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Posterior Thigh Flap (Gluteal-Thigh / Friedman-Reece)

The posterior thigh flap is a reliable fasciocutaneous workhorse for complex pelvic and perineal reconstruction, with a dual blood supply from the descending branch of the inferior gluteal artery (IGA) and the profunda femoris perforating arteries, optional sensate harvest via the posterior femoral cutaneous nerve (PFCN), and the major strategic advantage of avoiding laparotomy.[5][3] Friedman and Reece's MD Anderson series (n = 27 flaps, 19 patients) established its reliability for irradiated, oncologically complex perineal defects with 96.3% flap survival despite a 53% early-wound-complication rate reflecting the population, not the flap.[5]

For the genital-context summary see Scrotal Reconstruction Techniques; for related gluteal-fold and propeller variants see IGAP / gluteal-fold flap and propeller flap.

History​

YearContribution
1980 / 1985Hurwitz & Zwiebel described the gluteal-thigh flap as bilateral deepithelialized fasciocutaneous flaps transferred to chronic perineal wounds through the ischiorectal space on pliable musculofascial pedicles (40+ patients, 8 mo–5 yr follow-up, no wound recurrence).[1]
1984Achauer applied the flap for immediate vaginal reconstruction after gynecologic resection (n = 7, 9 flaps); identified sitting discomfort and PFCN paresthesias and recommended pivoting distal to the ischium.[2]
1995Rubin, Whetzel, Stevenson — cadaveric vascular foundation (10 cadavers, 14 specimens): posterior thigh skin nourished primarily by 1st / 2nd profunda perforating arteries with secondary supply from the IGA descending branch; flap survives even after prior IGA ligation.[3]
2002Windhofer (118 cadaveric gluteal regions) — IGA descending branch present in 91%; PFCN in a common connective-tissue sheath with the descending branch in 72%, with nerve loops around the vessel in 29%.[4]
2010Friedman & Reece — landmark MD Anderson clinical series of n = 27 flaps in 19 patients for complex pelvic / perineal oncologic defects.[5]

Vascular Anatomy​

1. Inferior gluteal artery (IGA) descending branch​

  • Exits the pelvis through the greater sciatic foramen below piriformis.
  • Descending branch ("arteria comitans nervi ischiadici") courses distally along the posterior thigh, typically in a common sheath with the PFCN (72% of cases).[4]
  • Present in 91% of cadaveric specimens; when absent, perfusion is taken over by medial / lateral femoral circumflex or PFA perforators.[4]
  • IGA cutaneous territory 177 ± 38 cm² (substantially larger than SGA at 69 ± 56 cm²).[8]
  • IGAP pedicle mean total length 13.36 cm (longer than SGAP at 9.80 cm).[9]

2. Profunda femoris artery (PFA) perforators​

  • 1st, 2nd, 3rd perforating arteries provide fasciocutaneous branches via an extensive fascial plexus — Rubin's data position these as the primary posterior-thigh supply, with the IGA descending branch as secondary.[3]
  • Third perforator courses through the short head of biceps femoris: mean diameter 1.68 mm, mean pedicle length 10.28 cm.[10]
  • Dual IGA + PFA supply is the basis of the flap's survival even when one system is sacrificed.[3]

3. Interconnecting fascial plexus​

Pan & Taylor angiosome studies — the posterior thigh receives IGA + PFA + medial / lateral femoral circumflex contributions interconnected through fascial and subfascial plexuses, enabling flexible pivot-point and orientation choices.[12]

Sensory Innervation — Posterior Femoral Cutaneous Nerve​

  • Origin: anterior and posterior divisions of S1–S3; exits below piriformis with the IGA.[13]
  • Courses superficial to and between medial and lateral hamstrings.
  • Supplies posterior thigh skin and a variable posterior calf area.
  • In a common sheath with the IGA descending branch in 72%; nerve loops around the vessel in 29% — this intimate relationship constrains arc of rotation when the nerve is preserved.[4]
  • PFCN perforating branches in the posterior thigh: mean diameter 1.34 ± 0.35 mm; mean length 8.82 ± 5.78 mm.[14]

Three options:

  • Include the PFCN — sensate flap (important for perineal / scrotal reconstruction where protective sensation matters).
  • Exclude the PFCN — maximize arc of rotation (Achauer's recommendation for subtotal vaginal reconstruction).[2]
  • Sacrifice — posterior thigh hypoesthesia is the most common donor sensory complaint.[15]

The Friedman & Reece Landmark Series[5]​

VariableValue
Patients / flaps19 / 27
Configurations11 unilateral + 8 bilateral (16 flaps)
SettingComplex pelvic / perineal wounds after colorectal / gynecologic ablation; most prior pelvic radiation; VRAM and gracilis unavailable or unsuitable
Flap survival96.3% (26 / 27)
Total flap failure3.7% (1 / 27)
Ultimate primary wound healing100% (19 / 19)
Early wound-healing complications53% (10 / 19)
Secondary procedures37% (7 / 19); only 1 patient required a secondary flap

Conclusions. Reliable workhorse when laparotomy should be avoided (robotic / laparoscopic ablation, abdominal-wall preservation); valuable when patients already have both urinary and fecal diversion (VRAM may be needed for stoma or already used); early wound complications reflect the irradiated oncology population, not the flap.

Indications​

Primary (Friedman / Reece emphasis):

  • Perineal defects after APR or pelvic exenteration for colorectal / gynecologic malignancy.
  • Previously irradiated perineum.
  • VRAM unavailable (prior abdominal surgery; need to preserve rectus for stoma; robotic / laparoscopic approach without laparotomy).
  • Gracilis insufficient (large dead space or bulk requirement).
  • Patients with both urinary and fecal diversion.

Broader: sacral pressure / radiation defects; recurrent ischial pressure ulcers; pelvic / perineal oncologic resection; vulvovaginal reconstruction; trochanteric defects; scrotal reconstruction as part of broader perineal coverage; buttock sarcoma defects.[7][17][18][19][20][21][22][23]

Surgical Technique​

Positioning​

  • Prone (preferred for isolated perineal / sacral defects).
  • Lithotomy (when harvested simultaneously with an abdominal procedure).
  • Repositioning is the key logistical constraint; Friedman & Reece showed it is manageable.

Design​

  • Skin paddle over the posterior thigh, centered on the ischial-tuberosity-to-mid-popliteal-fossa axis.
  • Width ≤ ~10 cm for primary donor closure; wider flaps (15–20 cm) require donor STSG.[7][11]
  • Configurations: V-Y advancement (Friedman / Reece default), rotation / transposition, propeller (90–180° on a skeletonized perforator), or fully islanded.[11][24]

Elevation​

  1. Incise the lateral border; dissect lateral → medial in the subfascial plane.
  2. Identify the PFA perforators (1st / 2nd / 3rd) between hamstrings; identify the IGA descending branch proximally.
  3. Select the dominant perforator(s); ligate non-dominant.
  4. Identify the PFCN; include / exclude / sacrifice based on goal.
  5. Complete the medial dissection; elevate the flap entirely in the subfascial plane.
  6. Advance / rotate / tunnel through the ischiorectal fossa into the perineal defect.

Hurwitz modification for deep pelvic dead space​

Bilateral flaps deepithelialized and transferred through the ischiorectal space on musculofascial pedicles to obliterate pelvic dead space — critical for preventing abscess and perineal hernia.[1]

Donor closure​

Primary up to ~10 cm; wider flaps require STSG. Donor-site morbidity is generally minimal and temporary apart from posterior-thigh hypoesthesia.[7][15][17]

Outcomes Across Published Series​

StudyYearnIndicationFlap survivalComplications
Hurwitz & Zwiebel[1]19856 (bilateral)Chronic perineal wounds100%Minimal donor morbidity
Rubin[3]199524 / 24Mixed perineal / ischial96% (23/24)21% early
Friedman & Reece[5]201019 / 27Pelvic / perineal oncologic96.3%53% early; 37% secondary procedures
Saito[17]20149Oncologic89% (1 total + 2 partial necrosis)66% overall (33% major / 33% minor)
Djedovic[20]201728Ischial pressure soresHighComplications → longer LOS
Ordenana (WPGTPF)[11]2021seriesPerinealHighImproved with wider design

Complications​

Early wound-healing (53% in Friedman / Reece)[5]​

  • Wound dehiscence — most common; usually conservative / minor revision.
  • Surgical site infection — common in irradiated perineum.
  • Partial flap necrosis — 22% in Saito's oncology cohort.[17]
  • Total flap failure — rare, 3.7%.[5]
  • Seroma / hematoma — occasional.
  • Perineal hernia — risk reduced by bilateral deepithelialized dead-space obliteration.[1][30]

Donor site​

  • Posterior thigh hypoesthesia — most consistent complaint, present even when PFCN is preserved.[15]
  • Sitting discomfort / paresthesias — Achauer's caveat; mitigated by pivoting distal to the ischium.[2]
  • Otherwise minimal; hamstrings preserved; gait and hip extension unaffected.[10][17]
  • Scar well-concealed on the posterior thigh.

Advantages​

  1. Avoids laparotomy — preserves the abdomen and rectus.[5][31]
  2. No abdominal-wall hernia risk (unlike VRAM).[32]
  3. Dual blood supply (IGA + PFA) — survives prior IGA ligation.[3]
  4. Large skin paddle; bilateral harvest possible.[5]
  5. Bulk for dead-space obliteration when deepithelialized.[1]
  6. Sensate when PFCN is included.[4]
  7. Minimal functional donor morbidity — hamstrings preserved.[10][17]
  8. Suitable in irradiated patients — donor outside the pelvic radiation field.
  9. Bilateral harvest for very large defects.

Limitations​

  1. Repositioning required if ablation was supine / lithotomy.
  2. High early wound-complication rate (53%) — population-driven.
  3. Posterior thigh hypoesthesia essentially universal.
  4. Sitting discomfort when pivoting at / proximal to the ischial tuberosity.
  5. Less familiar to many reconstructive surgeons than VRAM / gracilis.
  6. IGA descending branch absent ~9% — PFA perforators are the safety net.
  7. Width-limited for primary donor closure (~10 cm).
  • Wide Posterior Gluteal-Thigh Propeller Flap (WPGTPF) — Ordenana 2021. Widens the flap from ischial tuberosity to greater trochanter, incorporating both IGA descending branch and PFA perforators; propeller rotation 90–180°. Addresses the ~20% IGA-descending-branch shortfall.[11]
  • Gluteal Propeller Perforator Flaps (G-PPF) — Chrelias 2023 (n = 20 APR). 100% defect coverage; 55% complication rate (30% delayed healing, 15% flap complications).[24]
  • V-Y gluteal fasciocutaneous advancement (Myers 2019) — bilateral V-Y for perineal closure after robotic APR (n = 31, 51 flaps); 100% flap survival; 42% minor wound complications.[31]
  • U-shaped gluteal-thigh flap (Komuro 1993) — extends the design along the IGA axis for large sacral defects within the ~10 cm width constraint.[7]
  • Free posterior thigh perforator flap (Li 2017) — based on the third PFA perforator; 12 × 7 to 20 × 13 cm; pedicle ~10.28 cm, artery ~1.68 mm; 7/9 complete survival.[10]
  • Venous-supercharged freestyle posterior thigh flap (Fukunaga 2014) — biceps-femoris freestyle perforator + venous supercharging when the IGA descending branch is sacrificed during sarcoma resection.[33]

Comparison with Alternative Perineal-Reconstruction Flaps​

FlapPedicleSensateAvoids laparotomyDead-space fillDonor-hernia riskSurvival
Posterior thigh (Friedman / Reece)IGA + PFA perforatorsYes (PFCN)YesExcellent (bilateral deepi)None96.3%
VRAMDIEANoNoExcellentYes~95%
GracilisMCFAYes (obturator)YesLimitedNone~90–95%
IGAMIGAVariableYesGoodNone~95%
ALTLCFA descendingVariable (LFCN)YesGoodNone~95%
Profunda artery perforator (PAP)PFAYes (PFCN)YesModerateNone100% (n = 15)[36]

Galbraith 2023 (n = 122) — VRAM, gluteal, and thigh flaps gave comparable outcomes for perineal closure after advanced pelvic oncologic resection; infection rates were lower in the flap group despite higher radiotherapy exposure.[32]

See Also​

References​

1. Hurwitz DJ, Zwiebel PC. Gluteal-thigh flap repair of chronic perineal wounds. Am J Surg. 1985;150(3):386–391. doi:10.1016/0002-9610(85)90085-6

2. Achauer BM, Braly P, Berman ML, DiSaia PJ. Immediate vaginal reconstruction following resection for malignancy using the gluteal-thigh flap. Gynecol Oncol. 1984;19(1):79–89. doi:10.1016/0090-8258(84)90162-8

3. Rubin JA, Whetzel TP, Stevenson TR. The posterior thigh fasciocutaneous flap: vascular anatomy and clinical application. Plast Reconstr Surg. 1995;95(7):1228–1239. doi:10.1097/00006534-199506000-00014

4. Windhofer C, Brenner E, Moriggl B, Papp C. Relationship between the descending branch of the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery. Surg Radiol Anat. 2002;24(5):253–257. doi:10.1007/s00276-002-0064-z

5. Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap for complex pelvic and perineal reconstruction. Plast Reconstr Surg. 2010;126(1):146–155. doi:10.1097/PRS.0b013e3181da8769

6. Monstrey S, van Landuyt K, Blondeel P, Tonnard P, Matton G. Gluteal-thigh flap used as a fasciocutaneous free flap. Microsurgery. 1996;17(7):386–390.

7. Komuro Y, Takato T, Ueda K, Harii K. Experience with U-shaped gluteal-thigh flap for reconstruction of radionecrosis in the sacral region. Ann Plast Surg. 1993;31(5):475–478. doi:10.1097/00000637-199311000-00018

8. Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg. 2007;120(6):1551–1556. doi:10.1097/01.prs.0000282098.61498.ee

9. Georgantopoulou A, Papadodima S, Vlachodimitropoulos D, et al. The microvascular anatomy of superior and inferior gluteal artery perforator (SGAP and IGAP) flaps: a fresh cadaveric study and clinical implications. Aesthet Plast Surg. 2014;38(6):1156–1163. doi:10.1007/s00266-014-0398-z

10. Li X, Cui J, Maharjan S, et al. Clinical application and the free posterior thigh perforator flap. Ann Plast Surg. 2017;78(5):526–532. doi:10.1097/SAP.0000000000000920

11. Ordenana C, Dalla Pozza E, Rampazzo A, et al. Wide posterior gluteal-thigh propeller flap for reconstruction of perineal defects. Microsurgery. 2021;41(2):146–156. doi:10.1002/micr.30666

12. Pan WR, Taylor GI. The angiosomes of the thigh and buttock. Plast Reconstr Surg. 2009;123(1):236–249. doi:10.1097/PRS.0b013e3181934873

13. Dumitru D, Nelson MR. Posterior femoral cutaneous nerve conduction. Arch Phys Med Rehabil. 1990;71(12):979–982.

14. Swancutt MM, Marchese CR, Baumgartner BA, et al. Characterization of the posterior femoral cutaneous nerve and its clinical application for autologous breast reconstruction. Clin Breast Cancer. 2024;24(8):721–727. doi:10.1016/j.clbc.2024.08.020

15. Dupéré S, Bergeron L, Bortoluzzi P, Del-Duca T, Caouette-Laberge L. Donor-site morbidity of the inferior gluteal musculocutaneous flap for breast reconstruction in teenagers. Ann Plast Surg. 2007;59(6):617–620. doi:10.1097/01.sap.0000259595.65804.2f

17. Saito A, Minakawa H, Saito N, et al. Posterior thigh flap revisited: clinical use in oncology patients. Surg Today. 2014;44(6):1013–1017. doi:10.1007/s00595-013-0635-0

18. Angrigiani C, Grilli D, Siebert J, Thorne C. A new musculocutaneous island flap from the distal thigh for recurrent ischial and perineal pressure sores. Plast Reconstr Surg. 1995;96(4):935–940. doi:10.1097/00006534-199509001-00026

19. Demirseren ME, Ceran C, Aksam B, Demiralp CO. Clinical experience with the combination of a biceps femoris muscle turnover flap and a posterior thigh fasciocutaneous hatchet flap for the reconstruction of ischial pressure ulcers. Ann Plast Surg. 2016;77(1):93–96. doi:10.1097/SAP.0000000000000290

20. Djedovic G, Morandi EM, Metzler J, et al. The posterior thigh flap for defect coverage of ischial pressure sores — a critical single-centre analysis. Int Wound J. 2017;14(6):1154–1159. doi:10.1111/iwj.12776

21. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5

22. Staniorski C, Myrga J, Hayden C, Sterling J, Rusilko P. Fasciocutaneous flap perineal closure with testicular thigh pouch for scrotal defects: surgical technique and initial experience. Urology. 2023;182:231–238. doi:10.1016/j.urology.2023.07.039

23. Alammar A, Laing K, Somasundaram J, Wallace DL, Rogers AD. Flap reconstruction following Fournier's gangrene: a systematic review of techniques and outcomes. Burns. 2026;52(3):107888. doi:10.1016/j.burns.2026.107888

24. Chrelias T, Berkane Y, Rousson E, et al. Gluteal propeller perforator flaps: a paradigm shift in abdominoperineal amputation reconstruction. J Clin Med. 2023;12(12):4014. doi:10.3390/jcm12124014

30. Bowers C, Chandrasekar B, Dargan D, Mohammed P. Partial myocutaneous gluteal flap for perineal reconstruction of extralevator abdominoperineal defects. J Plast Reconstr Aesthet Surg. 2022;75(1):125–136. doi:10.1016/j.bjps.2021.06.007

31. Myers PL, Krasniak PJ, Day SJ, Bossert RP. Gluteal flaps revisited: technical modifications for perineal wound reconstruction. Ann Plast Surg. 2019;82(6):667–670. doi:10.1097/SAP.0000000000001771

32. Galbraith NJ, McCollum C, Di Mascio L, et al. Effect of differing flap reconstruction strategies in perineal closure following advanced pelvic oncological resection: a retrospective cohort study. Int J Surg. 2023;109(11):3375–3382. doi:10.1097/JS9.0000000000000617

33. Fukunaga Y, Miyamoto S, Kobayashi E, Sakuraba M. Venous-supercharged freestyle posterior thigh flap without a descending branch of the inferior gluteal artery for reconstruction in the infragluteal region. J Plast Reconstr Aesthet Surg. 2014;67(12):1740–1743. doi:10.1016/j.bjps.2014.08.005

36. Arquette C, Wan D, Momeni A. Perineal reconstruction with the profunda artery perforator flap. Ann Plast Surg. 2022;88(4):434–439. doi:10.1097/SAP.0000000000002986