Operative Technique in Plastic Surgery – Kevin C.Chung

■ Place a “beanbag” body positioner on the OR table if available.
FIG 2 • Lateral decubitus position with appropriate
padding.
■ Patient is transferred to OR table, monitoring equipment is applied, and the
patient is intubated. Ensure that tube is secure and eyes are protected.
■ Patient gown should be removed.
■ To place in the lateral position, with appropriate resources and careful
choreography, the patient is shifted and rolled into the lateral decubitus
position with the surgical site facing up (FIG 2).
■ Make note of all pressure points and pad appropriately.
■ Head is placed in a doughnut or head cradle; ensure ear lobe and helix are not
folded or compressed and eyes are protected.
■ The lower arm is placed on an arm board and pillows, or an additional arm
board is placed for the upper arm.
■ The arms are secured with straps.
■ Pad the olecranon if needed.
■ A gel roll is placed as an axillary roll.
■ A gel pad is placed between the OR table and the “bottom leg” knee and
ankle.
■ Foam or pillows are placed between the knees.
■ Place foam or a pillow between the ankle malleoli.

■ The beanbag positioner (if available) is “inflated” to help hold the patient in
the lateral position.
■ Ensure genitalia are free from compression.
■ Check EKG pads, monitoring devices, grounding pads, and catheters to make
sure they are not placing pressure on the skin and are outside of the operative
field.
■ Take care that any ostomies, if present, are free from compression.
■ Ensure no traction on indwelling catheters.
■ Secure patient to bed at both the trunk and lower legs.
■ Apply warming blankets or forced air to upper trunk.
Approach
■ To provide coverage for a greater trochanter pressure ulcer, the TFL flap is
raised and advanced into position as a V-Y advancement flap.
■ The flap is raised as a myocutaneous flap.
■ The V-Y advancement places the best perfused and bulkiest tissue into the
defect.
■ In most cases, the donor site can be closed primarily.
■ If the flap is greater than 9 cm in width, the donor site may need to be skin
grafted.
T E C H N I Q U E S
■ Excisional Debridement
■ Failure to adequately debride can lead to recurrent disease and poor wound
healing.
■ Probe wound prior to debridement so all tunneling is addressed.
■ Infiltration of the peribursal area with a wetting solution (1000 mL of normal
saline plus 30 mL of 1% lidocaine, plus 1 ampule of epinephrine 1:1000) can
assist with hydrodissection and decrease blood loss.6
■ Coating the cavity with methylene blue applied with gauze or a cotton
applicator can assist with bursa excision and verify the completeness of the
debridement.
■ Debridement removes necrotic tissue and biofilm and decreases bacterial

count.
■ Converts a chronic wound into an acute wound.
■ Quantitative wound cultures should be obtained following debridement so
that postoperative antibiotic coverage can be tailored appropriately.
■ Ostectomy
■ Because most pressure sores are overlying bony prominences and underlying
osteomyelitis and unhealthy bone is likely, the bony prominence should be
eliminated (TECH FIG 1).
■ The greater trochanter ostectomy should be performed conservatively to
lessen the prominence because its radical removal may redistribute pressure
points to adjacent tissue, result in excessive bleeding, and affect the origin
and/or insertion of skeletal muscle.
■ Send a portion of the ostectomy specimen as a bone biopsy to evaluate for
osteomyelitis.

TECH FIG 1 • A. Left trochanteric ulcer prior to
debridement. This ambulatory patient developed a
pressure ulcer while recovering from a major surgery.
B. Ulcer following debridement and ostectomy.
(Courtesy of Noopur Gangophadyay, MD.)
■ Tensor Fascia Lata V-Y Advancement Flap
Markings and Flap Design
■ Following debridement and limited ostectomy, begin with marking
anatomical landmarks (TECH FIG 2).
■ ASIS.

■ Lateral femoral condyle.
■ Draw a line between these two landmarks—this line marks the anterior
border of the muscle.
■ The LCFA enters the TFL 7 to 12 cm distal to the ASIS.
• Mark the position of the vascular pedicle.
• This can be confirmed with handheld Doppler.
■ Design the skin paddle so that is it centered over the TFL.
■ Mark a position on the iliac crest that is 3 cm posterior to the ASIS.
■ Draw a line from this point to the lateral condyle; this represents the
midaxis of the TFL.
■ Measure a point on the midaxis that is 8 to 10 cm proximal to the lateral
condyle—this marks the most distal extent that the flap can be designed.
TECH FIG 2 • TFL anatomical markings and flap
design. (Courtesy of Noopur Gangophadyay, MD.)
• The distal one-third of the skin territory is unreliable and the flap design
should exclude this area if possible.
■ The flap width should be less than 9 cm if primary closure is desired.
■ The posterior marking of the flap incorporates the anterior portion of the
debrided wound.
Flap Harvest and Inset
■ The flap is harvested from distal to proximal.
■ After the skin and fascia lata is incised inferiorly, it is helpful to suture these

structures together temporarily to prevent shear.
■ Dissection proceeds proximally in the subfascial plane (TECH FIG 3A).
■ Anticipate the vascular pedicle starting 12 cm distal to the ASIS and proceed
slowly when approaching this area.
■ The lateral femoral cutaneous nerve is also located near the anterior aspect
of the flap near the vascular pedicle; take care not to injure it.
■ Near the point that the dissection approaches the pedicle, it is usually
possible to advance the flap posteriorly into the defect.
■ A back-cut may be necessary to improve the rotation and advancement into
the defect.
■ Drains are placed into the donor site and the recipient site.
■ The flap is inset and the donor site closed with monofilament absorbable
sutures and the skin is closed with sutures or staples (TECH FIG 3B,C).
■ The advancement of the flap into the defect often produces a soft tissue
“dog-ear” at the proximal part of the flap. This will flatten with time. Do not
attempt to excise at this stage.
TECH FIG 3 • A. TFL flap dissection completed in the
subfascial plane. B. Flap inset. Two drains were used.
Donor site is closed primarily. C. TFL flap 3 months

postoperatively. (Courtesy of Noopur Gangophadyay,
MD.)
PEARLS AND PITFALLS
Preoperative
Planning
■ Correct any and all extrinsic and intrinsic factors that led to the
pressure ulcer development.

■ Sacrifice of the TFL could affect function in a patient who is an
athlete.
Operative
■ Avoid undue tension with flap inset; use a conservative back-cut if
needed.

■ The distal skin territory is unreliable; avoid excessive flap length.

■ Primary donor-site closure is facilitated by undermining the fascia
lata anteriorly and posteriorly.
Postoperative
Care
■ Engage a multidisciplinary team including nursing, social work,
and other consulting services as appropriate to ensure a safe
discharge and to the patient the “best chance” of preventing
recurrence.
POSTOPERATIVE CARE
■ Patients are hospitalized for 1 to 2 weeks following surgery, and many patients
will discharge to a rehabilitation hospital or an extended care facility for
several weeks to receive a higher level of nursing care.
■ A low air loss mattress should be ordered prior to the surgery and should be
available to move the patient onto the mattress directly from the operating
room table.
■ The patient should limit the HOB to less than 10 degrees for 1 week.
■ The patient should be repositioned every 2 hours, and kept off the surgical site
unless on an air fluidized bed.
■ The postoperative dressing should be left in place for 48 hours; after that time,
a light dressing can be applied to protect against shear and moisture or the
wound can be left open to the air to allow for ease of wound monitoring.

■ Bladder and bowel function should be controlled to prevent urinary or fecal
contamination of the surgical site.
■ Spasticity should be prevented with pharmacologic measures.
■ Obtain a dietary consultation so that the patient can maintain a positive
nitrogen balance.
■ Meticulous drain care should be performed in the hospital and taught to all
caregivers.
■ Obtain an infectious disease consultation for any positive operative cultures to
help guide antibiotic selection and duration of treatment.
■ Evaluate need for long-term intravenous access for antibiotics.
OUTCOMES
■ Recurrence rate is high, especially in those with hip flexion contractures.
■ Local wound/incision problems are common and should be treated with local
wound care.
■ Anticipate further reconstruction options with every surgical intervention.
■ Control for extrinsic and intrinsic factors that contributed to the initial pressure
ulcer formation.
COMPLICATIONS
■ Complications are not uncommon for those with significant preoperative
comorbidities.
■ Hematoma or seroma may occur.
■ If patient is on anticoagulants, work closely with the hematologist to
determine when these medications can be safely held and resumed in the
perioperative period.
■ One or more drains should be left under flaps for days to weeks to control for
fluid accumulation.
■ Small localized incisional breakdown should be treated with local wound care.
■ Persistent infection can be minimized with thorough debridement and long-
term antibiotics as deemed appropriate by infectious disease colleagues.
REFERENCES
1. National Pressure Ulcer Advisory Panel (NPUAP) Pressure Stages/Categories.
2016. Available at
resources/npuap-pressure-injury-stages.
2. Marin J, Nixon J, Gorecki C. A systematic review of risk factors for the

development of and recurrence of pressure ulcers in people with spinal cord
injuries. Spinal Cord. 2013;51(7):522-527.
3. Huang AB, Schweitzer ME, Hume E, et al. Osteomyelitis of the hips/pelvis in
paralyzed patients, accuracy and clinical utility of MRI. J Comput Assist
Tomogr. 1998;22:437.
4. Heggers JP, Sazy JA, Stenberh BD, et al. Bacterialcidal and wound-healing
properties of sodium hypochlorite solutions: The 1991 Lindberg Award. J Burn
Care Rehabil. 1991;12:420.
5. Janis JE, Kenkel JM. Pressure Sores. Sel Read Plast Surg. 2003; 9(39):1-42.
6. Han H, Fen J, Fine NA. Use of the tumescent technique in pressure ulcer
closure. Plast Reconstr Surg. 2002;110:711.
7. Bauer J, Phillips LG. MOC-PS(SM) CME Article: Pressure sores. Plast
Reconstr Surg. 2008;121:1-10.

32
CHAPTER
Repair of Flank and Lumbar
Defects
Sergey Y. Turin, Chad A. Purnell, and Gregory A. Dumanian
DEFINITION
■ A defect in the flank/lumbar region of the abdominal wall can be a challenging
problem as there is much discord in the literature regarding its etiology and
management. Defined as an inability of the abdominal wall to properly contain
the viscera and located lateral to the semilunar line, flank defects are
encountered after surgeries requiring retroperitoneal access (transplant,
vascular, urologic); these defects occurred fairly frequently, ranging from as
low as 8% to 23% in the literature.1–4 The etiology of these defects can be of
two types—a hernia or a focal weakness of the abdominal wall, usually
attributed to denervation injury. A true hernia implies violation of one or more
of the layers of the abdominal wall musculature. In contrast, a bulge secondary
to denervation injury leading to muscle attenuation and weakness implies
continuity of all three layers of the abdominal wall. In our recent review of 31
patients, we found that 55% of patients had a disruption of the internal oblique
and transversus abdominis muscles, whereas the external oblique muscle was
intact—a type of “partial” hernia often confused with a denervation bulge. In
32%, all three abdominal wall layers were disrupted as true incisional hernias.
In the remainder, the three layers of the abdominal wall were intact but had a
loss of tone due to denervation—true abdominal wall bulges.
■ We present a reliable technique to repair the flank defects that is efficacious
for true hernias and can be used for certain denervation injuries.
ANATOMY
■ The lateral and lumbar abdominal wall is composed of three load-bearing
muscular layers and their respective fascial envelopes—the external and

internal oblique and the transversus abdominis. All three of these can be
compromised by an incision for retroperitoneal access. Discontinuity of these
layers would lead to a hernia defect. (See the chapter on “Synthetic and
Biologic Mesh for Abdominal Wall Defects,” FIG 1, for example.)
■ The muscles of the abdominal wall are segmentally innervated by the 7th
through 12th intercostal as well as the iliohypogastric and ilioinguinal nerves
running between the transversus abdominis and the internal oblique muscles.
In this plane, they are vulnerable to transection during a retroperitoneal
approach for incisions that cross dermatomes. They are also susceptible to
focal injuries from retractors, cautery, and abdominal wall full-thickness
sutures (FIG 1).
FIG 1 • Innervation of the abdominal wall.
PATHOGENESIS

■ True hernias occur when the ultimate tensile strength of the repair is less than
the forces applied. Acutely, the sutures can tear through the abdominal muscles
during coughs and forceful movements and lead to a dehiscence or
evisceration. Chronically, tissue located within the loop of suture becomes scar.
When the strength of the scar, sutures, and foreign body reaction to those
sutures is less than the forces applied, an incisional hernia develops. In
comparison to incisional hernias, flank bulges are due to denervation of the
abdominal wall. Narrow zones of denervation with loss of just one or two
intercostal nerves during the original surgery do exist, often due to resection of
spinal cord roots for exposure or tumors. Alternatively, there can be a large
zone of denervation from a profound spinal injury. The larger the zone of
injury, such as with a spinal cord injury, the less the techniques in this chapter
apply.
■ With maneuvers that are intended to stabilize the torso such as the Valsalva
maneuver, the viscera instead distend the flank defect and cause a disagreeable
and sometimes painful contour irregularity. Patients complain of discomfort
due to an inability to raise their intra-abdominal pressure and altered torso
mechanics—a loss of “core strength.”
■ See the chapter on “Abdominal Hernia Reconstruction” for a discussion of the
biomechanics of the abdominal wall and the importance of evaluating
abdominal wall compliance when dealing with these defects.
NATURAL HISTORY
■ These defects can often be a cause of marked pain and lead to functional
impairment with diminished quality of life.5 The plastic surgeon will usually
see the patient in a delayed setting, with the consultation being prompted by
worsening symptoms.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients are encouraged to obtain all the previous operative notes, and it is
important to record if a rib was resected at the original procedure. Hernias
present for many years are more difficult to close than a hernia less than 1 year
from the index surgery. It is of great importance to discuss the medical history
and comorbid conditions, such as COPD, diabetes, cardiac disease, and any
rheumatoid conditions.
■ Prior incisions are recorded, and an evaluation of skin quality and abdominal
wall compliance is made. The patient is asked to stand as well as to lie in the

lateral decubitus position to clarify the borders and size of the defect. Palpate
the bulge with an eye toward feeling any muscle contraction or edge to the
defect to gain an idea of whether the remaining muscle is innervated and
continuous. Look for incisions of the midline back that denote spine pathology
and possible denervation.
■ A social history is important to appreciate the stresses on the torso required to
return to work or important social activities.
IMAGING
■ We routinely obtain a CT scan of the abdomen using oral and IV contrast to
assess the layers of the abdominal wall, to measure the size of the defect, and to
screen for any other intra-abdominal pathology (such as a recurrent cancer) as
dictated by the patient’s history. Any midline hernias would be documented
(though typically not addressed) at the time of the flank repair (FIG 2).
FIG 2 • CT Scan of a patient with a flank hernia.
NONOPERATIVE MANAGEMENT
■ If there is adequate soft tissue coverage over the viscera, we counsel the

patient that closure of these large defects is indicated if they are symptomatic
and the hernia affects their lifestyle and activities. Given the usually large size
of these hernias, bowel incarceration is infrequent. Nonoperative management
with binders or fajas is encouraged, but typically is only partially effective, and
patients typically do not feel comfortable in these hot and heavy garments.
Patients with significant medical problems and patients with large zones of
denervation are often encouraged not to have repair in an effort to balance risks
and benefits of the procedure.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients are optimized for surgery with smoking cessation, weight loss, and
improvement of exercise tolerance. A mechanical bowel prep with clear
liquids, magnesium citrate, and bisacodyl tablets by mouth shrinks the bowel
and improves the ability to perform the repair without changing the bowel
flora.
■ Use the Caprini risk-stratification model to assess the individual patient’s risk
for DVT/PE and assign chemoprophylaxis if appropriate.
■ The lateral position required for repair of a flank hernia is not appropriate for
other general surgery procedures with a single prepping and draping. Although
midline hernias can be repaired simultaneously, we have tended to focus on
one defect at a time.
Positioning
■ The patient is positioned in a lateral decubitus position with the planned
incision over the break in the operating table. (See Figure 3 for example.)
■ Appropriate padding for the dependent extremities and an axillary support are
placed.
■ The operative field should extend from the level of the nipples to the level of
the pubis and from the umbilicus anteriorly to the spinal column posteriorly
(FIG 3).
Approach
■ We approach these repairs through the original incision and then trim back any
excess soft tissue at the time of closing (FIG 4).

FIG 3 • Later decubitus positioning.

FIG 4 • Preoperative markings.
T E C H N I Q U E S

Video p5-c032
■ Approach and Development of Tissue Planes
■ Make a generous incision through the original scar and extend it to facilitate
later skin tailoring (TECH FIG 1A,B).
■ Incise the abdominal wall and/or hernia sac through the prior scar to enter
the abdomen and then clear the inner aspect of the abdominal wall of
omentum and bowel. At this point, raise skin flaps cranially and caudally to 4
cm past the level at which the abdominal musculature feels intact by a pinch
test. The retracted internal oblique and transversus abdominis muscles can
usually be palpated as a thickening of the abdominal wall layers.
00:00 / 00:00

TECH FIG 1 • A,B. Incision and exposure of the
hernia sac.
■ Determining Plane of Mesh Placement
■ Grasping this thick aspect of the abdominal wall, assess how easily these
two shelves of muscle tissue can be approximated once the operating table is
placed in the reflex position. If they can be closed easily and the defect is
relatively posterior, the two deep muscle layers are closed and mesh is placed
deep to the external oblique as shown in TECH FIG 2A.
■ If tissue quality is poor and the two deep muscle layers can only be closed
with reflex positioning and tension, mesh is placed intraperitoneally as an
underlay as shown in TECH FIG 2B.
■ Mesh sutured repairs use strips of macroporous mesh as sutures to
approximate layers of the abdominal wall work especially well in nonmidline
defects and are especially helpful where the ribs or the iliac crest limit the
ability to place even a narrow strip of mesh. The mesh sutures are introduced
through the abdominal wall tissue with a sharp hemostat.

TECH FIG 2 • Mesh placement illustration. A. Mesh is
placed deep to the external oblique if the deep muscle
layers are brought together easily. B. Mesh is placed
intraperitoneally if there is tension on the closure.
■ Mesh Placement and Muscle Approximation
■ The more anterior the defect, the more likely intraperitoneal placement is
required. The external oblique muscle and fascia thins at this anatomic area,
and renders placement of mesh between the internal and external obliques
quite problematic. Regardless of the plane, the technique of mesh placement
is the same. We use a 7.5-cm-wide piece of soft midweight polypropylene
mesh cut several centimeters longer than the defect with 4 cm bites on either
side (TECH FIG 3).

TECH FIG 3 • Mesh placement illustration—here, the
internal oblique and the transversus abdominis are
closed and the mesh is being placed deep to the
external oblique.
■ The mesh must be oriented so that tension across the mesh to close the
defect will maintain the mesh pores open and macroporous. If the mesh has a
smooth and rough side, place the smoother side facing the bowel if used
intraperitoneally.
■ When the mesh is placed deep to the external oblique, flex the table and
close the internal oblique and transversus abdominis layers using a 2-0
polydioxanone suture.
■ Place the mesh in the appropriate layer and then suture the mesh in place
using interrupted 0 polypropylene sutures in a horizontal mattress fashion.
Use transmuscular bites approximately 4 cm from the edges of the defect and
0.5 cm from the edge of the mesh. The sutures are spaced about 2 cm from
each other (TECH FIG 4).
■ The bites must be taken close to the edges of the mesh to minimize
wrinkling of the mesh. We avoid bone anchors, transosseous suturing to the
iliac crest, or sutures around ribs when possible. As the mesh is narrower (7.5

cm) than the distance between sutures on each side of the abdominal wall (4
cm × 2 = 8 cm), the lateral abdominal musculature falls together without
tension along the axis of the mesh.
■ Excise any redundant external oblique muscle, and close good quality
muscle with figure-of-8 0 polypropylene sutures (TECH FIG 5A,B).
■ This closure allows the mesh and abdominal wall suture lines to act as a
load-sharing construct, distributing the forces of closure. This lowers the
forces at each suture-tissue interface and minimizes suture pull-through,
which is a primary cause of hernia recurrence.
TECH FIG 4 • A. Diagram of mesh placement. B.
Narrow mesh sutured into position.

TECH FIG 5 • A. Diagram of closure of external
oblique over mesh. Closure of muscular layer after
mesh placement, creating three load-bearing suture
lines. B. Patient with closed external oblique over
mesh.
■ Closure
■ Once the muscular layers of the abdominal wall are closed, redundant skin is
excised to reduce dead space. Place one or two drains superficial to the
external oblique (TECH FIG 6).
TECH FIG 6 • Final result using flexion of the table to
facilitate closure
PEARLS AND PITFALLS

Scar
does
not aid
healing
■ Scar in the subcutaneous tissues, and even more so the scarred edges of
the oblique muscles, may seem like strong tissue that can hold a stitch,
but it is avascular and inelastic and has decreased potential to heal. With
time, the suture will cheese wire through the noncompliant tissue leading
to failure. We always excise all scar and make it a priority to close healthy
tissue to healthy tissue.
Suture
pull-
through
is the
enemy
■ Not using enough suture fixation points to spread out the load of the
closure along the suture lines will lead to disproportionately high force at
the suture-tissue interface, leading to pull-through and surgical failure.
mesh
sutured
repairs
■ These are efficacious and efficient means to close flank defects, though
long-term follow-up does not yet exist for this novel closure method. The
strips of mesh use the same concepts of force distribution and reduction of
pull-through as tenants of successful abdominal wall surgery.
POSTOPERATIVE CARE
Diet management
We keep the patients NPO until return of bowel
function. An aggressive antiemetic regimen is
necessary to prevent emesis and the high abdominal
wall stress associated with it.
Activity
Patients are instructed to ambulate on postoperative
day #1. The same activity protocol exists as for midline
hernias.
Pain management
We normally avoid the use of ketorolac given the fairly
large dissection. Patients who we anticipate will have
pain control difficulties undergo placement of an
epidural catheter by the anesthesia pain team for the
immediate postoperative period.
DVT Prophylaxis
DVT prophylaxis must be administered as dictated by
patient risk stratification on the Caprini score.
Binders
Patients are placed into an abdominal binder to aid
wound healing. They wear the binder for 1 month
postoperatively to compress the soft tissues to help
with healing.
Antibiotics
These are given preoperatively and for 24 hours after

surgery.
Drains
Drains are removed when the patient has returned to
normal activity and output is less than 30 mL/d.
OUTCOMES
■ In our recently published series of 31 patients6 treated with the technique
described above, 10 patients were found to have a hernia through all layers of
the abdominal wall, 17 had a defect in the internal oblique and transversus
abdominis with a continuous but bulging external abdominal oblique, and 4
had denervation injury with all the muscle layers in continuity. Mesh placement
was intraperitoneal in 19 patients and extraperitoneal in 12 patients. There were
no surgical sites infections, and with a mean follow-up time of 830 (± −1051)
days, there were 3 recurrences—2 had small bulges, which were successfully
repaired with an additional mesh layer between the internal and external
oblique muscles, and one was a small asymptomatic hernia detected on a
follow-up CT.
COMPLICATIONS
■ Abdominal compartment syndrome
■ Hematoma/Seroma
■ Infection
■ DVT/PE
■ Dehiscence
REFERENCES
1. Fahim DK, Kim SD, Cho D, et al. Avoiding abdominal flank bulge after
anterolateral approaches to the thoracolumbar spine: cadaveric study and
electrophysiological investigation. J Neurosurg Spine. 2011;15:532-540.
2. Ballard JL, Abou-Zamzam AM Jr, Teruya TH, et al. Retroperitoneal aortic
aneurysm repair: long-term follow-up regarding wound complications and
erectile dysfunction. Ann Vasc Surg. 2006;20:195-199.
3. Gardner GP, Josephs LG, Rosca M, et al. The retroperitoneal incision: an
evaluation of postoperative flank ‘bulge’. Arch Surg. 1994; 129:753-756.
4. Honig MP, Mason RA, Giron F. Wound complications of the retroperitoneal
approach to the aorta and iliac vessels. J Vasc Surg. 1992;15:28-33.
5. Chatterjee S, Nam R, Fleshner N, Klotz L. Permanent flank bulge is a
consequence of flank incision for radical nephrectomy in one half of patients.

Urol Oncol. 2004;22:36-39.
6. Purnell CA, Park E, Turin SY, Dumanian GA. Postoperative flank defects,
hernias, and bulges: a reliable method for repair. Plast Reconstr Surg.
2016;137(3):994-1001.

33
CHAPTER
Section VI: Posterior Trunk
Reconstruction
Erector Spinae
(Paraspinous) Muscle Flap
Lauren M. Mioton and Gregory A. Dumanian
DEFINITION
■ The erector spinae muscle flap is used for coverage of spinal wounds.
ANATOMY
■ The erector spinae, also known as the paraspinous muscles, are paired
structures comprised of the iliocostalis (most medial), longissimus, and spinalis
muscles (most lateral).
■ The iliocostalis muscle originates from the sacrum, erector spinae aponeurosis,
and iliac crest, with insertions onto the ribs and transverse processes of C6-C4.
It contributes to extension and lateral flexion of the vertebral column.
■ The longissimus muscle is the largest of the erector spinae with varying
portions originating from the sacrum and transverse processes of the lumbar
and thoracic vertebra. It inserts into the transverse processes of lumbar,
thoracic, and cervical vertebrae. It contributes to extension and lateral flexion
of the vertebral column.
■ The spinalis muscle originates from and inserts into the spinous process of
lumbar and thoracic vertebrae. It aids with extension of the vertebral column.
■ The erector spinae muscles are round and large along the inferior aspect of the
lumbar region but become thinner more superiorly along the underside of the
trapezius.
■ They have a convex shape with segmental blood vessels originating from the

thoracic and abdominal aorta, entering on the lateral and deep aspects of the
longissimus and iliocostalis muscles. There are typically both lateral and
medial vessels entering the erector spinae, and all of the muscle will stay
viable just on its lateral blood flow. In the thorax, these vessels travel through
the lateral border of the erector spinae to be the minor pedicle of the
latissimus muscle.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Past medical and surgical history with attention to the back is necessary. Prior
spine incisions, their location, a history of radiation, and a history of prior
infections should be sought. A focused physical examination documenting
prior incisions and the suppleness of the posterior soft tissues should be
performed. A history of spina bifida, a cord lipoma, or lack of fusion of the
posterior spinal tube implies a lack of development and/or small size of the
erector spinae inferiorly.
■ A prior, or planned, lateral approach to the spine may lead to transection of the
erector spinae muscles and eliminate it as a flap option.
IMAGING
■ No preoperative imaging is warranted in preparation for this flap.
SURGICAL MANAGEMENT
■ The erector spinae muscles are no longer functional for spine extension and
flexion and seen as expendable following spine fusion.
■ It is an appropriate flap for wounds ranging from the high cervical to low
lumbar region.
■ It may not provide coverage of high occipital or the sacral recess (between
the sacrum and lumbar spine).
Preoperative Planning
■ The patient’s medical history should be reviewed as prior to any planned
surgery.
Positioning
■ The patient is placed in the prone position for the erector spinae flap
procedure. Arms may be tucked at the patient’s side or abducted with elbows at
90 degrees.

Approach
■ The spinal wound, especially if chronic in nature, should be appropriately
excised and debrided prior to reconstruction.
■ Patients who have undergone prior spine surgery may have notable scar tissue
in the wound bed. Clearing the surgical bed of this fibrous tissue will reduce
the likelihood of postoperative wound complications as well as allow the
surgeon to properly identify the erector spinae muscles and dissection planes.
■ Spinal closures are performed prophylactically after spine instrumentation to
help achieve a durable closure (especially after multiple prior surgeries) and
also for treatment of acute postoperative spinal hardware infections. In the
latter, the hardware should be assessed for stability and maintained if it feels
stable. Switching out of components of the hardware and rendering it less
prominent is at the discretion of the spine team. Loose nonincorporated bone
graft should be removed, but it is not necessary to remove every piece of bone
graft.
T E C H N I Q U E S
■ Erector Spinae Muscle Flap
Video p5-c033
■ Skin flaps are elevated on either side of the wound either deep or superficial
to the thoracolumbar fascia, allowing the latissimus and trapezius muscles to
00:00 / 00:00

stay attached to the skin.
■ Retractors can be placed on the soft tissues, and cautery can be used to
enter the granulation tissue prior to bluntly dissecting in the appropriate
plane.
■ The cutaneous perforators and dorsal sensory nerves can often be identified
and preserved during elevation of the skin flaps.
■ Over undermining should be avoided to decrease the change of marginal
skin vascularity and to limit dead space.
■ When the dissection plane is initially superficial to the thoracolumbar fascia,
palpation of the lateral border of the erector spinae should reveal its lateral
border clearly. The lateral blood supply enters the muscle along this lateral
line, and perforators extending to the latissimus and skin are often identified.
Near this lateral border, the thoracolumbar fascia is incised along its length to
allow it to mobilize medially (TECH FIG 1A,B).
■ With the skin still retracted, dissection proceeds along the medial and deep
aspects of the erector spinae muscles (TECH FIG 1C,D).
■ Division of the medial row of blood vessels entering the erector spinae
muscles is necessary for full mobilization of the erector spinae muscles.
One places dissecting fingers on the lateral border of the muscle, and one
should limit the deep dissection so that the muscle maintains its lateral
attachments and lateral segmental blood supply.
■ Following this dissection on both its deep and superficial surfaces allows
the erector spinae muscles unfold, changing shape from a rounded muscle
mass to a more elliptical form (TECH FIG 1E).
■ With the tissues fully mobilized, stiff and inflamed tissue along the medial
aspect of the skin, subcutaneous tissue, and paraspinous muscles should be
sharply debrided.
■ The erector spinae muscles should be reapproximated in the midline with
two or more drains placed both deep and superficial to muscles (TECH FIG
1F).
■ Drains should be placed both deep to the muscle closure and between the
muscle closure and the undermined skin. The exit sites for the drains should
not be on bony prominences of the back. Quilting sutures help to avoid
troublesome seromas.
■ The overlying skin is then closed with interrupted monofilament sutures.

TECH FIG 1 • A. Cross-sectional anatomy of
superficial aspect of dissection for creation of erector
spinae muscle flaps. B. Superficial dissection

performed in a patient with a postoperative spinal
fusion procedure infection. Arrow shows incised
thoracolumbar fascia. A nerve can be seen passing
through the muscle to reach the overlying skin, and it
can be preserved. C. Cross-sectional anatomy of
deep aspect of dissection for creation of erector
spinae muscle flaps. D. Deep dissection performed in
a patient with a postoperative spinal fusion procedure
infection. Arrow shows lateral-most dissection along
deep surface of the erector spinae muscle. E. Cross-
sectional anatomy of erector spinae flaps mobilized
and approximated in the midline. Note the shape
change that occurs in the muscles. F. Erector spinae
muscle flaps used to close a postoperative spinal
fusion procedure infection. Multiple drains placed
above and below the muscle closure.
PEARLS AND PITFALLS
Technique
■ Lateral release of the erector spinae muscle alone allows the muscle to
move only an estimated 30% of its full potential.
■ When proceeding with the medial dissection of the erector spinae
muscles, place your nondominant hand on the lateral aspect of the
muscle along the lateral row of vessels to ensure they are protected.
Outcomes
■ When the erector spinae muscle closure is of good quality, there
should be no need for a second overlying muscle flap.
POSTOPERATIVE CARE
■ The patient is placed under physical activity restrictions based on the location
of spinal fusion. These are often coordinated between plastic surgery and spine
surgery services.
■ Patients with high-level fusions often have upper arm restrictions, including

limitations in shoulder abduction and forward flexion, that are kept in place
for 6 weeks.
■ The surgical dressing is kept in place for 72 hours following surgery. Once
removed, the incision can be left open to the air.
■ When appropriate, patients should be walking and working with physical
therapy on postoperative day 1, pending approval by the spine surgery team.
■ The largest and lowest closures require the patients to be on a pressure-relief
bed to allow the skin and muscle flaps to be directly lied on and compressed.
■ Drains are left in place until drainage reaches less than 30 cc a day for 2 days
in row.
OUTCOMES1–3
■ A systematic review of the evidence regarding prophylactic and therapeutic
use of flaps for coverage of complex spinal defects revealed that the erector
spinae muscle flap was the most commonly used flap for reconstruction of
spinal wounds (56% of cases).
■ Use of such flaps in a prophylactic setting in patients undergoing spinal
instrumentation with spinal neoplasms led to a markedly decreased
postoperative complication rate when compared to those who did not receive
prophylactic flap coverage (20% vs 45%).
COMPLICATIONS
■ Skin flap or muscle flap dehiscence
■ Seroma
■ Hematoma
■ Abscess
■ Hardware extrusion
■ Osteomyelitis
REFERENCES
1. Chieng LO, Hubbard Z, Salgado CJ, et al. Reconstruction of open wounds as
a complication of spinal surgery with flaps: a systematic review. Neurosurg
Focus. 2015;39(4):e17.
2. Dumanian GA, Ondra SL, Liu J, et al. Muscle flap salvage of spine wounds
with soft tissue defects or infection. Spine. 2003;28:1203-1211.
3. Wilhelmi BJ, Snyder N, Colquhoun T, et al. Bipedicle paraspinous muscle
flaps for spinal wound closure: an anatomic and clinical study. Plast Reconstr

Surg. 2000;106:1305-1311.

34
CHAPTERTrapezius Muscle Flap
Lauren M. Mioton and Gregory A. Dumanian
DEFINITION
■ The trapezius muscle flap is a reliable option for coverage of the posterior
trunk and for defects of the head and neck.
ANATOMY
■ The trapezius muscle, which has a unique triangular shape, is the most
superficial muscle on the posterior neck and thorax (FIG 1).
■ It is composed of three parts: descending, transverse, and ascending portions.
■ The descending or superior part originates from the occiput and inserts into
the lateral third of the clavicle. It acts to elevate the scapula.
■ The transverse or middle part originates from the spinous processes of the 1st
to 5th thoracic vertebra and inserts into the acromion. It acts to retract the
scapula.
■ The ascending or inferior part originates from the spinous processes of the
6th to 12th thoracic vertebra and inserts into the spine of the scapula. It acts
to depress the scapula.
■ There are three arterial supplies to the trapezius muscle. The relative
importance and the origin of these vessels are quite variable.
■ The upper one-third of the muscle receives its blood predominantly from the
transverse cervical artery, which itself is a branch of the thyrocervical trunk or
the suprascapular artery almost 80% of the time. It passes through the
posterior triangle of the neck to the anterior border of the levator scapulae
muscle before dividing into two main branches.

FIG 1 • Regional anatomy of the back.
■ The branch entering the upper trapezius is termed the superficial cervical
artery, or the superficial branch of the transverse cervical.
■ The dorsal scapular artery (DSA) supplies the middle one-third of the
trapezius.
■ In 75% of cases, the DSA originates off the subclavian artery and passes
between the upper and middle (or middle and lower) trunks of the brachial
plexus before coursing through the rhomboids.
■ A branch emerging from between the rhomboid muscles serves as the
perforator to the inferior trapezius. It also supplies the skin paddle above and
lateral to the overlying latissimus.
■ The third source of blood to the inferior-most trapezius is from segmental,
posterior intercostal arteries 3 to 6. Due to these numerous small perforators
and a dominant larger perforator, most classify this muscle as Mathes and
Nahai type V.
■ Dominance of one source vessel tends to cause a lack of development of the
adjacent vascular territory.

■ The entry point of the transverse cervical is cephalad and medial in location to
the entry point of the DSA.
■ The trapezius muscle is innervated by the spinal accessory nerve (CN XI).
■ It accompanies the superficial branch of the transverse cervical artery in the
superior portion of the muscle and the dorsal scapular artery in the inferior
portion. It crosses superficial to the superficial cervical artery in a majority of
cases.
■ The levator scapulae, rhomboid minor, rhomboid major, and latissimus dorsi
muscles all lie deep to the trapezius.
■ The levator scapulae extend from the 1st to the 4th cervical vertebrae and
insert on the superior angle of the scapula.
■ The rhomboid minor originates from the spinous process of the 6th and 7th
cervical vertebrae and inserts into the medial aspect of the scapula.
■ The rhomboid major begins off the spinous processes of the 1st to 4th
thoracic vertebrae and inserts into the medial border of the scapula, below the
spine of the scapula.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The medical evaluation of patients is based on their pre-existing medical
conditions. No special considerations are needed for this procedure. Importance
of shoulder abduction for work may lead to the choice of an alternate
reconstruction.
■ Physical examination
■ The skin is examined for scars or previous incision sites. If a previous radical
neck dissection or instrumentation of the subclavian artery has been
performed, a preoperative evaluation of the transverse cervical artery and the
dorsal scapular artery with duplex ultrasound or even arteriogram may be
necessary to determine vascular patency.
■ A functional assessment of the shoulder and arm mobility should be
performed with baseline function documented.
IMAGING
■ Imaging, such as CT or MR angiography, is often not performed in the
preoperative evaluation for a trapezius muscle flap.
SURGICAL MANAGEMENT
■ The trapezius muscle flap can be used for coverage of the posterior back or for

soft tissue defects of the head and neck.
■ The decision to use such a flap should be based on the location of the defect
and tissue required.
■ Smaller defects of the posterior trunk that only require the muscle supplied by
the dorsal scapular artery (descending branch) can be performed without
significant arm dysfunction, as the upper and middle aspects of the muscle
remain present to help with shoulder stability. However, mobilization of the
entire muscle to reach the neck, face, and anterior trunk is associated with a
sizeable donor site morbidity including limited arm elevation and pain. It
should only be considered when other flap options have been eliminated,
microsurgery is not an option, or the accessory nerve has already been divided
during tumor resection.
Preoperative Planning
■ Oncologic history, including radiation, should be well documented.
■ One should be aware of the location and type of hardware involved.
■ Any pulmonary conditions or other baseline medical comorbidities that would
prohibit lateral decubitus or prone positioning should be noted.
Positioning
■ Patient positioning will depend on the recipient site.
■ Trapezius muscle flap coverage of occipital, posterior neck or spinal wounds
can be done in the prone position. The ipsilateral arm should be prepped into
the field, and the arms should remain abducted (at 90 degrees) with the
shoulder dropped to move the scapula laterally.
■ The patient may be placed in the lateral decubitus position for cases requiring
coverage of the anterior head, neck, or axilla. The ipsilateral arm should be
prepped in so that it remains flexible and allows the surgeon to manipulate the
scapula.
Approach
■ The upper trapezius muscle flap is based on the transverse cervical artery and
the lower on the dorsal scapular artery. The latter is the more common. The
upper (descending) portion of the trapezius based on the occipital artery and
the lower-most trapezius based on segmental intercostal perforators are rarely
utilized on their own.
■ The entire trapezius muscle flap can be based on the transverse cervical artery,

though the most distal aspects of the flap may not remain viable.
■ A trapezius flap based on the branches of the transverse cervical can support
the transversely oriented fibers of the muscle and can be harvested as a
myocutaneous or osteocutaneous flap if need be.
■ This flap can be utilized for soft tissue defects of the anterior neck and lower
face, back, axilla, posterior neck, and occipital regions.
■ Trapezius muscle flap based on the DSA
■ The inferior segment of the trapezius can be elevated leaving the rest of the
muscle alone based on the dorsal scapular artery with limited morbidity. It is
ideal for coverage of hardware in the upper thoracic and lower cervical spine
area. This flap is ideal for soft tissue defects of the midface and orbital region
as well as defects of the anterior neck, lower face, back, axilla, posterior neck,
and occipital region.
■ Preoperative markings are best done with the patient sitting or standing with
the arms adducted, with a clear mark placed over the tip of the scapula and the
scapular spine.
T E C H N I Q U E S
■ Trapezius Flap Based on the DSA
■ The inferior portion of the trapezius can be isolated and harvested alone
based on the dorsal scapular artery (TECH FIG 1).
■ The lower part of the trapezius muscle and scapula should be marked.
■ The medial border of the scapula and the rhomboid muscles are outlined to
identify the perforating point of the pedicle artery. A handheld ultrasound
Doppler can be used to mark the putative entry point of the DSA into the
trapezius. The main pedicle of the inferior trapezius from the DSA enters the
muscle 7 to 8 cm on its deep aspect lateral to the midline at the level of the
C7 spinous process.
■ A skin island, if planned, should be designed so that at least one-third of its
diameter overlies the distal border of the muscle. It must not lie more than 10
cm distal to the inferior angle of the scapula. Extensions of skin distal to the
muscle are notoriously unreliably, and alternatives to this flap design
including skin grafts placed on the muscle flap should be considered.

■ Identify the distal and inferior triangular portion of the trapezius as it
overlies the latissimus dorsi muscle. The crossing muscle fiber directions of
these two muscles allow for easier distinction.
■ Identification of a blood vessel on the lateral border of the inferior trapezius,
termed the superficial dorsal scapular artery, can make more reliable carrying
of a skin paddle.
■ The skin lying lateral and cephalad to the skin paddle can be elevated off of
the trapezius.
■ An inferior-to-superior muscle elevation is performed until one reaches this
perforator entering the deep substance of the muscle.
■ Dissection around the medial attachments may be most unclear given the
thickness of the attachments, whereas the lateral border of the muscle is
clearly distinct from the deeper back muscles. Therefore, the medial
attachments are divided only after the muscle has been elevated off of the
back. As one nears the scapular spine, the lateral border also becomes
indistinct. It is acceptable to divide the tendinous lateral border of the
trapezius rather than continuing to follow it further laterally toward the
posterior axially line.
■ With the main perforator identified and under direct view, the muscle flap
can be turned into an island for greater arc of rotation. The DSA pedicle itself
can be mobilized to facilitate movement.
■ For extreme cephalad mobilization, the DSA can be temporarily clamped
with a vascular bulldog, and flow from the transverse cervical system can be
assessed. A viable muscle flap with the DSA clamped can allow for further
muscle mobilization up to the transverse cervical vessel to harvest an
extremely large flap. Caveats to creation of a flap based on the entire
trapezius include the following:
■ The higher the dissection proceeds, the greater the postoperative morbidity
due to shoulder drop. The morbidity is attributed to both pain and
dysfunction.
■ The donor site should be closed directly, if possible, over a normal suction
drain in two layers. Quilting sutures may help to limit troublesome seromas
that often accompany muscle elevation.

TECH FIG 1 • Trapezius myocutaneous flap based on
the dorsal scapular artery. SCA, superficial cervical
artery; SAN, spinal accessory artery; DSN, dorsal
scapular nerve.
■ Trapezius Flap Based on the Transverse Cervical
(Superficial Cervical Artery)
■ A smaller portion of the trapezius muscle, the transverse portion in
particular, can be harvested on the superficial cervical artery (TECH FIG 2).
■ The anterior border of the trapezius muscle; the scapula, including the spine
of the scapula; and the acromion are marked. A handheld ultrasound Doppler
can be used to mark the position and course of the course of the arteries.
■ The acromion should be left intact. If a cutaneous component is planned, the
skin island should be marked transversally with the distal aspect overlying
the scapular spine. It should not extend over the middle of the scapula to
ensure inclusion of the vascular pedicle.
■ To allow for direct closure of the donor site, skin islands should not extend
beyond 8 cm vertically and 6 cm transversally.

TECH FIG 2 • A. Elevated trapezius myocutaneous
flap based on the superficial cervical artery. SCA,
superficial cervical artery; SAN, spinal accessory
artery; DSN, dorsal scapular nerve. B. Incised
myocutaneous trapezius flap based on the SCA. The

skin paddle was oriented at the inferior aspect of the
muscle. The patient had a cervical wound following
excision of a metastatic neuroendocrine tumor. C. The
trapezius flap inset with a 180-degree twist (arrow).
The superficial dorsal scapular artery was not included
with this flap, resulting in mild hypoperfusion of the
skin paddle.
PEARLS AND PITFALLS
Technique
■ The higher the dissection proceeds along the lateral muscle dissection,
the greater the arc of rotation but the greater the postoperative
morbidity due to shoulder drop.
Therapy
■ Physiotherapy is needed to strengthen shoulder muscle agonists.
POSTOPERATIVE CARE
■ The ipsilateral shoulder should be immobilized in an adducted position for 1 to
2 weeks if the donor site incision is more cephalad in location. Lower incisions,
such as those seen with trapezius flaps based off the DSA, do not require
immobilization for healing.
■ The flap (either muscle or skin island) should be monitored for the first 5 days.
■ No particular anticoagulation regimen is warranted.
■ It is important to avoid pressure on the pedicle vessels.
■ Beds with air cushions may offload pressure on posterior recipient sites,
including occipital, posterior neck, and cervical and thoracic spine regions.
■ Physiotherapy is recommended to strengthen the muscle agonists.
OUTCOMES
■ Donor site function is acceptable when the accessory nerve is preserved and
muscle function—the upper and middle parts of the muscle in particular—is
maintained.
■ Aesthetically, a trapezius myocutaneous flap has an appropriate skin match for

posterior recipient sites but may prove lighter than surrounding skin in anterior
head and neck sites. The long scars over the back are often visible and
cosmetically unappealing.
COMPLICATIONS
■ Loss of scapula stabilization (winged scapula) weakens shoulder and arm
elevation.
■ Skin necrosis (in cases of skin paddles placed very distally)
■ Donor site seroma
SUGGESTED READINGS
1. Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius
musculocutaneous flap from pedicled to free flap: anatomical basis and clinical
applications based on the dorsal scapular artery. Plast Reconstr Surg.
2004;113:1580-1590.
2. Huelke DF. A study of the transverse cervical and dorsal scapular arteries.
Anat Rec. 1958;132:233-245.
3. Yang D, Morris SF. Trapezius muscle: anatomic basis for flap design. Ann
Plast Surg. 1998;41:52-57.

35
CHAPTER
Superior Gluteal Artery
Perforator Flap
Lauren M. Mioton and Gregory A. Dumanian
DEFINITION
■ The superior gluteal artery flap is relevant to the treatment of pressure ulcers,
coverage of the lower lumbar spine, and breast reconstruction.
ANATOMY
■ The superior gluteal artery is a continuation of the posterior division of the
internal iliac artery (FIG 1).
■ It runs between the lumbosacral trunk and the first sacral nerve.
■ It exits the pelvis above the piriformis and immediately divides into
superficial and deep branches.
• The deep branch passes between the gluteus medius and the iliac bone.
• The superficial branch continues on to supply the upper portion of the
gluteus muscle and overlying fat and skin.
■ The superior gluteal nerve supplies this flap.
■ It arises from the dorsal divisions of the 4th and 5th lumbar and 1st sacral
nerves.
■ It exits the pelvis through the greater sciatic foramen with the superior
gluteal vessels.

FIG 1 • Anatomic landmarks of piriformis, superior
gluteal artery, and superior cluneal nerve.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history and physical examination should be performed on the
patient in the preoperative setting.
■ Prior lower surgery in the gluteal region should be noted as it may preclude
the use of the SGAP flap. A history of spina bifida could be associated with
lack of formation, small size, or aberrant location of the superior gluteal
artery.
IMAGING
■ Specific preoperative imaging is not standard workup for SGAP flaps, though
it could be performed with a computed tomography angiography.
SURGICAL MANAGEMENT

■ The SGAP flap can be used for pressure ulcer reconstruction. Additionally, it
is a dependable option for autologous breast reconstruction when abdominal
tissue is not available.
■ When designing the SGAP flap, the incisions can be in an oblique or more
horizontal orientation. A horizontal scar is often deemed more cosmetically
acceptable.
■ Beveling on dissection creates more dead space and can therefore lead to
greater seroma development. Positioning the SGAP more superiorly on the
buttock allows for beveling more superiorly and is often associated with
decreased revision rates and contour deformities.
■ Perforators designed more laterally will lead to longer pedicles.
■ The average height and length of the SGAP flap are 10 and 24 cm.
Preoperative Planning
■ Patients should undergo additional medical clearance pending their
comorbidities.
■ The SGAP flap should be avoided in severely obese patients.
Positioning
■ Positioning for an SGAP flap depends on the area to be reconstructed.
■ For pressure sore reconstruction or bilateral breast reconstruction, the patient
should be placed in the prone position with the arms tucked.
■ In the cases that an SGAP flap is being used for unilateral breast
reconstruction, the patient may be in the lateral decubitus position.
• In both bilateral and unilateral breast reconstruction cases, the patient is
subsequently rolled supine for final flap inset. They should be re-prepped
and draped during the position change.
Approach
■ Markings are placed on the patients in the position that they will be in the OR.
■ A line is drawn from the posterosuperior iliac spine (PSIS) to the superior
portion of the greater trochanter of the femur. The superior gluteal artery exits
the greater sciatic foramen and enters the buttock at the junction of the
proximal and middle thirds of this line. The location is confirmed with a
handheld Doppler probe.
■ Another line is drawn from the PSIS to the coccyx. The intersection of this

line with the superior edge of the greater trochanter helps identify the position
of the piriformis.
■ Perforators located just superior to the piriformis should be considered for flap
harvesting.
■ The skin paddle is marked to include these perforators.
T E C H N I Q U E S
■ Superior Gluteal Artery Flap
■ With the patient properly marked, prepped, and positioned, the previously
drawn marks are incised (TECH FIG 1A,B).
■ Electrocautery is then used to divide the fat to the level of the gluteal fascia.
■ The fat can be beveled superiorly and inferiorly to include as much fat as
necessary for the reconstruction.
■ Avoid harvesting of soft tissue over the ischium to avoid painful sitting.
■ The cluneal nerves are encountered after dissection through the superficial
fascia at the cranial aspect of the flap.
■ The gluteal fascia is then incised laterally, and dissection proceeds in a
subfascial manner lateral to medial (TECH FIG 1C,D). The patient should
be paralyzed to reduce the likelihood of movement and possible damage to
the pedicle during dissection.
■ Perforators with an artery of 1 mm or more in diameter are traced through
the muscle. The muscle is split longitudinally to reveal the proximal aspect of
the perforator.
■ The perforator is freed through both blunt and sharp dissection, and the deep
aspect of the gluteus maximus and its associated anterior fascia are reached
(TECH FIG 1E,F).
■ The dissection can terminate at this level for pedicled SGAP flaps with
appropriate pedicle length.
■ If a longer pedicle is desired for either a pedicled or free flap, the fascia is
incised to expose the subgluteal fat pad. The pedicle is traced as medially
as required into the pelvis.
• There is a delicate vascular network in this region that requires broad
exposure and careful dissection. The fascia is strong, rendering blunt

dissection quite difficult.
• The flap is detached from the gluteus muscle in the suprafascial plane, and
the pedicle is sectioned off.
■ Once the pedicled flap or free flap is placed into the recipient site, the donor
site may be closed in multiple layers over a drain (TECH FIG 1G,H).
■ The skin is undermined and the hip can be extended to reduce tension on
the closure.
■ The dermal edges of the donor site are often reapproximated with
interrupted mattress or simple sutures in patients requiring a SGAP flap for
sacral wound coverage.
■ When the SGAP is utilized as a free flap for breast reconstruction, the
donor site epidermis may be closed with a running subcuticular suture.

TECH FIG 1 • A. Surface landmarks for identification
of superior gluteal artery entrance into the upper
buttock soft tissues. B. Lumbosacral wound 3 weeks