SGAP AND IGAP FLAPS Marking

Twen dan Nabila

Landmarks : With the hip slightly flexed and rotated inward, a line is drawn from the
posterior superior iliac spine to the posterior superior angle of the greater
trochanter; the point of emergence of the superior gluteal artery from the
upper part of the greater sciatic foramen corresponds to the junction of
the upper and middle thirds of this line. A second line is drawn from the
posterior superior iliac spine to the outer part of the ischial tuberosity; the
junction of the lower and middle third marks the point of emergence of
the inferior gluteal arteries from the lower part of the greater sciatic
foramen.

Composition : Both types of GAP aps are harvested as fasciocutaneous aps (skin, fat,
fascia).

Dimensions :
 - SGAP
Length: 22cm (range up to 30cm) Width: 8cm (range 5–12cm)
Maximum to close primarily: 5–15cm depending on the surrounding tissues
The skin pattern dimensions are determined by several fac- tors: the skin requirements for
the breast, the thickness of the fat, and the volume requirement. The patient can bring
underwear or a swim suit to keep the scar concealed. To minimize contour deformity, the
beveling is primarily supe- riorly and may be beveled in all directions except medially and a
layered closure is done. In general, the recommended skin design is 8 22 cm. The ap
dimensions including beveling are 14–15 22–24 cm.
- IGAP
Length: average 8cm (maximum 12cm)
Width: average 18cm (maximum 30cm)
Adipose tissue may be beveled up to 5cm superiorly and laterally and 2 cm inferiorly for extra
tissue.

Arterial supply of the flap

Dominant: superior gluteal artery (5–7 cm)

Dominant: inferior gluteal artery (7–10 cm)
Minor
None of clinical significance. Gluteus maximus is a type III Mathes–Nahai classification muscle;
therefore, it is considered to have no minor pedicles.

Venous drainage of the flap

Primary: SGAP and IGAP

Venae comitantes.
Secondary
None.

Flap innervation

Sensory
SGAP and IGAP – cluneal nerves; direct branches off the spinal cord L1–S3.
Motor
None

Design and Marking

SGAP

Markings are placed on the patient in the decubitus position. The orientation of the ap can vary from
an angle down along an oblique line to the intergluteal crease or perpendicular to the crease. Oblique
incisions are associated with contour deformity. A flap designed more horizontally produces a more
favorable scar. Skin flap design can be customized to almost any orientation as long as the outline
contains a perforator. It should be noted that perforators located laterally will produce longer
pedicles. The average flap height and length are 10 and 24 cm, respectively. The skin paddle may be
as large as 12x30 cm

Beveling creates dead space, which encourages seroma and can delay healing. By designing the SGAP
high on the buttock and beveling mostly superiorly, the revision rate and contour deformities are low.

The Doppler probe is used to locate

perforating vessels from the superior gluteal
artery. These are usually located
approximately one-third of the distance on a
line from the posterior superior iliac crest to
the greater trochanter. Additional perforators
may be found slightly more lateral from above.
The skin paddle is marked in an oblique
pattern from inferior medial to superior lateral
to include these perforator

For marking the day before surgery, the

patient is positioned as she will be on the OR table for flap harvest, usually lateral decubitus for
unilateral, prone for bilateral. The SGA exits the pelvis one-third down from the posterior iliac spine
to the greater trochanter. There is almost always a perforator at this spot. However, this will be the
shortest pedicle since the perforator goes straight through the muscle. A more lateral perforator will
pass obliquely back to the point of origin of the SGA, giving a longer pedicle. All things considered, we
select the largest perforator as long as it is not right on the edge of the ap and do not worry much
about the length. We prefer the oblique incision because the scar is covered better by clothing and
the contour is better. A horizontal design may accentuate the concavity naturally present between
the are of the pelvic bones and look unattractive.
IGAP

The flap is designed as a horizontal ellipse with the

axis centered above the gluteal crease. The gluteal
crease is marked with the patient in the standing
position. The inferior incision is then drawn
parallel to the crease and 2cm inferior to it. Then,
with the patient in the lateral decubitus position, a
hand-held Doppler probe is used to locate
perforating vessels to the skin. The superior aspect
of the skin island ellipse is then marked to capture
these perforators. The orientation of the skin
paddle usually parallels the inferior gluteal crease.
The dimensions of the ap are typically 7x18 cm,
with only slightly smaller maximum skin paddle
sizes compared to the SGAP. Depending on the
amount of skin needed (less with a skin-sparing
mastectomy) and the amount of excess buttock
tissue available, the design of each flap varies
accordingly.

Some patients have more tissue available in the

lower buttock and saddle bag area. In a patient
with relatively small breasts and large buttocks,
the ITC can give an excellent result, particularly
with secondary liposuction of the lateral thighs.

For the IGAP, the gluteal fold is noted with the patient in a standing position. The inferior limit of the
flap is marked 2cm inferior and parallel to the fold. The patient is then placed in the lateral position
with the flap side up and the Doppler probe is used to find the perforating vessels from the inferior
gluteal artery. An ellipse is drawn for the skin paddle to include these perforators, with the final shape
having a longer length of the superior limb than the inferior limb. The final dimensions are 8–10 x 18–
20 cm for both flaps.

Semicircular Advancement Flap

A large semicircular advancement flap can be designed to take advantage of the excess tissue of the
buttock. Undermining of the ap should be limited in the areas of the superior and inferior gluteal
perforators. The remainder of the areas may be undermined and advanced medially. Direct closure
of this donor site is usually possible, although back-grafting is always an option. It is not necessary to
visualize the pedicle in these aps. For added rotation, the muscle can be divided laterally as the ap is
advanced medially
References:

1. Zenn M, Jones G. Reconstructive Surgery: Anatomy, Technique, and Clinical Application.

CRC Press; 2012 Mar 9.
2. Wei FC, Mardini S. Flaps and Reconstructive Surgery E-Book. Elsevier Health Sciences;
2016 Aug 26.