
==== Front
Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00623
00073
10.1097/GOX.0000000000006188
3
Breast
Original Article
Anatomical Analysis of the Superior Gluteal Artery in 100 Women for Superior Gluteal Artery Perforator Flap Breast Reconstruction
Aoki Hironobu MD *
Kamegai Mina MD *
Inoue Mariko MD *
Taga Marie MD *
Hokazono Yu MD *
Mitsuwa Hideyuki MD *
Kurita Tomoko MD, PhD †
Takei Hiroyuki MD, PhD †
Ogawa Rei MD, PhD, FACS *
From the * Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
† Department of Breast Surgery, Nippon Medical School Hospital, Tokyo, Japan.
Hironobu Aoki, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan, E-mail: hiro-hockey@nms.ac.jp
9 2024
20 9 2024
12 9 e61886 6 2024
24 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background:

The superior gluteal artery (SGA) perforator (SGAP) flap is used more rarely for breast reconstruction with autologous tissue than other flaps because the SGA is often narrow, and the SGAP can be short. However, it provides ample fat, including in lean women. To improve its safety and utility, the preoperative SGA course in women who underwent autologous breast reconstruction was determined with three-dimensional computed tomography angiography.

Methods:

Consecutive deep inferior epigastric perforator, profunda artery perforator, and SGAP flap cases in 2019–2023 were identified. Frequencies of the following favorable preoperative SGA-anatomy variables were determined: branching of the main-SGA trunk on top/posterior of the greater sciatic foramen (designated M1/2), which allows access to a sufficiently wide SGA artery; superolateral perforating location of the superficial-SGA branch (SP3), which means the perforator is sufficiently long for uncomplicated flap placement; and nonbranching of the deep-SGA branch (D1/D2), which means this branch can used a venous and an arterial graft to extend an insufficiently long perforator.

Results:

A total of 100 cases of deep inferior epigastric perforator (n = 80), profunda artery perforator (n = 13), and SGAP flap-based breast reconstructions (n = 7) were identified. Out of 200 buttocks, 89%, 91.5%, and 62% had the favorable M1/2, SP3, and D1/D2 variables, respectively. An atypical descending branch feeding the lower buttocks (DES1/2) was observed in 34%.

Conclusions:

The branching position of the main-SGA trunk, perforating location of the SGAP, and the shape of the deep branch were classified in detail in 100 patients. By creating a surgical plan that understands the anatomy taking preoperative three-dimensional computed tomography angiography, the SGAP flap can accommodate many patterns, increasing the possibility of safe execution.

OPEN-ACCESSTRUE
COUNTRYJAPAN
==== Body
pmcTakeaways

Question: This study solved anatomy of superior gluteal artery (SGA) and perforater (SGAP).

Findings: We analyzed SGA running patterns by three-dimensional computed tomography angiography and showed that an arterial diameter of the superficial branch is large due to the presence of descending branches, and that the deep branch can be used for venous and arterial grafting.

Meaning: Our study classified the branching position of the main-SGA trunk, perforating location of the SGAP, the shape of the superficial branch, deep branch, and descending branch. By creating a surgical plan that understands the anatomy taking preoperative three-dimensional computed tomography-angiography, the SGAP flap can accommodate many patterns, increasing the possibility of safe execution.

INTRODUCTION

Breast cancer is the most common malignant tumor in women worldwide.1 Due to improvements in screening and its widespread uptake, it can now be detected and treated at an early stage, thus greatly reducing the mortality rate. Consequently, quality of life is now a key consideration in patient management after tumor resection.2 Breast reconstruction improves quality of life because it increases patient self-esteem, reduces the psychological burden of surgery, and promotes social participation.3–8

Compared with prosthesis reconstruction, breast reconstruction with autologous tissue yields more stable aesthetic results and therefore greater long-term satisfaction.7,9–13 Various autologous tissue breast reconstruction methods have been proposed, including using a deep inferior epigastric perforator (DIEP), profunda artery perforator (PAP), latissimus dorsi (LD), or lumbar artery perforator flap or fat grafting. In many facilities, the DIEP or LD flap is the first choice.7,14–17 However, they may not be suitable for very lean patients with large breasts or patients with a history of abdominal surgery/liposuction. In such cases, the surgeon must choose another flap or fat grafting depending on the body type and wishes of the patient and the surgeon’s preference, experience, and skill.7,18–22

A possible but frequently overlooked flap alternative is the free superior gluteal artery (SGA) perforator (SGAP) flap. This flap originated from the free superior-gluteal myocutaneous flap that was first described by Fujino et al and was used for breast construction in breast/pectoral aplasia cases.23 Shaw24 and Codner and Nahai25 then described using a gluteal myocutaneous flap for breast reconstruction after mastectomy. Allen and Tucker reported using the free SGAP flap for breast reconstruction.26 These studies and others showed that the SGAP flap is both safe and reliable.12,25–28 A recent survey of breast-reconstruction cases also indicates that the SGAP flap associates with similarly high levels of satisfaction as the DIEP and lumbar artery perforator flaps.16 The SGAP flap may be particularly suitable for patients who are young, lean, have large breasts, and/or in whom reconstruction with a DIEP, LD, or PAP flap or fat grafting is not possible.14,16,19–22 This is because even in lean patients, the gluteal area provides excellent fat volume for recreating the natural shape of the breast.22

However, the SGAP flap is widely viewed as more technically challenging than the DIEP or LD flap. This is partly because of the complex branching pattern of the SGA, which has been described as the Medusa head.4,7,12–14,18,22,28 Briefly, the SGA is a continuation of the posterior division of the internal iliac artery and emanates in the posterior direction from the greater sciatic foramen of the pelvis above the upper border of the piriformis muscle, where it soon divides into a superficial branch and a deep branch.21,29 The superficial branches run under the gluteus maximus, whereas the deep branch runs between the iliac bone and gluteus medius. These branches, especially the superficial branches, insert smaller branches into the gluteus muscle above them; some then perforate the overlying fat and skin. The division of the SGA into superficial and deep branches occurs in the Medusa head and can take various patterns.12,22 The classical SGAP flap is located at the upper buttock and is fed by musculocutaneous SGAPs from the superficial branches.7,21,29 Rad et al also identified a septocutaneous perforator termed the lateral SGAP (LSGAP) that also arises from a superficial branch but feeds the side of the buttock22 (Fig. 1).

Fig. 1. Schematic depiction of the general course of the perforators and muscular branches that originate from the superficial and deep branches of the superior gluteal artery.

Several major problems can complicate SGAP-flap surgery, namely, the narrowness of the SGA artery, the shortness and variable length of the perforator, and the general lack of familiarity of many reconstructive surgeons with this donor-tissue region.22 The latter reflects the fact that although many papers have described the point on the gluteus maximus where the SGAP emerges into the subcutaneous-fat layer, other aspects of SGAP anatomy remain poorly researched.7,13,14,21,22,28–31

To improve the safety and utility of the SGAP flap, we analyzed the course of the bilateral SGAs of 100 Japanese women by examining their three-dimensional computed-tomography angiography (3D-CTA) images, which were acquired before breast reconstruction surgery.

PATIENTS AND METHODS

Study Design and Ethics

This retrospective single-center cross-sectional study was conducted in Nippon Medical School Hospital, Tokyo, Japan. It was approved by the hospital institutional ethics review board (No. B-2022-556). It conformed to the Declaration of Helsinki. All patients gave informed written consent to the use of their medical data for research purposes.

Patient Recruitment

The medical records were searched for consecutive patients who underwent contrast-enhanced 3D-CTA of the SGA before autologous-tissue breast reconstruction using a DIEP, PAP, or SGAP flap from April 2019 to June 2023.

Analyses of 3D-CTA Data

The 3D-CTA images of the SGA were assessed for the following five bilateral variables: (1) The location relative to the greater sciatic foramen where the SGA branched into the superficial and deep branches. This was categorized as the top of the greater sciatic foramen (M2); posterior of this point (M1); or anterior of this point (M3; Figs. 2 and 3). (2) The location where the superficial-branch SGAPs (defined as ≥1 mm on 3D-CTA) protruded into the fat layer. This was categorized as the inner (SP1) or outer (SP2) half of the gluteus-maximus muscle belly (ie, the perforator was a classical musculocutaneous SGAP); at the gluteus-maximus lateral edge (SP3) (ie, the perforator was the septocutaneous LSGAP); or under the gluteus maximus (SP4; Fig. 4). (3) The branching pattern of the deep branch. This was categorized as either a single branch (D1); eventually branching into two or more smaller branches (D2); and immediately branching into two or more smaller branches (D3). (4) The branching pattern of the descending branch emerging from the Medusa head was newly detected on 3D-CTA. This was categorized as being the same trunk from which the superficial branches arose (DES1); and the SGA before it split into the superficial and deep branches (DES2) (Figs. 5 and 6). (5) The arterial diameter before and after merging with the superficial branch and deep branch.

Fig. 2. Location relative to the greater sciatic foramen of the point where the SGA branches into the superficial and deep branches. This was categorized as either the top of the greater sciatic foramen (M2), posterior of this point (M1), or anterior of this point (M3). Schematic depiction of the posterior view of the greater sciatic foramen, the branching of the SGA into the superficial (upper) and deep (lower) branches, and the M1, M2, and M3 patterns.

Fig. 3. Representative 3D-CTA images of the M1 (A), M2 (B), and M3 (C) patterns. DB, deep branch; SB, superficial branch.

Fig. 4. Location where the SGA perforator protruded into the fat layer. This was categorized as being from the inner half of the muscle belly of the gluteus maximus (SP1), the outer half of the gluteus maximus (SP2), near the lateral edge of the gluteus maximus (SP3), or under the gluteus maximus (SP4). A representative 3D-CTA image of a patient. The dots show the bilateral locations where the 801 superficial SGA perforators (defined as ≥1 mm on 3D-CTA) in the 200 buttocks emerged into the fat layer.

Fig. 5. The branching patterns of the deep branch and the descending branch. The descending branch was newly detected in the present study. The branching pattern of the deep branch was categorized as no major branching (D1), eventually branching into two or more smaller branches (D2), and immediately branching into two or more smaller branches (D3). The branching pattern of the descending branch was categorized as originating from the same trunk that gave rise to the superficial branches (DES1) or originating from the SGA before it split into the superficial and deep branches (DES2). Schematic depiction of D1-3 and DES1-2.

Fig. 6. Representative 3D-CTA images of the D1 (A), D2 (B), D3 (C), DES1 (D), and DES2 (E) patterns.

Statistical Analysis

Continuous variables were expressed as mean ± SD (parametric distribution). Univariate analysis with categorical variables was performed with unpaired Student t test and Mann-Whitney U test. All analyses were conducted with SPSS version 29. P values of less than 0.05 indicated statistical significance.

RESULTS

In total, 100 patients underwent breast reconstruction with a DIEP (n = 80), PAP (n = 13), or SGAP flap (n = 7). On average, they were 47.7 ± 0.7 years old and had a body mass index (BMI) of 21.9 ± 0.4 kg per m2.

Anatomical SGA Analysis

In 62.5%, 26.5%, and 11% of the 200 buttocks, the SGA branching into the superficial and deep branches occurred at (M2), posterior of (M1), and anterior of (M3) the top of the greater sciatic foramen (M2), respectively. The favorable M1/M2 pattern, which indicates ready access to the main SGA trunk, was present in one and both buttocks in 97% and 81% of patients, respectively (Fig. 2 and Table 1).

Table 1. Number of the M1-3, SP1-4, D1-3, and DES1-2 Patterns in the Left and Right Buttocks of the 100 Patients

M1/2/3, SP1/2/3/4, D1/2/3 and DES1/2 Pattern in 100 Patients	
Variable	n	Variable	n	Variable	n	
M1		SP1		D1		
 Left	58	Left	82	Left	34	
 Right	67	Right	63	Right	35	
M2		SP2		D2		
 Left	28	Left	96	Left	26	
 Right	25	Right	96	Right	29	
M3		SP3		D3		
 Left	14	Left	90	Left	40	
 Right	8	Right	92	Right	36	
		SP4				
Bilateral M1	50	Left	9	DES1		
M1 and M2	19	Right	6	Left	23	
M1 and M3	6			Right	29	
M2 and M2	12			DES2		
M2and M3	10			Left	9	
M3 and M3	3			Right	7	

There were 801 perforators from superficial branches (on average four perforaters/side). In 72.5%, 96%, 91%, and 7.5% of the 200 buttocks, the perforaters protruded from the gluteus-maximus inner half (SP1 location), outer half (SP2), lateral edge (SP3), and below the gluteus maximus (SP4), respectively. Unilateral and bilateral surgical procedures with the classical SGAP flap (SP1/SP2 perforators) were possible in 100% of patients. Unilateral and bilateral LSGAP flap surgical procedures (SP3 perforator) were possible in 97% and 86% of patients, respectively (Fig. 4 and Table 1).

In 34.5%, 27.5%, and 38% of the 200 buttocks, the deep branch did not branch (D1 pattern) or eventually (D2) or immediately (D3) branched into two or more smaller branches, respectively. The favorable D1/D2 pattern shows that the deep branch can be used to extend an insufficiently long perforator: in the 17 buttocks where an LSGAP was absent, 71% of 17 buttocks had the D1/D2 pattern (Figs. 5, 6 and Table 1).

We noted that all 15 SP4 cases, and another 13 cases, had an SGA branch that descended from the Medusa head (Fig. 4). In 26% and 8% of buttocks, this descending branch respectively originated from the same trunk that generated the superficial branches (DES1 pattern) or the SGA before it split into the superficial and deep branches (DES2; Figs. 5, 6 and Table 1).

The average arterial diameter after merging with superficial branch and deep branch was 2.84 ± 0.55 mm. The average arterial diameter before merging with superficial branch and deep branch was 1.78 ± 0.46 mm. There was a difference in arterial diameter before merging with the superficial branch and deep branch between those with descending branches and those without (1.67 ± 0.39 versus 2.08 ± 0.51 mm, P < 0.001). There were no differences in arterial diameter depending on age, BMI, or left-hand and right-hand sides.

DISCUSSION

In our hospital, 7% of patients who undergo autologous-tissue reconstruction receive the SGAP flap. We consider the SGAP flap to be suitable for patients with large breasts, breasts with less ptosis, lean patients, young patients, and patients who cannot have/do not want an abdominal flap donor site. These SGAP surgery indications have also been reported by other studies,7,13,16,18,21,22,27 which also note the predominance of younger and leaner patients in the SGAP-flap surgery population.12,30,32 In particular, the SGAP flap is very useful for providing large volumes in patients with low BMI.7,12,18 Indeed, Flores et al reported that the SGAP flap could yield 186–1117g of tissue from patients with an average BMI of 23.8 kg per m2, which is sufficient for reconstructing large breasts.12 Thus, in a subset, albeit small, of patients, the benefits of SGAP outweigh those of DIEP and PAP.

Other SGAP-flap advantages are its reliable vascular base; its ability to be removed from the contralateral side; its suitability for patients who want children; and its donor-site scars being easily hidden by underwear.7,18,21,22,28,29,32

However, the SGAP flap also has some disadvantages: postural changes are needed; micromanipulation can be difficult because of the narrow artery and the short pedicle; defects in buttock contour can make this flap unsuitable for ptotic breasts; and the Medusa head complicates detection of the SGA-related vessels. To determine how severe these anatomical problems are, we examined the SGA course in 100 women (200 buttocks).

First, we observed that SGA branching into the superficial and deep branches rarely occurred anterior of the greater sciatic foramen (11% of cases; M3). This is relevant because the narrow artery of the free SGAP flap12,18,21,22,28 means that it is necessary to expose and separate the blood vessel up to the main SGA trunk, where the artery is thicker: this will facilitate the subsequent vascular anastomosis with the internal mammary artery.7 In our study, in 34% of the buttocks, the diameter of the superficial branch artery before merging with the deep branch was less than 1.5 mm. The rarity of the M3 pattern, which limits access to the main trunk, means that the M pattern will favor unilateral and bilateral SGAP-flap surgery in 97% and 81% of patients, respectively. The M3 pattern which had a diameter of less than 1.5 mm at the base of superficial branch was five of 200. In this case, we thought that it was necessary to consider contralateral or other flaps. Rodriguez et al reported that arterial diameter at the hypothetical suture site was also rather constant, with an average of 1.6 mm and an SD of 0.2.19 Baumeister et al reported that the perforators have an average a diameter of 1–1.5 mm, and the superior gluteal artery measures 3.5 mm on average.7 Our study showed that the diameter of the SGA and the superficial branch varies widely among individuals (2.84 ± 0.55 mm, 1.78 ± 0.46 mm). It is necessary to measure the diameter of an artery at the site where the anastomosis is planned before surgery using 3D-CTA and consider how far it should be followed. We consider the diameter of the internal mammary artery and plan to follow the arterial diameter at the suture site to 2.0–2.5 mm.

Second, The SGA perforator can be short (as small as 3 cm), which complicates flap placement,7,12,18,21,22,28 and the reported vascular pedicle length ranges widely depending on the individual patient (3–13 cm).7,13,18,21,28,29,31,32 We noted that although 72.5% of buttocks had short SP1 perforators (ie, those that entered the subcutaneous fat from the inner gluteus-maximus muscle belly and were therefore close to the SGA base), 91.5% of buttocks had long SP3 perforators that were far from the SGA base. Based on the cadaver study of Rad et al, the short SP1 perforators are the classical SGAP that extends to the superomedial side of the buttock and is on average 5.5-cm long, whereas the long SP3 perforators are the alternative LSGAP that extends to the superolateral side of the buttocks and is on average 13-cm long.22 Rad et al22 reported that eight of 12 cadaver buttocks (66%) had an LSGAP with a caliber that was equivalent to that of the classical SGAP. Tuinder et al33 reported that 92.3% (24 of 26) of buttocks had LSGAP in a study of three cadaver dissections and using color Doppler in 10 adult volunteers. Our study showed that unilateral and bilateral LSGAP flap surgery could potentially be performed in 97% and 86% of patients, respectively.

Third, in 62% of cases, the deep branch displayed no branching (D1) or branched only later (D2). This is relevant because in cases where the only available SGA perforator is short, we use the deep branch of the SGA to extend it. We used the deep branch as a venous and arterial graft because the thickest perforator selected preoperatively was predicted to have a short pedicle length, and the deep branch had a D1 pattern. An example of this procedure is shown in Figure 7. Other studies reported using axillary vessels or the deep inferior epigastric artery and vein18 for perforator extension, but we prefer to use the deep SGA branch because it is safer, requires less time, and imposes less burden on the patient. However, it is difficult to use the deep SGA branch if it branches into smaller branches immediately after arising from the main SGA trunk (D3). Our study suggested that this will only rarely be a problem: in our study, 97.5% of buttocks either had an LSGAP perforator or the deep branch was suitable for extension.

Fig. 7. A representative example of a case where the deep SGA branch was used to extend the short classical perforator. A, View of the donor buttock showing the superficial and deep branches of the SGA. B, The resected deep SGA branch. C, After the deep SGA branch was grafted to the superficial SGA branch.

We also noted a variation found in one-fourth of cases, namely, an SGAP that emerged in the lower buttock and arose from a descending SGA branch. The descending branch itself either came from the same trunk that generated the superficial branches or SGA before it split into the superficial and deep branches (DES1/2). This variation was present in 34% of buttocks, including small variations, and some of which could indicate a substitution of the inferior gluteal artery. Furthermore, in the case of DES1, we discovered that the vascular pedicle became thicker after the superficial branch merged with the descending branch (Fig. 6E). Therefore, we found that it was possible to obtain a large blood vessel diameter without having to go all the way to the root where it merges with the deep branch.

Thus, our 3D-CTA analyses showed that: dissection up to the main SGA branch would be possible in 97% and 86% of unilateral and bilateral SGAP-flap cases, respectively; 91.5% (183/200) of SGAP flaps would have a relatively long perforator; and the deep SGA branch in the remaining 6% (12/200) of SGAP flaps would be suitable for perforator extension, 2.5% (5/200) of SGAP flaps would be unsuitable for perforator extension. These findings also highlight the importance of conducting 3D-CTA before surgery: this could help reduce the incidence of flap problems that could be caused by the narrow SGAP artery and the short classical perforator.12

With regard to complications, Zoccali et al18 observed that SGAP-flap-related complications were observed more frequently at the donor site than at the breast, although they reported a lower donor-site seroma rate (9%). Other facilities also reported lower seroma rates after SGAP-flap transfer (0%–35%).7,12,13,18,20,21,28,32

At our hospital, all SGAP flap patients had a seroma at the donor site. Our high seroma rate reflects the fact that we harvest a large amount of fat flap without removing much skin: this leaves a large cavity that is prone to seroma. The seroma after SGAP-flap transfer generally resolves within 2 months with treatment with puncture every 1–2 weeks in an outpatient setting.

We observed that none of our SGAP flaps demonstrated partial or total flap necrosis. A high SGAP-flap necrosis rate is seen in some7,34 but not other studies13,14,18,20,22 (range: 87.5–100%) and thus seems to vary depending on the facility. Thus, our study suggests that the SGAP flap can be performed relatively safely.

In our hospital, the first option for autologous-breast reconstruction is DIEP, followed by PAP or LD, with SGAP being the fourth choice. When deciding between SGAP and the other flap alternatives, it should be noted that SGAP, PAP, and LD, but not DIEP, can be used for bilateral metachronous breast cancer.14 In our experience and that of others,16 patients undergoing breast reconstruction with the SGAP flap are as satisfied with the appearance and results as patients who underwent DIEP-flap surgery. An example of the excellent outcomes of the SGAP flap is shown in Figure 8. Although it has been postulated that SGAP flaps may become less relevant as autologous breast reconstruction evolves further,15 we believe that the SGAP flap is still very useful in some patients.

Fig. 8. Representative example of the aesthetic outcomes after breast reconstruction with an SGAP flap. A, Before tumor resection. B, After tumor resection and insertion of a tissue expander. View of the recipient (C) and donor site (D) 2 years after breast reconstruction with an SGAP flap.

Considering the relationship between breast implants and anaplastic large cell lymphoma, it is likely that the demand for autologous breast reconstruction will rise in the future. Providing patients with a choice of various surgical methods will increase patient satisfaction and well-being.

LIMITATIONS

Our study has some limitations. First, there were only seven SGAP patients. Second, the 3D-CTA data for DIEP patients were obtained in the supine position. Thus, some different results could be observed with 3D-CTA in the prone position.

CONCLUSIONS

Our study showed that the arterial diameter of the superficial branch is large due to the presence of descending branches, and that the deep branch can be used for venous and arterial grafting. We were also able to provide a more detailed dissection with more patients than previous studies. Several feared problems of the free SGAP flap, namely, narrow artery and short perforator, can be circumvented by performing preoperative 3D-CTA and classifying the branching position of the main-SGA trunk, the perforating location of the SGAP, the shape of the deep branch, and the presence of the descending branch.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Published online 20 September 2024.

Disclosure statements are at the end of this article, following the correspondence information.
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