The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.     

Preferential use of the posterior approach to blood vessels of the lower leg in microvascular surgery.

A posterior approach to the vessels of the lower leg, with particular emphasis on the posterior tibial artery, is presented as the method of choice for microvascular free-tissue transfer to the region. This approach offers wide exposure, better definition of the zone of injury, appropriate selection of the recipient vessel and of the site of anastomosis, and enough room for microsurgical work. Exposing the large posterior tibial artery down to the distal third of the lower leg facilitates the use of end-to-side anastomosis and makes the transfer of large muscle flaps to that region more predictable, in part by obviating the need for long vein grafts. This exposure leaves no functional and few aesthetic deficits.     

Microvascular free transfer of iliac bone based on the deep superior branches of the superior gluteal vessels

The findings from dissection, injection studies, corrosion specimens, and angiograms in 300 specimens of the iliogluteal region taken from 150 cadavers are reported. These findings suggest that the deep superior branches of the superior gluteal vessels may serve a nutritive pedicle in microvascular free transfer of iliac bone. Therefore, the operative technique has been developed and applied clinically with good results. The selection of different vessels as a nutritive pedicle for the free transfer of iliac bone is discussed.     

Selection of the recipient vessel in the free flap around the knee: the superior medial genicular vessels and the descending genicular vessels

In reconstructions around the knee, the use of a free flap is indicated in a limited number of cases, but it plays a critical role in cases of extensive defects or unavailability of local flaps. The selection of the recipient vessel is an essential and challenging step for a successful free tissue transfer. Popliteal vessels and other small vessels around the knee have been reported to be used as recipient vessels, but the choice of recipient vessels around the knee has not been established. In this study, after a thorough investigation of the vascular anatomy at the knee region, the superior medial genicular vessels and the descending genicular vessels were considered to be the proper recipient vessels, and a clinical application was tried. From July of 1997 to July of 1999, a total of seven cases of soft-tissue defects around the knee-four cases in the posterior region and three cases in the anterior region-were reconstructed with free flaps, using the superior medial genicular vessels and the descending genicular vessels, respectively. All flaps survived completely, with no flap loss. The advantages of these vessels are their proximity to the knee and their reliability, versatility, simplicity, and size match. The outstanding characteristic of this combination of vessels is their versatility, because the combination can cover all defects around the knee. The clinical application and the versatility of the combination of the superior medial genicular vessels and the descending genicular vessels as the recipient vessels was confirmed for the reconstruction of posterior and anterior knee defects.     

Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: an anatomical and clinical analysis

A variety of useful recipient sites exist for breast reconstruction with free flaps, and correct selection remains a significant decision for the surgeon. Among the main pedicles, the disadvantages of the internal mammary vessels are the necessity of costal cartilage resection and the impairment of future cardiac bypass. This study was designed to reduce morbidity and to seek alternative recipient vessels. In the anatomical part of the study, 32 parasternal regions from 16 fresh cadavers were used. The locations and components of internal mammary perforator branches were measured and a histomorphometric analysis was performed. In the clinical part of the study, 36 patients underwent 38 deep inferior epigastric perforator (DIEP) flap and two superior gluteal artery perforator flap breast reconstructions (31 immediate and four bilateral). The recipient vessels were evaluated. In the anatomical study, there were 22 perforating vessels, with 14 (63.6 percent) on the second intercostal space and 11 (50 percent) with one artery and vein. The average (+/-SD) internal and external perforator artery diameters were 598.48 +/- 176.68 microm and 848.97 +/- 276.68 microm, respectively. In the clinical study, 13 successful anastomoses (32.5 percent) were performed at the internal mammary perforator branches (second and third intercostal spaces) with 12 DIEP flaps and one superior gluteal artery perforator flap (all performed as immediate reconstructions). One case of intraoperative vein thrombosis and one case of pedicle avulsion during flap molding were observed. The anatomic and clinical studies demonstrated that the internal mammary perforator branch as a recipient site is a further refinement to free flap breast reconstruction. However, it is neither a reproducible technique nor potentially applicable in all patients. Preoperative planning between the general surgeon and the plastic surgeon is crucial to preserve the main perforator branches during mastectomy. The procedure was not demonstrable in late reconstructions. The main advantages of internal mammary perforator branches used as recipient sites are sparing of the internal mammary vessels for a possible future cardiac surgery, prevention of thoracic deformities, and reduction of the operative time by limited dissection. Despite this, limited surgical exposure, caliber incompatibility, and technical difficulties have to be considered as the main restrictions.     

An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients

The thoracodorsal vessels have been the standard recipient vessels for the majority of surgeons performing free transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Recently, the internal mammary vessels have been recommended as the first-choice recipient vessels for microvascular breast reconstruction. This approach requires a shorter pedicle length, allows for central placement of flap tissue, and avoids axillary scarring. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction. The authors performed a prospective trial examining the differences in operative and aesthetic outcomes between each recipient site. A prospective trial of 108 consecutive free-tissue transfers was conducted in 100 patients. The first 60 TRAM flap patients were randomized so that 30 flaps were anastomosed to the internal mammary vessels and 30 were anastomosed to the thoracodorsal vessels, whereas the recipient vessels for the remaining 40 patients were left to the discretion of the surgeon. Of the 40 nonrandomized patients, 10 patients underwent reconstruction using the internal mammary vessels and 30 patients underwent reconstruction using the thoracodorsal vessels. The patients' medical history and hospital course were noted. To evaluate aesthetic outcome, a group of five blinded nonmedical observers and three blinded plastic surgeons graded the reconstructions in the 60 TRAM flap patients for symmetry and overall aesthetic result on a scale of 1 to 5. Blinded practitioners administered postoperative questionnaires to patients regarding recovery time and satisfaction with the aesthetic result. Forty-three flaps were transferred to the internal mammary vessels and 65 were transferred to the thoracodorsal vessels. No significant differences existed between groups with regard to age of preoperative risk factors. Average operative time was 6 hours in each group. Average hospital stay was 5.8 days in each group. Conversion from initial recipient vessel to a secondary recipient site occurred in 12.5 percent of internal mammary reconstructions and 7 percent of thoracodorsal reconstructions. All converted internal mammary cases occurred in left-sided reconstructions and were attributable to problems with the veins. Overall, 20 percent of left-sided internal mammary reconstructions were found to have an inadequate recipient vein. Unusable thoracodorsal vessels were found only in delayed reconstructions, at a rate of 15 percent in the delayed setting. All flaps from converted procedures survived without complications. Average follow-up was 20 months, during which time there was one flap loss in the thoracodorsal group. There were no significant differences in complication rates between groups. Average aesthetic grade was 3.6 in each group. Postoperative recovery time and overall patient satisfaction were not significantly different between groups. Either recipient site can provide for a safe and acceptable result; however, surgeons should be aware of conversion rates and plan appropriately if recipient vessels appear unusable for free-tissue transfer.     

The gluteal fasciocutaneous rotation-advancement flap with V-Y closure in the management of sacral pressure sores

The sacral region is one of the most frequent sites of pressure sore development, and local flaps in the gluteal region are usually preferred when surgical closure is needed. The authors used the gluteal fasciocutaneous rotation-advancement flap with V-Y closure to manage sacral pressure sores in 15 patients. The design was a combination of the classic rotation and V-Y advancement flap patterns. When the wound was closed, the tension at the distal end of the rotation flap was relieved by flap advancement and the combined rotation-advancement action was supported laterally with V-Y closure. A wide skin pedicle was preserved at the inferomedial part of the flap. This pedicle augmented the blood supply to the flap skin and kept the surgical incision small, thus helping to reduce the risk of fecal contamination and associated wound-healing problems. This flap can also be converted to any design of fasciocutaneous or musculocutaneous V-Y advancement flap, should such a change be required. The largest defects that were closed with a unilateral rotation-advancement flap and bilateral rotation-advancement flaps were 12 and 18 cm in diameter, respectively. In 1.5 to 35 months of follow-up, none of the patients developed wound dehiscence or flap necrosis requiring repeated surgery. This technique is simple, can be performed quickly, has minimal associated morbidity, and yields a good outcome.     

Alternative venous outflow vessels in microvascular breast reconstruction

The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors' experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10-year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful.     

The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery

The pedicled lower trapezius musculocutaneous flap is a standard flap in head and neck reconstruction. A review of the literature showed that there is no uniform nomenclature for the branches of the subclavian artery and the vessels supplying the trapezius muscle and that the different opinions on the vessels supplying this flap lead to confusion and technical problems when this flap is harvested. This article attempts to clarify the anatomical nomenclature, to describe exactly how the flap is planned and harvested, and to discuss the clinical relevance of this flap as an island or free flap. The authors dissected both sides of the neck in 124 cadavers to examine the variations of the subclavian artery and its branches, the vessel diameter at different levels, the course of the pedicle, the arc of rotation, and the variation of the segmental intercostal branches to the lower part of the trapezius muscle. Clinically, the flap was used in five cases as an island skin and island muscle flap and once as a free flap. The anatomical findings and clinical applications proved that there is a constant and dependable blood supply through the dorsal scapular artery (synonym for the deep branch of the transverse cervical artery in the case of a common trunk with the superficial cervical artery) as the main vessel. Harvesting an island flap or a free flap is technically demanding but possible. Planning the skin island far distally permitted a very long pedicle and wide arc of rotation. The lower part of the trapezius muscle alone could be classified as a type V muscle according to Mathes and Nahai because of its potential use as a turnover flap supplied by segmental intercostal perforators. The lower trapezius flap is a thin and pliable musculocutaneous flap with a very long constant pedicle and minor donor-site morbidity, permitting safe flap elevation and the possibility of free-tissue transfer.     

The expansive gluteus maximus flap

The rich vascular network of the gluteal and posterior thigh region provides for a larger range of flaps for reconstructive surgery than previously described. Facility with these flaps requires an appreciation of relevant anatomy, embryology, and anthropology. Structural changes in the gluteus maximus muscle are critical to the evolutionary advance toward an upright stance during walking. The superficial and deep segmentation of the gluteus maximus are best appreciated by phylogenic and ontogenetic study. Femoral arterial and gluteal arterial anastomotic hemodynamics are affected by the relative involution of the gluteal system in late embryogenesis. The gluteal thigh flap should include contributions from the femoral system when the cutaneous branch of the inferior gluteal artery cannot be identified. Huge sacral wounds can be closed with gluteus maximus myocutaneous flaps with maintenance of muscular function by detaching the entire origin, sliding the muscle medially, and reconstructing these attachments. By dissection between the divergent inserting fibers of the gluteus maximus, a long, superficial portion of the muscle can be raised that forms the basis of the extended gluteus maximus flap. The pedicle of the flap is at the level of the piriformis muscle and the skin paddle can be placed over the midportion of the posterior thigh. Finally, the first deep femoral perforating artery forms the basis of a posterolateral fasciae latae flap that is well suited for coverage of defects over the trochanter.     

Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction.

The internal mammary vessels have been recommended as the first choice recipient vessels for delayed breast reconstruction with the free TRAM flap. This approach has avoided surgery in the previously operated axilla, has required a shorter pedicle length, and has allowed for more medial placement of the TRAM tissue. Frequency of nonusable axillary vessels has been reported at 11 percent, with a 6 percent incidence of flap loss in the delayed reconstructive setting. We reviewed our experience with the thoracodorsal vessels as recipient vessels in delayed free TRAM breast reconstruction to assess more accurately the adequacy of these potential recipient vessels. All patients undergoing delayed TRAM reconstruction were reviewed. Forty-seven of 300 consecutive TRAM procedures were for planned delayed free reconstruction. In seven of the patients (15 percent), the thoracodorsal vessels were found to be inadequate for free reconstruction. A supercharged pedicled TRAM was used for reconstruction in each of these seven patients. Average operating room time was 7 hours. Mean follow-up time was 38 months. Nineteen percent of all patients developed at least one complication. Twelve percent of free TRAM patients developed a complication, whereas 57 percent of supercharged patients developed a postoperative complication. The difference in complication rates was statistically significant. The thoracodorsal vessels have provided an adequate recipient vessel in 85 percent of delayed free TRAM reconstructions, comparable to previous reports. Pedicling and supercharging the flap, in those situations in which the thoracodorsal vessels were inadequate, were associated with an increased incidence of postoperative complications. This suggests that in the delayed reconstructive setting, higher-risk patients benefit from free reconstruction over supercharged reconstructions. A second recipient vessel should be used when the thoracodorsal vessels are inadequate for planned free TRAM reconstruction. In these circumstances, we would recommend the use of the internal mammary vessels followed by the thoracoacromial vessels as reliable alternative recipient sites for delayed free TRAM reconstruction.     

Neurovascular free-muscle transfer for the treatment of established facial paralysis following ablative surgery in the parotid region

Neurovascular free-muscle transfer for facial reanimation was performed as a secondary reconstructive procedure for 45 patients with facial paralysis resulting from ablative surgery in the parotid region. This intervention differs from neurovascular free-muscle transfer for treatment of established facial paralysis resulting from conditions such as congenital dysfunction, unresolved Bell palsy, Hunt syndrome, or intracranial morbidity, with difficulties including selection of recipient vessels and nerves, and requirements for soft-tissue augmentation. This article describes the authors' operative procedure for neurovascular free-muscle transfer after ablative surgery in the parotid region. Gracilis muscle (n = 24) or latissimus dorsi muscle (n = 21) was used for transfer. With gracilis transfer, recipient vessels comprised the superficial temporal vessels in 12 patients and the facial vessels in 12. For latissimus dorsi transfer, recipient vessels comprised the facial vessels in 16 patients and the superior thyroid artery and superior thyroid or internal jugular vein in four. Facial vessels on the contralateral side were used with interpositional graft of radial vessels in the remaining patient with latissimus dorsi transfer. Cross-face nerve grafting was performed before muscle transfer in 22 patients undergoing gracilis transfer. In the remaining two gracilis patients, the ipsilateral facial nerve stump was used as the primary recipient nerve. Dermal fat flap overlying the gracilis muscle was used for cheek augmentation in one patient. In the other 23 patients, only the gracilis muscle was used. With latissimus dorsi transfer, the ipsilateral facial nerve stump was used as the recipient nerve in three patients, and a cross-face nerve graft was selected as the recipient nerve in six. The contralateral facial nerve was selected as the recipient nerve in 12 patients, and a thoracodorsal nerve from the latissimus dorsi muscle segment was crossed through the upper lip to the primary recipient branches. A soft-tissue flap was transferred simultaneously with the latissimus muscle segment in three patients. Contraction of grafted muscle was not observed in two patients with gracilis transfer and in three patients with latissimus dorsi transfer. In one patient with gracilis transfer and one patient with latissimus dorsi transfer, acquired muscle contraction was excessive, resulting in unnatural smile animation. The recipient nerves for both of these patients were the ipsilateral facial nerve stumps, which were dissected by opening the facial nerve canal in the mastoid process. From the standpoint of operative technique, the one-stage transfer for latissimus dorsi muscle appears superior. Namely, a combined soft-tissue flap can provide sufficient augmentation for depression of the parotid region following wide resection. A long vascular stalk of thoracodorsal vessels is also useful for anastomosis, with recipient vessels available after extensive ablation and neck dissection.     

Arterial and venous anatomical features of the pectoralis minor muscle flap pedicle

The pectoralis minor muscle has been used as an innervated, vascularized, free-muscle graft in the field of facial reanimation for 20 years. Throughout this period, several centers have demonstrated consistent success with functional muscle transfer; however, opinions regarding the arterial pedicle of the flap have varied. The lateral thoracic and thoracoacromial arteries have been proposed as the predominant arterial sources. It has been the experience of our unit that a vessel (not described in anatomy textbooks) arising directly from the axillary artery and entering the muscle from its dorsal surface provides the dominant supply to the flap and is capable of sustaining it for free-tissue transfer. The vascular pedicle encountered was recorded and photographed in 97 consecutive cases in which the pectoralis minor muscle flap was raised. The findings demonstrated that the dominant supply to the muscle was from a single artery in 77 percent of cases and took the form of an artery arising directly from the axillary vessel in 72 percent of cases. More than one major arterial source was noted in the remainder of the cases. The venous outflow was usually through single or multiple veins running directly from the muscle into the axillary vein.     

Reconstruction of large sacral defects following total sacrectomy

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.     

Combined transplantation of free tissues

Combined transplantation of free tissues is a new microsurgical technique by which, with only one set of vessels supplying blood, two or more free tissues can be transplanted simultaneously. Very large soft-tissue defects that are not amenable to conventional transplantation, or defects of two or more tissues, either similar or different in nature, can be repaired in a one-stage operation. It is accomplished by vascular combination; i.e., by means of anastomosing the corresponding vessels of their pedicle, the free tissues to be transplanted are reconstituted into an assembly with only one common vascular pedicle which is then rejoined to the vessels selected to supply blood to the grafts in the recipient site. From December of 1983 to July of 1985, the author has performed 17 combined free-tissue transplantations of seven different clinical types for microsurgical repair and reconstruction of extremities. All the transplanted parts survived, and the extremities regained very good function. Seven patients are reported individually in the paper, each representing a definite clinical type. The concepts and operative technique introduced and the indications and advantages of the newly designed procedure are discussed.     

The functional pectoralis major musculocutaneous island flap in head and neck reconstruction

We describe our experience with the true island pectoralis major musculocutaneous flap in patients with high-volume defects for whom free-tissue transfer is unsuitable. Our operative technique is presented. We have modified the method of making a true island of the pectoralis major musculocutaneous flap on a muscle-free pedicle as first described by Wei et al. in 1984. This maintains maximal donor-site muscle function and facilitates closure of the donor-site defect. We present our results in 24 patients, in whom the flap has proved to be robust and reliable. The flap's advantages in terms of increased pedicle length, wider arc of rotation, decreased pedicle bulk, and improved cosmesis of the reconstruction are discussed.     

Breast reconstruction with free-tissue transfer

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the rationale for the use of free tissue transfer for breast reconstruction. 2. Understand the indications, advantages, and disadvantages of this method of reconstruction.The authors discuss the indications, advantages, and disadvantages of free-tissue transfer for breast reconstruction. The most common free flaps used today are individually discussed. Details about indications, contraindications, pertinent anatomy, pedicle characteristics, flap pliability, perfusion characteristics, advantages, and disadvantages for each of these flaps are presented. Details pertaining to the more common recipient vessels are presented. Future considerations are also briefly discussed.     

Fascia canals of the greater sciatic foramen and their practical importance

Fasciae and fat tissue spaces in the gluteal region, topography of the suprapiriform and infrapiriform foramina have been studied by means of a complex anatomical experimental technique. The suprapiriform foramen should be considered as a fascialosseous canal, as it is 4-4.5 cm long and 0.6-1.0 cm wide. It is formed by the upper margin of the greater sciatic notch covered with a thin fascia, fasciae of the gluteal and piriform muscles and the parietal layer of the pelvic fascia. The proper fascial vaginae of the upper gluteal vessels and nerves are adhered to fascial walls of the canal. This peculiarity is used for the method of ligation of the superior gluteal artery within the limits of the suprapiriform canal. The infrapiriform foramen is either narrow or wide enough (up to 2.0 cm in diameter). Inferior gluteal vessels at the level of the sacrospinous ligament go from the parietal layer of the pelvic fascia into the duplicature of the deeper layer of musculus gluteus maximus. The inferior gluteal nerve, above the lower margin of the piriform muscle, ajoining the vessels gets into the fissure of the parietal layer of the pelvic fascia, under the lower margin neurovascular fasciculus also goes through the fissure of the pelvic fascial parietal layer, downward and parallel to the inferior gluteal vessels. The knowledge of possible ways of connections through the canals of the greater sciatic foramen, fat tissue spaces at the subperitoneal level of the small pelvis and the gluteal region is of great practical value.     

Algorithm for recipient vessel selection in free tissue transfer to the lower extremity.

The proper selection of a recipient vessel is essential for the success of free tissue transfer, especially when the transfer is to the lower extremity. However, a general agreement on which vessel to use has not been reached yet. Conflicting data have been reported on the survival and outcome of the transferred flaps, depending on the vessel used or the location of anastomosis. The aim of this study was to identify the patterns and problems in the selection of recipient vessels for free tissue transfer to the lower extremity and to establish a general guideline for proper selection. From September of 1990 to December of 1997, 50 consecutive, microvascular, free tissue transfers were performed on the lower extremity. The causes requiring soft-tissue coverage included trauma (25), unstable scar (11), chronic osteomyelitis (7), and tumors (7). The mean follow-up period was 22.4 months (range, 2 to 41 months). In 25 cases, the posterior tibial vessel was used as the recipient vessel. The microvascular anastomosis was done proximal to the zone of injury in 45 cases. The two most important factors in the selection of a recipient vessel are the site of injury and the vascular status of the lower extremity. Less important factors include the flap to be used, method, and site of microvascular anastomosis. All the currently feasible options for recipient vessels are included, and the opinions of other surgeons are reviewed. A general guideline is established, and an algorithm for the proper selection of a recipient vessel is proposed. This algorithm is a fast and convenient guide for evaluating the wound and planning the free flap to the lower extremity.     

Breast reconstruction by superior gluteal microvascular free flaps without silicone implants

The author's experience with 10 gluteus maximus myodermal free flap breast reconstructions is reviewed against the current methods of reconstruction using silicone implants, latissimus dorsi flaps, regional skin flaps, and rectus abdominis myodermal flaps. The superior gluteal free flap can achieve a reliable, permanent, and aesthetic reconstruction of the breast without silicone implants. The softness, projection, natural appearance, and patient satisfaction are excellent compared with other methods. It is particularly useful in patients who object to the use of artificial implants, are not suitable for regional flaps, or have disappointing results from previous reconstructions. Technical modifications of the flap design and selection of the recipient vessels are important.