We read with interest the article by Amy S. Colwell and Loren J. Borud entitled “Autologous Gluteal Augmentation after Massive Weight Loss: Aesthetic Analysis and Role of the Superior Gluteal Artery Perforator Flap” (Plast. Reconstr. Surg. 119: 345, 2007). The authors describe their technique of gluteal autologous augmentation with “rotation of the flap inferomedially,” and compare their flap to Pascal and Le Louarn’s island flap1 (Fig. 1) as they write, “tissue flaps were designed within the lower body lift incisions but not mobilized; rather, the inferior gluteal tissue is mobilized and brought over the stationary flaps.”
We want to point out that in our article we wrote, “This requires undermining a third of the external flap to turn it downward and inward,” and “as the flap consists of very mobile tissues … often it is possible for the flap to extend to the groove below the buttocks.” The figure associated with this description, similar to Figure 1, demonstrates with an arrow the inferomedial rotation of the flap. Consequently, we never described a “stationary” flap but its inferomedial mobilization.
Our flap is a superior gluteal artery perforator flap. Fujino was the first to introduce gluteal tissues as a free flap, thanks to gluteal artery perforators, for breast reconstruction, 20 years ago. Colwell and Borud state, “the locations of the two key superior gluteal perforators, at approximately 7 and 9 cm from the midline, were reliable and reproducible” to specifically nourish their flap. Therefore, they write, “the flaps were dissected laterally to medially starting at the midaxillary line until the lateral perforator was encountered approximately 9 cm from the midline.” However, converging anatomical studies2,3 demonstrate that, statistically, perforators are located at a middle distance between the posterior superior iliac spine and the greater trochanter (Fig. 2), which is more lateral (10 to 12 cm) than what the authors describe and could explain their case of unilateral major fat necrosis in 18 patients. Since 1999, we have operated on 225 patients using this island flap with no major fat necrosis, because only the lateral third of the flap is released and not the lateral half, to ensure the preservation of most of the perforators.
It is well known that Kankaya et al.4 have written that the superior gluteal zone combines 48.5 percent of perforators, whereas the central gluteal zone is the most poorly vascularized region. Nevertheless, Sozer et al.5 affirmed, “The base of the flap should originate more inferiorly than the surface,” which is obviously not the superior gluteal zone. Besides, Sozer et al. report only two cases of partial fat necrosis in 20 cases.
To conclude about vascularization, we can assert that the gluteal island flap is very safe thanks to its numerous perforators. Therefore, various types of undermining are possible, if not exceeding a third of the flap surface, to achieve a nice inferomedial mobilization.
Concerning the extension of the gluteal pocket, Colwell and Borud are a bit confusing because they write, “the pocket … extending down to the inferior gluteal crease” and “[a] gluteal pocket … extending to within 5 cm of the inferior gluteal crease” and “[t]he gluteal pocket should extend only over the medial half of the buttock.”
The precise answer, determined after one case of buttock numbness, is that we need to stop the downward dissection above the inferior border of the gluteus maximus muscle, because at the inferior border of the muscle emerge two sensitive nerves, the clunium medii and the cutaneus femoris posterior, that innervate the buttock skin. To avoid definitive buttock numbness, dissection has to stop above the inferior border of the gluteus maximus muscle, and therefore well above the inferior gluteal crease in obese patients.
Finally, the four drains, removed by the authors after 15 days, can be eliminated in that type of surgery, thanks to well-localized traction sutures closing all the dead spaces. Patient mobilization and scar nursing become easier. Also, use of these traction sutures in the trochanteric area would have helped the authors to avoid the persistent saddlebag deformity shown in Figures 4, 6, and 7. We named this lateral traction “the high lateral tension body lift.”
Claude Le Louarn, M.D.
Jean François Pascal, M.D.
1. Pascal, J. F., and Le Louarn, C. Remodeling body lift with high lateral tension. Aesthetic Plast. Surg.
26: 223, 2002.
2. Nojima, K., Brown, S. A., Acikel, C., et al. Defining vascular supply and territory of thinned perforator flaps: Part II. Superior gluteal artery perforator flap. Plast. Reconstr. Surg.
118: 1338, 2006.
3. Mu, L. H., Yan, Y. P., Luan, J., Fan, F., and Li, S. K. Anatomy study of superior and inferior gluteal artery perforator flap. Zhonghua Zheng Xing Wai Ke Za Zhi
21: 278, 2005.
4. Kankaya, Y., Ulusoy, M. G., Oruç, M., et al. Perforating arteries of gluteal region: Anatomic study. Ann. Plast. Surg.
56: 409, 2006.
5. Sozer, S. O., Agullo, F. J., and Wolf, C. Autoprosthesis buttock augmentation during lower body lift. Aesthetic Plast. Surg.
29: 133, 2005.
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