This study examined 758 deep inferior epigastric perforator flaps for breast reconstruction, with respect to risk factors and associated complications. Risk factors that demonstrated significant association with any breast or abdominal complication included smoking (p = 0.0000), postreconstruction radiotherapy (p = 0.0000), and hypertension (p = 0.0370). Ninety-eight flaps (12.9 percent) developed fat necrosis. Associated risk factors were smoking (p = 0.0226) and postreconstruction radiotherapy (p = 0.0000). Interestingly, as the number of perforators increased, so did the incidence of fat necrosis. There were only 19 cases (2.5 percent) of partial flap loss and four cases (0.5 percent) of total flap loss. Patients with 45 flaps (5.9 percent) were returned to the operating room before the second-stage procedure. Patients with 29 flaps (3.8 percent) were returned to the operating room because of venous congestion. Venous congestion and any complication were observed to be statistically unrelated to the number of venous anastomoses. Overall, postoperative abdominal hernia or bulge occurred after only five reconstructions (0.7 percent). Complication rates in this large series were comparable to those in retrospective reviews of pedicle and free transverse rectus abdominis musculocutaneous flaps. Previous studies of the free transverse rectus abdominis musculocutaneous flap described breast complication rates ranging from 8 to 13 percent and abdominal complication rates ranging from 0 to 82 percent. It was noted that, with experience in microsurgical techniques and perforator selection, the deep inferior epigastric perforator flap offers distinct advantages to patients, in terms of decreased donor-site morbidity and shorter recovery periods. Mastery of this flap provides reconstructive surgeons with more extensive options for the treatment of postmastectomy patients.

Fujino was the first to introduce gluteal tissue as a free flap for breast reconstruction. The use of the musculocutaneous flap from the buttock in breast reconstruction has been championed by Shaw. Despite the initial enthusiasm for this area as a donor site, few other large series exist on the subject. Two decades of experience with this region as a donor site led to recognition of advantages and drawbacks. Furthermore, use of both the superior and inferior gluteal musculocutaneous flap was associated with certain important donor site complications and the use of vein grafts to allow for microvascular anastomosis. The evolution of free tissue transfer has progressed to the level of the perforator flap. This reconstructive technique allows elevation of tissue from any region consisting only of fat and skin. This minimizes donor site morbidity by allowing preservation of the underlying muscle and coverage of important structures in the region such as nerves. The superior and inferior gluteal perforator flaps have been used at our institution for breast reconstruction since 1993. The superior gluteal artery perforator (S-GAP) flap is our preferred method of breast reconstruction when the abdomen is not available or preferable. We report the result of this flap over the past 9 years and point out important surgical refinements, advantages, disadvantages, and lessons learned during this time.