Free Inferior Gluteal Flap Harvest with Sparing of the Posterior Femoral Cutaneous Nerve

Abstract

The free inferior gluteal flap is a major secondary choice of autologous tissue for breast reconstruction if the TRAM flap is not an option. Loss of posterior thigh and popliteal sensibility is a frequent sequela of harvesting the free inferior gluteal musculocutaneous flap and the inferior gluteal artery perforator (I-GAP) flap. The posterior femoral cutaneous nerve of the thigh lies directly on the deep surface of the gluteus maximus muscle, having a very close anatomic relationship with the inferior gluteal artery. The purpose of this study was to gain a better understanding of the anatomy of the posterior femoral cutaneous nerve (PFCN), its branches, and their relationship with the inferior gluteal artery (IGA). Eighteen fresh human pelvic halves were dissected for examination during harvesting of the inferior gluteal myocutaneous free flap, to determine if a nerve-sparing approach was possible and how this information might impact on I-GAP flap harvest. Seventeen of 18 pelvic halves had at least some of the PFCN branches intact after isolation of the IGA pedicle and flap elevation. Three of 18 of the pelvic halves had the entire PFCN and its branches intact after flap elevation. One of 18 pelvic halves required complete transection of the PFCN and its branches in order to isolate the IGA pedicle. In 94.5 percent of the pelvic halve dissections, it was possible to maintain at least a portion of the PFCN intact after isolation of the inferior gluteal artery pedicle while harvesting the free inferior gluteal myocutaneous flap. These findings support a nerve-sparing approach to inferior gluteal myocutaneous flap elevation to minimize the sequela of posterior thigh anesthesia. These data also emphasize the intimate relationship of the PFCN and the gluteal artery and the real possibility of injury to the PFCN during I-GAP harvest.

Breast Reconstruction Using the Geometrically Modified Profunda Artery Perforator Flap From the Posteromedial Thigh Region

“…Change of posterior thigh sensibility is an undesirable sequela of flap harvest in the vicinity of the posterior femoral cutaneous nerve. 25,26,31 In comparison to PAP flap harvest, IGAP flap dissection is performed closer to the cluneal nerves and the root of the posterior femoral cutaneous nerve, thereby increasing the risk of nerve damage.…”

Donor-site morbidity of the inferior gluteal artery perforator flap for breast reconstruction in teenagers

“…Testing with the Semmes-Weinstein monofilament demonstrated hypoesthesia in that area for only two patients, therefore indicating dysesthesia for the other four patients. Two studies have documented the close anatomical relationship between the posterior femoral cutaneous nerve and the inferior gluteal pedicle at their exit point usually below the piriformis muscle (17,18). They course together underneath the gluteus maximus muscle, where the nerve can cross or even loop around the inferior gluteal artery.…”

Gluteal Flap Breast Reconstruction

“…The superior gluteal artery runs superior to the piriformis muscle and gives several branches to the gluteus maximus muscle. 11,12 The perforators of the inferior gluteal artery are located along a line in the middle third of the gluteal region above the gluteal crease. The diameter of the major perforators ranges from 1.0 to 1.5 mm in Koshima's series and averages 3.5 mm in Allen's report.…”