases were done by the same surgical team with a follow up period ranging from 2 to 18 months. Results: Thirteen out fourteen flaps (92%) passed completely and uneventfully with no need for additional surgery throughout eighteen months of follow up. However, two cases developed wound dehiscence that required secondary sutures to one of them, two cases developed seroma, and one case developed partial flap loss which re-advanced by V-Y technique.Conclusion: The superior and inferior gluteal artery perforator flaps are versatile reconstructive coverage option for gluteal defects of different size, site and pathology. They are easy to perform; suitable for large defect reconstruction of the lower back, buttock, and upper thigh areas.

Alternative Perforator Options for Insufficient Profunda Artery Perforators: A Case and Anatomical Study.

The profunda artery perforator (PAP) flap can be an alternative to the deep inferior epigastric artery flap. However, in some cases, the PAP may not be adequate to perfuse the whole flap. In this study, we describe 3 cases in which an alternative perforator was used for PAP flap perfusion. In addition, we describe an anatomical study to explore the perforasome of the PAP and alternative perforators. Three cases are described in which an alternative perforator was used to successfully perfuse the pap flap. For the anatomical study, 7 PAP flaps were raised from cadavers. Ink was injected in the PAP, the gracilis perforator (GP) and the descending branch of the inferior gluteal artery perforator (DBIGA). Then, perfused area of the flap by each perforator was calculated. The 3 patients with alternative perforators recovered without complications, in addition, no signs of fat necrosis were observed. Concerning the anatomical study, mean perfusion area of the PAP pedicle was 204 ± 90 cm (range, 141-364 cm). The GP and the DBIGA had a perfusion area of 182 ± 42 cm (range, 123-235 cm) and 157 ± 22 cm (range, 136-192), respectively. Although the PAP flap has considerable benefits over the more traditional inferior gluteal artery perforator and transverse upper gracilis flaps, a plastic surgeon might encounter a PAP flap perforator that is not deemed viable for flap perfusion. In these cases, the GP and DBIGA may be suitable "escape" alternatives to complete the reconstruction.

Wound care in patients with perineal reconstruction

Nurses play an essential role in monitoring and managing wounds after any surgery. This article focuses on how to optimise perineal wound healing after an extra-levator abdominoperineal excision of the rectum (ELAPE) or a pelvic exenteration for locally advanced rectal cancer. After radical rectal surgery, a perineal defect may be created that requires perineal reconstruction to fill the remaining cavity. Reconstruction of these defects is essential to restore form and function and reduce patient morbidity. A range of reconstructive options are available for perineal reconstruction. This includes inferior or superior gluteal artery perforator (IGAP/SGAP) flaps, which are fasciocutaneous flaps that provide robust, well-vascularised tissue to fill the perineal defect in a V-Y configuration while significantly reducing donor-site morbidity. The inferior gluteal artery perforator (IGAP) is most suitable when stoma formation is being considered. Possible complications after flap reconstruction include wound infection, abscess, flap necrosis, full-thickness dehiscence, bone exposure, delayed healing and persistent perineal sinus. Prevention is key to wound management; this encompasses regular monitoring, careful positioning and use of pressure-relieving equipment until the flap tissue is well perfused and healing well. Negative-pressure wound therapy is a therapeutic technique that uses a vacuum dressing to promote wound healing and enhance the formation of healthy granulation tissue and it can be useful to promote the healing of surgical wounds. Good nursing care is vital in optimising wound healing.

ASSESSMENT OF PERFORATER SPARING GLUTEAL FASCIOCUTANEOUS FLAP FOR SACRAL PRESSURE SORE

Despite advances in reconstruction techniques, sacral pressure ulcers continue to present a challenge to the plastic surgeon.
 Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous tissue and the underlying fascia. Including the deep fascia with its prefascial and subfascial plexus enhances the circulation of these flaps. They can be raised without skin and are then referred to as fascial flaps. The present study was planned to evaluate the perforater Sparing Gluteal Fasciocutaneous flap for Sacral pressure sore.
 The rotation Gluteal Fasciocutaneous flap for sacral pressure sore coverage have distinct advantage of rotation in the event of ulcer recurrence. The flap from the gluteal crease derives blood supply from the inferior gluteal artery perforator (IGAP) and reliably preserves the entire contralateral side as a donor site.
 The author describe their approach of preserving and incorporating musculocutaneous perforators into the conventional rotation design.Data from 11 patients (8 men, 3 women; mean age [range 24-71] years old) whose sacral ulcers were closed with an IGAP flap between from Jan 2017 to Apr 2018 June were retrieved and reviewed. All patients were bedridden; 1 patient in a vegetative state with a diagnosis of Cerebro vascular accident was referred from a local clinic, 2 patients had pelvic bone fracture on long duration traction, and 2 patients had a history of Cervical injury leading to quadriplegia , and 6 patient have hemiplegia due to spinal injury . The average defect size was 110 cm(2) (range 78-134 cm(2)). The average flap size was 75.8 cm(2) (range 46-111 cm(2)).
 After surgery, the patients' position was changed every 2 hours; patients remained prone or on their side for approximately 2 weeks until the flap was healed. After healing was confirmed, patients were discharged. Complications were relatively minor and included 1 donor site wound dehiscence that required wound reapproximation. No surgery-related mortality was noted; the longest follow-up period was 24 months.
 The present study was planned in the Department of Plastic Surgery, Pulse Emergency Hospital, Patna, Bihar. Total 11 cases of the operated from Jan 2017 to Apr 2018 were included in the present study. All the patients were informed consents. The aim and the objective of the present study were conveyed to them. Approval of the institutional ethical committee was taken prior to conduct of this study.
 The data generated from the present study concludes that the modified method we proposed is relatively simple and easy for reconstructing sacral sores, provides sufficient padding, and has little donor-site morbidity. Once sufficient padding is established in cases like this, a takeaway from this report would be to study the recurrence rates compared with the classic fasciocutaneous flap.
 Keywords: Fasciocutaneous flaps, Sacral pressure, sore, etc.

Inferior gluteal artery perforator flap for closure of sacral defects after pilonidal sinus surgery

Introduction: The aim of the current study was to introduce the use of the inferior gluteal artery perforator flap (IGAPF) as a new alternative surgical technique for closure of sacral defects after pilonidal sinus surgery. Patients and Methods: Inferior gluteal artery perforators were used on 15 male patients operated in the plastic and reconstructive surgery department of our tertiary care centers between March 2014 and May 2017. Age, size of the defect, duration of follow-up, complications, and recurrence rate were assessed. Results: The average age was 30.2 (range: 17–54) years, and the mean duration of follow-up was 8.2 (range: 7–16) months. No recurrence was detected within the follow-up period, and the only remarkable complication reported was total flap necrosis attributed to venous congestion in one patient. The mean size of the defects after excision was 21.6 cm2. Conclusion: Our preliminary results imply that IGAPF can be a safe and effective alternative for closure of large defects after pilonidal sinus surgery. Further controlled trials on larger series are warranted to establish the advantages and disadvantages of this alternative technique.

Safe and easy way to reconstruct pressure ulcers: Gluteal artery perforator flaps

Introduction: Pressure ulcers continue to be a reconstructive challenge due to the growing number of patients under risk. Frail nature of the affected patient makes this problem even more complicated. Commonly pressure ulcers are reconstructed with random pattern flaps or musculocutaneous flaps. With the emergence of the perforator concept and expanding knowledge in the vascularity of the gluteal integument, gluteal artery perforator flaps became popular in reconstructing pressure ulcers. In this study, we aimed to review the technical tips to improve clinical outcomes of superior gluteal artery perforator and inferior gluteal artery perforator flaps in the light of our clinical experience. Materials and Methods: Between 2015 and 2018, nine patients with pressure ulcers in the sacral and ischial regions were reconstructed with gluteal artery perforator flaps. Anatomical landmarks were marked, and Doppler ultrasound was also used to identify individual perforators. The subfascial dissection was opted, and skin island was inseted resembling an advancement pattern to prevent peforator kinking and to include maximum number of perforators. Results: All flaps survived, seroma was seen in two patients, and two of the patients had wound dehiscence at donor site. Conclusions: In the era of perforator flaps, with their safe anatomical basis, less morbidity and versatility in design we offer gluteal artery perforator flaps as a reliable alternative in reconstructing pressure ulcers.

The Use of Magnetic Resonance Imaging in Planning a Pedicled Perforator Flap for Pressure Sores in the Gluteal Region.

Pedicled perforator flaps (PPFs) have been widely used to treat pressure sores in the gluteal region. Selection of a reliable perforator is crucial for successful surgical treatment of pressure sores using PPFs. In this study, we evaluate the role of magnetic resonance imaging (MRI) in planning PPF reconstruction of pressure sores in the gluteal region. A retrospective chart review was performed in patients who had undergone these PPF reconstructions and who had received preoperative MRI. Preoperatively, the extent of infection and necrotic tissue was evaluated using MRI, and a reliable perforator was identified, considering the perforator location in relation to the defect, perforator size, and perforator courses. Intraoperatively, the targeted perforator was marked on the skin at the locations measured on the MRI images, and the marked location was confirmed using intraoperative handheld Doppler. Superior gluteal artery, inferior gluteal artery, or parasacral perforators were used for the PPFs. Surgical outcomes were evaluated. A total of 12 PPFs were performed in 12 patients. Superior gluteal artery perforator flaps were performed in 7 patients, inferior gluteal artery perforator flaps were performed in 3 patients, and parasacral perforator flaps were performed in 2 patients. We could identify a reliable perforator on MRI, and it was found at the predicted locations in all cases. There was only one case of partial flap necrosis. There was no recurrence of the pressure sores during the mean follow-up period of 6.7 months (range = 3-15 months). In selected patients with gluteal pressure sores, MRI is a suitable means for not only providing information about disease extent and comorbidities but also for evaluating perforators for PPF reconstructions.

The use of perforator flaps for the reconstruction of sacral defects

Background: Despite advances in reconstruction techniques, sacral defects continue to challenge surgeons. The perforator flap preserves the entire contralateral side as a future flap donor site and the gluteal muscle itself on the ipsilateral side to minimize donor-site morbidity. Materials and Methods: Between April 2003 and March 2013, data obtained from 60 patients with sacral defects reconstructed with perforator flaps were retrospectively analyzed. Results: We analyzed the sacral defects reconstructed with three different perforator flaps into the following groups: group 1, 30 patients with superior gluteal artery perforator flaps, (average flap size was 83.8 cm2); Group 2, 19 patients with parasacral perforator flaps (average flap size was 94.2 cm2); and Group 3, 11 patients with inferior gluteal artery perforator flaps (average flap size was 85.8 cm2). The overall flap survival rate was 93.3% (56/60). Conclusion: Perforator flaps are a reliable option for soft-tissue defect reconstruction as they provide a sufficient amount of tissue to cover large sacral defects. We recommend perforator flaps as a viable alternative in the management of sacral defects that cannot be reconstructed with primary closure or local fasciocutaneous flaps.

Reconstruction of a Sacral Pressure Ulcer With an Inferior Gluteal Artery Perforator Flap After Failed Reconstruction Using Bilateral V-Y Advancement Flaps

Many types of flaps are available if surgical reconstruction of a pressure ulcer is indicated, including a gluteus maximus flap, V-Y advancement flap, and superior gluteal artery perforator flap. Regional flap failure can complicate treatment, requiring additional flap surgery. An 80-year old woman with a 2-year history of being unconscious following a cerebrovascular accident presented with a Stage 4 sacral pressure ulcer of 2 months' duration with eschar and abscess formation. Because the wound measured 15 × 10 cm2, bilateral V-Y advancement flaps were used for surgical closure. However, 1 week later, ischemic change of the wound edges and wound dehiscence were observed. The wound was subsequently closed with an artery perforator (IGAP) flap, an approach that took into consideration religious preference of keeping the body intact. The patient was discharged with a healed wound 6 weeks postoperatively; long-term postoperative surveillance was hindered by the patient's distance from the care facility (she lived on an outlying island). This is the first case report to describe IGAP flap application in a patient with a sacral pressure ulcer after failed reconstruction using bilateral V-Y advancement flaps.

Reconstruction of acquired ischiatic and perineal defects: an anatomical and clinical comparison between gluteal thigh and inferior gluteal perforator flaps

BackgroundFlap coverage is the gold standard in treating pressure sores, and due to the high recurrence rate, the possibility of multiple surgical procedures should be considered during flap selection. The gluteal thigh (GT) flap has become a workhorse for ischiatic pressure sore treatment at our hospital. Follow-up revealed a group of patients presenting recurrence of the pressure sore that needed a second flap. The inferior gluteal artery perforator (IGAP) flap was chosen in this series. The positive experience with both flaps raised the question of which flap should be the first option for the treatment of ischiatic and perineal pressure sores.MethodsIGAP and GT flaps were dissected in 21 fresh human cadavers to allow comparison of anatomical features. In a series of 60 patients, the authors used both the gluteal thigh and the IGAP flap to cover 76 ischiatic and perineal ulcers.ResultsThe IGAP flap was found to be wider and thicker than the gluteal thigh, but presented a shorter pedicle. All flaps healed uneventfully. Recurrent ulcers were treated successfully with both flaps.ConclusionsBoth flaps are suitable for coverage ischiatic and perineal sores. Due to its anatomical features, the IGAP flap should be considered the first choice of treatment for ischiatic ulcers. The gluteal thigh flap should be used in the recurrent sores.Level of Evidence: Level IV, therapeutic study.

Effects of perforator flaps combined with muscle flaps for repairing grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients

Objective: To explore effects of perforator flaps combined with muscle flaps for repairing grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients. Methods: Nine elderly patients with grade Ⅳ pressure ulcers in ischial tuberosity were hospitalized in our burn ward from April 2014 to April 2017. Size of wounds ranged from 5 cm×3 cm to 12 cm×7 cm, and depth of sinus ranged from 6 to 22 cm. After admission, emergency debridement or debridement in selective time was performed. After debridement, the wounds were treated with continuous vacuum assisted closure therapy. After the treatment for 1 to 2 weeks, tissue flaps repair operations were performed. Four patients were repaired with inferior gluteal artery perforator flaps combined with long head of biceps femoris muscle flaps. Three patients were repaired with inferior gluteal artery perforator flaps combined with semimembranous muscle flaps. One patient was repaired with inferior gluteal artery perforator flap combined with gracilis muscle flap. One patient was repaired with femoral profound artery perforator flap combined with gluteus maximus muscle flap, and the distal area of femoral profound artery perforator flap of the patient which showed intraoperative cyanosis of 6 cm×4 cm was thinned to medium thickness skin to cover the muscle flap. The other eight patients showed no abnormality during operation. Size of perforator flaps ranged from 7 cm×5 cm to 14 cm×12 cm, and size of muscle flaps ranged from 11 cm×4 cm to 24 cm×6 cm. The donor sites of flaps were all sutured directly. Results: The tissue flaps and skin graft of all patients survived well after operation. During follow-up of 8 to 35 weeks, operative area of all patients showed good shape and texture, with no local diabrosis or recurrence of pressure ulcers. Conclusions: The combination of perforator flaps and muscle flaps is effective in repairing and reducing recurrence of grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients.

Radiological anatomy of the perforators of the gluteal region: The "radiosome" based anatomy.

The superior (SGA) and the inferior gluteal artery (IGA) perforator flaps are widely used in pressure-sore repair and in breast reconstruction. The aim was to exhaustively depict the topographical anatomy of the whole system of perforators in the buttock. Eighty lower-extremity computed tomographic angiography (CTA) of patients (20 males/20 females, mean age 61-years old, range 38-81) were considered. The source artery, location, type, and caliber of gluteal perforators were analyzed. The location of perforators was reproduced using a standardized two-dimensional grid on the coronal plane, centered onto defined bone landmarks. We defined "radiosome" the cutaneous vascular territory of a source artery inferred through the representation of its whole perforator system at the exit point through the deep fascia. A mean number of 25.6 ± 5.7 perforators in the gluteal region was observed, distributed as follows: 11.6 ± 4.8(45.2%) from SGA; 7.9 ± 4.5(30.8%) from IGA; 1.5 ± 0.8(5.8%) from fifth lumbar artery; 1.2 ± 0.8(4.7%) from internal pudendal artery; 1.2 ± 1(4.8%) from lateral circumflex femoral artery; 0.3 ± 0.7(1.2%) from circumflex iliac superficial artery. At least one large (internal diameter > 1 mm) SGA septocutaneous perforator was present in 77.5% of patients. The gluteal region is vascularized by perforators of multiple source arteries. Septocutaneous perforators of SGA and IGA were planned along a curve drawn from the posterior-superior border of the iliac crest to the greater trochanter. The lumbar artery perforators are clustered over the apex of the iliac crest; the internal pudendal artery perforators are clustered medially to the ischiatic tuberosity. Contributions can also come from the sacral and superficial circumflex iliac arteries.

Bilateral V TO Y Inferior Gluteal Artery Perforator (IGAP) flaps for abdominoperineal (ap) reconstruction

Bilateral V TO Y Inferior Gluteal Artery Perforator (IGAP) flaps for abdominoperineal (ap) reconstruction

Surgical treatment of low rectal cancers with APER and IGAP flap.

This article describes current treatments for individuals with a low rectal cancer. It examines the rationale for surgical treatment involving abdominoperineal excision of the anus and rectum (APER) and outlines how surgery for rectal cancer has evolved over recent years. Surgical advances mean the use of regional flaps is advocated to overcome the common problem of impaired perineal wound healing and the principles of this surgery are summarised. Postoperative nursing considerations relating to the inferior gluteal artery perforator (IGAP) flap will be discussed, as well as the importance of scrupulous wound care and patient education. The implications of this form of surgery on a patient's recovery and discharge planning are also explored.

PTH-287 7-year experience with perineal reconstruction following abdominoperineal or multivisceral resection using inferior gluteal artery perforator flaps

<h3>Introduction</h3> Aim of this study is to present our long-term experience of the use of inferior gluteal artery perforator (IGAP) flaps for the immediate reconstruction of the perineum following excisional surgery. To our knowledge, this is the largest series of immediate perineal reconstruction using IGAP flaps published to date. <h3>Method</h3> We performed a retrospective analysis of a group of 142 patients who over a period of 7 years (from April 2007 to April 2014) underwent abdominoperineal resection (57 patients, 40%), multivisceral resection (49 patients, 34.5%), local perineal excision (14 patients, 9.8%), panproctocolectomy (3 patients, 2.1%) and perineal hernia repair (2 patients, 1.4%). The remaining 17 patients of our group (11.9%) underwent various perineal procedures such as fistula resections, pilonidal sinus resections or postoperative perineal sinus resections. We used IGAP flaps to immediately reconstruct the perineal defect of all these patients. 74 patients (52%) were male and 68 female (48%), with a mean age of 60 years (range 19–88). The indication for the excision was rectal cancer in 53 patients (37.3%), recurrent rectal cancer in 27 patients (19%), anal cancer in 12 patients (8.4%), recurrent anal cancer in 11 patients (7.7%), gynaecological malignancy in 8 patients (5.6%), inflammatory bowel disease in 12 patients (8.4%), postoperative wound dehiscence in 3 patients (2.1%) and postoperative perineal sinus formation in 9 patients (6.3%). The remaining 7 patients (4.9%) underwent excision and reconstruction for persistent perineal sinuses or pilonidal sinuses. 111 patients (78%) underwent neoadjuvant chemoradiotherapy. <h3>Results</h3> The average length of inpatient stay was 17.6 days (range 3–100). Most patients are still being followed up in our outpatient clinic and are being assessed with regards to pain, discomfort and herniation. The commonest complication observed was a dehiscence of the IGAP flaps, which was observed in 53 patients (37.3%). 44 dehiscence cases were observed following surgery for malignant disease and 9 following surgery for benign disease. 81% of these cases were managed conservatively in the form of simple wound care (dressings), negative-pressure wound dressings (VAC) or primary suturing of the defect. Only 10 of the patients had to be re-operated for debridement, washout and closure or flap revision. A total of 2 patients formed a chronic perineal sinus following dehiscence. <h3>Conclusion</h3> Our experience has shown that the IGAP flaps are a safe, robust and reliable option for the reconstruction of the perineum following major excisions, with an acceptable rate of complications when compared to other reconstruction options. <h3>Disclosure of interest</h3> None Declared.

PTH-282 Perineal reconstruction following abdomino-perineal excision: results from a “hub and spoke” model

Introduction Abdomino-perineal excision (APE) for anorectal malignancy, particularly following chemo-radiotherapy, is associated with a high rate of perineal wound complications. Biological meshes and tissue flaps such as Vertical Rectus Abdominis Myocutaneous (VRAM) or Inferior Gluteal Artery Perforator (IGAP) flaps can improve wound healing. Should this be carried out in the context of a district general hospital (DGH)? We present a single centre experience using such techniques in a “hub and spoke” model with the regional plastic surgical unit. Method A retrospective study of 21 patients undergoing APE for malignancy between January 2011 and June 2014 was conducted. IGAP flap reconstruction was performed by a visiting consultant plastic surgeon. Data collection included patient demographics, underlying pathology, neoadjuvant therapy and operative details, length of hospital stay, and wound complications. Patients were followed-up by both colorectal and plastic surgical teams. Results 21 patients (11 female, mean age 66 ± 12 yrs) underwent APE for cancer (20 rectal adenocarcinoma, 1 anal squamous cell carcinoma). 12 of these patients had received neoadjuvant chemo-radiotherapy. 3 patients had primary closure, 7 biological mesh-assisted, and 12 had tissue flaps (5 VRAM and 7 IGAP). Mean length of hospital stay was 15 ± 8 days. There were no major complications following primary or mesh-assisted closure of the perineum. Perineal wound complications necessitating a return to theatre were seen in 3 patients who had undergone flap closure. Each had received neoadjuvant chemo-radiation. Conclusion This data suggests that perineal reconstructions following APE for malignancy can be undertaken in a DGH setting using a “hub and spoke” model with a regional plastic surgery unit. Disclosure of interest None Declared.

Unilateral breast reconstruction using bilateral inferior gluteal artery perforator flaps.

Background:For reconstructing moderate-to-high projection breasts in nulliparous patients with insufficient abdominal tissue or prior abdominal surgeries, a unilateral inferior gluteal artery perforator (IGAP) flap is an alternative procedure. In patients with slim hips, however, unilateral gluteal tissue is insufficient and inferior gluteal crease displacement may develop postoperatively. Donor-site asymmetry is also a major disadvantage. In these circumstances, bilateral IGAP flaps provide sufficient tissue without significant gluteal deformity.Methods:We retrospectively reviewed 20 patients who underwent unilateral breast reconstruction using bilateral IGAP flaps by a single surgeon between November 2007 and December 2012. A quantitative outcome assessment was performed and compared with that of 22 unilateral IGAP flap patients operated on by the same surgeon.Results:Twenty patients underwent reconstruction with 40 IGAP flaps. Of the 40 flaps, 39 survived and 1 developed total necrosis due to repeated venous thrombosis. In 15 of 20 patients, the size of reconstructed breast was comparable to that of the contralateral breast. Final inset flap weight was 462.3 g for bilateral flaps and 244.3 g for unilateral flaps. Total operating time was 671.1 minutes (bilateral flaps) and 486.8 minutes (unilateral flaps).Conclusions:Use of bilateral IGAP flaps for breast reconstruction helps to avoid asymmetry of the inferior buttock volume and shape. Bilateral flaps provide sufficient tissue volume and allow for reconstruction of a breast comparable to the unaffected side. In patients with moderate-to-high projection breast whose abdominal tissue cannot be used for reconstruction, IGAP flaps may be a suitable alternative.

The microvascular anatomy of superior and inferior gluteal artery perforator (SGAP and IGAP) flaps: a fresh cadaveric study and clinical implications.

Our study aimed to highlight anatomical similarities, differences, and variations in the microvascular anatomy between superior and inferior gluteal artery perforator (SGAP and IGAP) flaps. Thirty gluteal flaps (15 SGAP and 15 IGAP) were studied on 22 adult fresh cadavers. We recorded the number and location of perforators, the characteristics of the main perforator (course, length, and diameter at the level of division at the greater sciatic foramen), and the anatomical variations of the submuscular venous plexus. The mean number of perforators was similar in both flaps (n = 7). We found a statistically significant difference in the total length of the vascular pedicle between SGAP (mean = 9.80 cm) and IGAP (mean = 13.36 cm) flaps, which correlated strongly with the difference in the intramuscular length (mean difference = 3.40 cm) of the perforator. There was no statistically significant difference in the diameter of the superior and inferior gluteal vessels at the point of pedicle division. The complex submuscular venous plexus, which is typically found on SGAP flaps deep to the sacral fascia, was never encountered on IGAP flaps. Perforators originating from the inferior gluteal artery were found on the lower half of five superior gluteal flaps. These were dominant perforators in two cases. We also report a rare anatomical communication between superior and inferior gluteal vessels deep to the piriformis muscle and a case of atheromatous disease of the inferior gluteal artery. Our findings are highly relevant to clinical practice and contribute to the understanding of the vascular anatomy of SGAP and IGAP flaps and the successful use of these challenging flaps. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Perianal Paget's Disease

The incidence of extramammary Paget's disease (EMPD) is very low. An 84-year-old Korean man was treated with topical and oral medications at a local dermatologic clinic for a year, but the symptoms did not improve. He visited Severance Hospital and underwent a perianal skin biopsy and was finally diagnosed with EMPD. The authors performed a wide local excision according to a 1-cm margin around the lesion. For the skin and the soft tissue defects, bilateral inferior gluteal artery perforator flap transpositions were performed. The size of the lesion was 14 cm2 × 9 cm2, and the lateral and the basal margins were all disease free.

The Evolution of Perforator Flap Breast Reconstruction: Twenty Years after the First DIEP Flap

It is over 20 years since the inaugural deep inferior epigastric perforator (DIEP) flap breast reconstruction. We review the type of flap utilized and indications in 2,850 microvascular breast reconstruction over the subsequent 20 years in the senior author's practice (Robert J. Allen). Data were extracted from a personal logbook of all microsurgical free flap breast reconstructions performed between August 1992 and August 2012. Indication for surgery; mastectomy pattern in primary reconstruction; flap type, whether unilateral or bilateral; recipient vessels; and adjunctive procedures were recorded. The DIEP was the most commonly performed flap (66%), followed by the superior gluteal artery perforator flap (12%), superficial inferior epigastric artery perforator flap (9%), inferior gluteal artery perforator flap (6%), profunda artery perforator flap (3%), and transverse upper gracilis flap (3%). Primary reconstruction accounted for 1,430 flaps (50%), secondary 992 (35%), and tertiary 425 (15%). As simultaneous bilateral reconstructions, 59% flaps were performed. With each flap, there typically ensues a period of enthusiasm which translated into surge in flap numbers. However, each flap has its own nuances and characteristics that influence patient and physician choice. Of note, each newly introduced flap, either buttock or thigh, results in a sharp decline in its predecessor. In this practice, the DIEP flap has remained the first choice in autologous breast reconstruction.