Reply: TUGs into VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option

Abstract

Sir: We appreciate the thoughtful commentary of Drs. Craggs et al. regarding our article describing transverse upper gracilis (TUGs), vertical upper gracilis (VUGs), and bilateral stacked vertical upper gracilis flaps (BUGs).1 Their assessment provides valuable guidelines for optimizing hiding the transverse scars of the TUG flap while minimizing donor-site morbidities such as scar migration and labial spread. However, this is not an either/or scenario where one flaps trumps the other. Certain women’s thigh skin laxity benefits from a transverse excision, whereas others are better served with a vertical excision.2 We know from basic plastic surgical principles that the best scars are those that heal without any tension. Furthermore, we caution that the anterior portion of the TUG flap often projects over the femoral triangle, where a deeper dissection would encounter groin lymph nodes and can possibly lead to lymphedema.2,3 The prudent dissection in this area is superficial and, therefore, the anterior aspect of the TUG flap does not contribute any significant subcutaneous volume. The literature on the use of the upper thigh tissue for breast reconstruction has focused predominantly on the transverse orientation of the upper gracilis flap (TUG). Most body contouring operations of the thigh have migrated away from the transverse lift in favor of the vertical pattern to reduce possible complications with scar or labial spreading.4 We believe this migration should also occur in reconstructive surgery as well. Thus, we feel it is important to shine the spotlight on the vertical variation of the upper gracilis flap (VUG), describe its virtues, and introduce it—along with the bilateral upper gracilis flap for unilateral reconstruction (BUG)—for use by reconstructive surgeons. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Julie E. Park, M.D.David H. Song, M.D., M.B.A.Section of Plastic and Reconstructive SurgeryUniversity of Chicago MedicineChicago, Ill.