Autologous - Gluteal

The lower abdomen represents the major donor site for autologous breast reconstruction. However, this source of tissue can sometimes be limited, for example, if a patient is very thin or there is extensive scarring of the anterior abdominal wall. In these circumstances, the buttock offers a valuable alternative.

The microsurgical transfer of a gluteal myocutaneous flap for breast reconstruction was first described by Fujino et al in 1975. Despite initial enthusiasm, this flap was plagued by a difficult dissection, short vascular pedicle and significant donor site morbidity. The advent of perforator flaps in the early 1990s marked a major technical improvement.

The superior gluteal artery perforator flap (SGAP) and inferior gluteal artery perforator flap (IGAP) include tissue from the upper and lower part of the buttock, respectively. However, in both cases, donor site morbidity is minimised, by avoiding the unnecessary resection of important underlying locomotor muscles.

As a result, the SGAP flap is our preferred choice for autologous breast reconstruction after the DIEAP flap.


Both perforator flaps from the buttock, like the DIEAP flap, are composed of skin and subcutaneous fat only The superior gluteal artery perforator flap (SGAP) is based on the superior gluteal artery (fig. 1, 2) and the inferior gluteal artery perforator flap (IGAP) is based on the inferior gluteal artery (fig. 1, 3). The blood vessels supplying both flaps are dissected from between the fibres of the gluteal muscles. As a result, the muscles are left completely intact and are fully functional post-operatively (fig. 4 a, b). The vessels (fig 4c, d) can then be connected to the internal mammary artery and vein, lying next to the sternum.

Gluteal perforator flaps can be shaped into an excellent three dimensional breast (fig. 4e). The surgery moderately raises the buttock and leaves a diagonal scar, though this is covered when wearing underwear or a bikini (fig. 4f).

Fig. 1

Fig. 2 Fig. 3


Fig. 4a Fig. 4b
Fig. 4c Fig. 4d
Fig. 4e Fig. 4f

Fig. 4: Schematic representation of the SGAP procedure: (a) location of the skin paddle over the vessels, (b) splitting of the gluteal muscle and isolation of the vascular pedicle between the fibres, (c, e) the flap consisting out of skin, fat and the supplying gluteal blood vessels connected to the internal mammary vessels, (d) result following delayed reconstruction after a modified radical mastectomy, (f) the donor site scar.


  • A significant amount of tissue can be harvested form the buttock and even slim women may have sufficient tissue for this procedure
  • The blood vessels supplying gluteal perforator flaps are often large and the anatomy is less variable than the DIEAP flap
  • The location of the donor site scar means that it is not readily visible when one looks in the mirror.
  • The scar from the SGAP flap can easily be hidden by underwear or a bikini.


  • The firmer consistency of gluteal tissue means that shaping the breast can be more challenging and further surgery may be required to perfect the appearance of the reconstruction.
  • The skin island of gluteal perforator flaps is often relatively small and in delayed reconstruction, particularly in thin women with tight, irradiated skin, it may not be possible to recreate the natural droopiness of the breast.
  • There may be some buttock asymmetry, as tissue is only taken from one side.
  • The IGAP flap leaves a scar in, or just below, the lower crease of the buttock which can be more difficult to hide.
  • IGAP flap surgery can expose the sciatic nerve which may lead to problems when sitting.
  • As with all microsurgical reconstruction, the operating time is prolonged; a unilateral gluteal flap takes 5-6 hours and bilateral cases take 8-10 hours.


Fig. 5a Fig. 5b
Fig. 5c Fig. 5d
Fig. 5e Fig. 5f


Fig. 5: Pre-(a, e)) and postoperative (b, c, d, f) pictures of a 47-year-old woman who had previously undergone a breast reduction and abdominal wall liposuction before developing a right breast cancer. A skin-sparing mastectomy of the right breast combined with immediate reconstruction using an SGAP flap. A nipple reconstruction and left breast reduction were performed at a second procedure to improve symmetry. Although the donor site scar on the buttock is clearly visible, it rarely produces a significant contour deformity.

                          Fig. 6a
Fig. 6b

Fig. 6: postoperative pictures of a patient who underwent an immediate reconstruction of the right breast with a free SGAP flap and a delayed reconstruction of the left breast with the same flap. Nipple reconstruction and tatto were performed in a secondary procedure. Additional liposuction and lipofilling procedures were necessary at the breasts and at the gluteal area (b) to optimize the shape and the aesthetic outcome.


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