Transverse Upper Gracilis Flap Research Articles

Myocutaneous Gracilis Free Flaps in Microsurgical Breast Reconstruction: A Systematic Review Comparing Variations of the Upper Gracilis Flap.

Background The transverse upper gracilis (TUG) flap has gained increasing acceptance as a reliable option for breast reconstruction, specifically in patients without adequate abdominal tissue. Three major flap designs of the upper gracilis flap have been proposed to balance volume needs with flap vascularity. A systematic review was performed to identify outcomes of the major gracilis flaps: TUG, vertical-transverse upper gracilis (V-TUG), and longitudinal gracilis myocutaneous (LGM) flaps. This study is the first and only systematic review to date reviewing the variations of the upper gracilis flap in microsurgical breast reconstruction. Methods A systematic review of the literature was conducted using PubMed database from 1966 through 2015. Inclusion and exclusion criteria were applied. Outcomes assessed included total flap volumes, additional breast procedures to achieve intended breast volume, and complication rates. Results A total of 485 gracilis-type flaps were performed in 335 patients. V-TUG flaps provided the largest mean flap weights and did not require additional lipofilling or implant placement, whereas the majority of TUG flaps (50.6%) required additional fat grafting or implant placements. All flap types demonstrated a low incidence of donor-site morbidity. Overall flap loss rate was low; TUG flaps reported 2.3% total and 2.0% partial flap losses, while V-TUG and LGM flaps reported no flap losses. Conclusion This review found V-TUG yielded highest mean flap weights and did not require additional breast augmentation procedures as compared with the TUG. Also, the V-TUG was a safer donor-site option with fewer flap and donor-site morbidities.

Microsurgical refinements with the use of internal mammary (IM) perforators as recipient vessels in transverse upper gracilis (TUG) autologous breast reconstruction.

The transverse upper gracilis (TUG) flap is the senior authors' second choice for autologous breast reconstruction when the DIEP flap is not available. It provides durable, pliable tissue with well hidden scars. The main criticism of this flap is the limited volume, donor site complications, short pedicle and vessel mismatch depending on which recipient vessels are used. We described methods of reducing vessel mismatch, complications of venous coupler and refinements to help give a more superior aesthetic outcome. We describe several maneuvers to help reduce vessel mismatch with the use of the internal mammary (IM) perforator vessels with a modification of the Harashina fish-mouth technique or the use of a vessel bifurcation to increase vessel diameter. We also describe the optimum method of perforator preparation and potential methods to prevent palpable venous couplers. The author's describe their case series of 14 TUG flaps to reconstruct 13 breasts in 12 patients. Eight unilateral, 2 partial breast reconstruction, 1 bilateral and 1 bilateral TUG flap for a unilateral reconstruction was carried out. All flaps survived with one partial flap necrosis, one donor site seroma and two cases of palpable/tender venous couplers. The mean reconstructed breast was 320 grams. The TUG flap is a reconstructive challenge, but with correct planning a good aesthetic outcome is possible. The IM perforator is our first choice recipient vessel in TUG breast reconstructions. With meticulous preparation and by overcoming vessel mismatch the use of this recipient vessel is a reliable option.

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

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.

Recent advances in microvascular autologous breast reconstruction after ablative tumor surgery.

Breast cancer is a ubiquitous disease and one of the leading causes of death in women in western societies. With overall increasing survival rates, the number of patients who need post-mastectomy reconstruction is on the rise. Especially since its psychological benefits have been broadly recognized, breast reconstruction has become a key component of breast cancer treatment. Evolving from the early beginnings of breast reconstruction with synthetic implants in the 1960s, microsurgical tissue transfer is on the way to become the gold standard for post oncology restoration of the breast. Particularly since the advent of perforator based free flap surgery, free tissue transfer has become as safe option for breast reconstruction with low morbidity. The lower abdominal skin and subcutaneous fat tissue typically offer enough volume to create an aesthetically satisfying breast mound. Nowadays, the most commonly used flap from this donor site is the deep inferior epigastric artery perforator flap. If the lower abdomen is not available as a donor site, the gluteal area and thigh provide a number of flaps suitable for breast reconstruction. If the required breast volume is small, and there is enough tissue available on the upper medial thigh, then a transverse upper gracilis flap may be a practicable method to reconstruct the breast. In case of a higher amount of required volume, a gluteal artery perforator flap is the best choice. However, what is crucial in addition to selecting the best flap option for the individual patient is the timing of the operation. In patients with confirmed post-mastectomy radiation therapy, it is advisable to perform microvascular breast reconstruction only in a delayed fashion.

The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction.

Surgical options for breast reconstruction include alloplastic and autogenous reconstructions. In autologous cases where the abdomen is not a suitable primary donor site, secondary donor sites such as the thigh or buttock are considered. The aim of this report is to describe a novel approach, the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap, aimed at medium to large volume breast reconstruction, with a single donor site used per breast. Between January 2011 and June 2013, 32 consecutive unilateral immediate breast reconstruction cases were performed using free flaps. In nine cases, patients had previously undergone abdominal surgery, therefore abdominal flaps were excluded and TUGPAP flaps were performed. The TUGPAP flap consisted of the combination of two well-described flaps: the transverse upper gracilis (TUG) and the profunda artery perforator (PAP) flap. All TUGPAP flaps were based on two pedicles: the ascending branch of the medial circumflex femoral artery (MCFA) for the TUG component, and the profunda artery perforator itself for the PAP component. The mean size of the harvested skin paddle was 28.6 × 8 cm2 (range, 27 × 7 cm2 to 30 × 9 cm2). The average length of the TUG flap pedicle was 7 cm (range, 6-8 cm) and the PAP flap pedicle was 9 cm (range, 8.5-10 cm). The flap survival rate was 100% with no re-exploration, and no partial flap loss. Post-operatively there was one case of persistent donor site seroma, which was managed conservatively. With appropriate patient selection and surgical technique the TUGPAP flap could be a valuable option as an alternative method for autologous breast reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Vascular Variations of the Transverse Upper Gracilis Flap in Consideration for Breast Reconstruction

The transverse upper gracilis (TUG) myocutaneous flap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability. A retrospective review of records was performed on patients undergoing a TUG flap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.). A total of 36 TUG flaps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of flap harvest. Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for flap dissection when the microsurgeon encounters such aberrancies.

Evolution from the TUG to PAP flap for breast reconstruction: Comparison and refinements of technique

Limitations of the transverse upper gracilis (TUG) flap for autologous breast reconstruction include: short pedicle, modest volume, muscle sacrifice and a problematic donor site. The Profunda Artery Perforator (PAP) flap utilises large perforators posterior to the gracilis muscle. We describe our preliminary experience of its use and compare it to our large series of TUG flaps. Our technique has evolved from frog-leg to lithotomy position, and from an anterio-posterior to cranio-caudal raise. This allows either the descending branch of the inferior gluteal artery perforators (IGAP) or the TUG flap as alternatives should PAP perforators be unsuitable intra-operatively. A prospective database was utilised to compare TUG and PAP flaps undertaken 2010-2013. 54 TUG and 22 PAP flaps were performed. 4 PAP flaps were converted to IGAP flaps and 1 to TUG intra-operatively. 97% of all flaps were successful. Mean flap weight was 295g (TUG) and 242g (PAP). Donor site complications for both series included seroma (4 TUG, 1 PAP) sensory disturbance (2 TUG, 1 PAP) and scar revision (3 TUG, 1 PAP). Our preliminary experience of the PAP flap has not been universally favourable compared to the TUG flap. It is a more challenging flap to raise, which carries with it a learning curve, especially if raised in the supine position; we present our learning points for safer flap harvest, allowing the TUG as a bail out option. The benefits of the PAP include a longer pedicle, without the need to sacrifice muscle; the perforators should have a more defined and larger perfusion zone. The scar is better hidden, but we have not yet proven significant improvements to the donor site compared to the TUG flap. III.

The Evolution of Perforator Flap Breast Reconstruction: Twenty Years after the First DIEP Flap

It is over 20 years since the inaugural deep inferior epigastric perforator (DIEP) flap breast reconstruction. We review the type of flap utilized and indications in 2,850 microvascular breast reconstruction over the subsequent 20 years in the senior author's practice (Robert J. Allen). Data were extracted from a personal logbook of all microsurgical free flap breast reconstructions performed between August 1992 and August 2012. Indication for surgery; mastectomy pattern in primary reconstruction; flap type, whether unilateral or bilateral; recipient vessels; and adjunctive procedures were recorded. The DIEP was the most commonly performed flap (66%), followed by the superior gluteal artery perforator flap (12%), superficial inferior epigastric artery perforator flap (9%), inferior gluteal artery perforator flap (6%), profunda artery perforator flap (3%), and transverse upper gracilis flap (3%). Primary reconstruction accounted for 1,430 flaps (50%), secondary 992 (35%), and tertiary 425 (15%). As simultaneous bilateral reconstructions, 59% flaps were performed. With each flap, there typically ensues a period of enthusiasm which translated into surge in flap numbers. However, each flap has its own nuances and characteristics that influence patient and physician choice. Of note, each newly introduced flap, either buttock or thigh, results in a sharp decline in its predecessor. In this practice, the DIEP flap has remained the first choice in autologous breast reconstruction.

The Infragluteal Sulcus: A Histologic and Ultrasonographic Study

The buttocks are a major component of sexual attraction, and they have their place in the concept of beauty in most cultures and ethnic groups. The infragluteal sulcus, an important part of the gluteal region, determines the attractiveness of the buttocks. For that reason, any small change in the infragluteal sulcus makes a major cosmetic difference in the morphology of the buttock. In recent years, some flaps such as the infragluteal flap, the transverse upper gracilis flap, and the transverse musculocutaneous gracilis flap have become popular because of reduced donor area morbidity and their availability for hiding incision scars. In these cases, there may be distortion of the gluteal morphology and infragluteal sulcus. In this study, the anatomic and histologic features of the tissues that form the infragluteal sulcus were analyzed for their contribution to successful reconstruction of the infragluteal sulcus. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin-sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.

Introducing the Profunda Artery Perforator Flap for Breast Reconstruction

Popularized alternatives to abdominally-based autologous breast reconstruction include the superior or inferior gluteal artery perforator (SGAP or IGAP) flaps and transverse upper gracilis (TUG) flaps. The SGAP flap places a scar across the superior buttock and can create a contour deformity. The IGAP flap has been associated with sitting difficulties, secondary to loss of fat over the ischial tuberosity. The TUG flap has been criticized for its small volume, short pedicle, sacrifice of the gracilis muscle, and a visible scar anteriorly. The authors have explored the posterior thigh, where the profunda artery can supply a perforator (PAP) flap, as a better alternative.

Modifications to Extend the Transverse Upper Gracilis Flap in Breast Reconstruction: Clinical Series and Results

Modifications to Extend the Transverse Upper Gracilis Flap in Breast Reconstruction: Clinical Series and Results

Tug ‘O’ war: Challenges of transverse upper gracilis (TUG) myocutaneous free flap breast reconstruction

Autologous tissue microsurgical breast reconstruction is increasingly requested by women following mastectomy. While the abdomen is the most frequently used donor site, not all women have enough abdominal tissue excess for a unilateral or bilateral breast reconstruction. A secondary choice in such women may be the transverse upper gracilis (TUG) myocutaneous flap. This study reviews our experience with TUG flap breast reconstruction looking specifically at reconstructive success rate and the requirement for secondary surgery. A total of 16 free TUG flaps were performed to reconstruct 15 breasts in eight patients over a period of five years. Data were collected retrospectively by chart review. Follow up ranged from 14 to 41 months. During the follow up period, there was one (6.3%) complete flap loss in an immediate breast reconstruction patient. Four further flaps (25%) failed in their primary aim of breast reconstruction, as they required additional significant reconstruction with either deep inferior epigastric perforator (DIEP) flaps (two flaps (12.5%), one patient) or augmentation with silicone breast implants (two flaps (12.5%), one patient), giving a successful breast reconstruction rate with the TUG flap of only 66.7%. In all of the remaining reconstructed breasts, deficient flap volume or breast contour was seen. Eight flaps were augmented by lipofilling. A total of 62.5% of the donor sites had complications, namely sensory disturbance of the medial thigh (25%) and poor scar (37.5%) requiring revision. This series demonstrates a high rate of reconstructive failure and unsatisfactory outcomes from TUG flap breast reconstruction. We feel this reinforces the necessity of adequate pre-operative patient assessment and counselling, including discussion regarding the likelihood of subsequent revisional surgery, before embarking on this form of autologous breast reconstruction.

Breast Reconstruction with the Profunda Artery Perforator Flap

The use of perforator flaps has allowed for the transfer of large amounts of soft tissue with decreased morbidity. For breast reconstruction, the deep inferior epigastric perforator flap, the superior and inferior gluteal artery perforator flaps, and the transverse upper gracilis flap are all options. The authors present an alternative source using posterior thigh soft tissue based on profunda artery perforators, termed the profunda artery perforator flap. Preoperative imaging helps identify posterior thigh perforators from the profunda femoris artery. These are marked, and an elliptical skin paddle, approximately 27 × 7 cm, is designed 1 cm inferior to the gluteal crease. Dissection proceeds in a suprafascial plane until nearing the perforator, at which point subfascial dissection is performed. The flap has a long pedicle (approximately 7 to 13 cm), which allows more options when performing anastomosis at the recipient site. The long elliptical shape of the flap allows coning of the tissue to form a more natural breast shape. All profunda artery perforator flaps have been successful. The donor site is well tolerated and scars have been hidden within the gluteal crease. Long-term follow-up is needed to evaluate for possible fat necrosis of the transferred tissue. The authors present a new technique for breast reconstruction with a series of 27 flaps. This is an excellent option when the abdomen is not available because of the long pedicle, muscle preservation, ability to cone the tissue, and hidden scar. Therapeutic, V.

Transverse Upper Gracilis Flap as an Alternative to Abdominal Tissue Breast Reconstruction

The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous flap blood supply provide an autologous donor area with qualities favorable to microvascular breast reconstruction. The flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection, and has a consistent blood supply. The characteristics and skin color of the flap allow for immediate nipple-areola complex reconstruction in skin-sparing mastectomy. From 2004 to 2007, the authors performed 32 free inner thigh flap microvascular breast reconstructions after mastectomy for breast cancer in 20 patients, in both delayed and immediate settings. All flaps survived without any soft-tissue loss or fat necrosis. Complications were a single take-back for venous thrombosis with salvage, donor-site skin breakdown in eight flaps, and five seromas. There was no functional loss at the donor site, and all patients resumed normal activity. Transverse upper gracilis musculocutaneous flap microvascular breast reconstruction is an excellent option for patients who desire autologous reconstruction and who do not have adequate abdominal donor tissue or who do not desire abdominal scarring. Therapeutic, IV.

Transverse Upper Gracilis (TUG) flap for volume replacement in breast conserving surgery for medial breast tumours in small to medium sized breasts

Excision of medial sited breast tumours in small breasted patients can result in poor cosmetic outcomes, making this a difficult group of patients to manage. Traditional oncoplastic volume replacement techniques available to treat this area of the breast are limited and usually require disruption of the remaining breast to allow access for pedicled flaps. The alternative is mastectomy and total breast reconstruction. The use of a small volume free Transverse upper Gracilis (TUG) flap allows like for like replacement for these defects. Excellent cosmetic results are achievable with minimal breast and donor site morbidity. This initial experience of small volume TUG flaps used in four patients is presented to support the feasibility and assess early outcomes of this technique in the management of this niche group of patients.

The transverse upper gracilis flap for breast reconstruction following liposuction of the thigh

A particular flap with rising prominence in breast reconstruction is the transverse upper gracilis (TUG) flap. With the increasing prevalence of patients opting for various forms of elective liposuctions, breast reconstruction with flaps has necessitated a more meticulous yet perhaps more flexible screening for potential donor sites. We present a case of a bilateral breast reconstruction using TUG flaps in a patient with a previous history of liposuction to her abdomen and thighs. The dimensions of the TUG flaps were 7 × 31 cm². The patient did not undergo any flap or donor site complications. We speculate that perhaps much of the tissue and muscle in the medial thigh region is more robust than previously thought and that there is high potential for neo-vascularization in the thigh region following a liposuction. Accordingly, we advocate the effective use of the TUG flap for breast reconstruction in spite of previous liposuctions to the thighs.

Breast reconstruction by the free transverse gracilis (TUG) flap

The transverse upper gracilis (TUG) flap is a free musculocutaneous (type II) flap consisting of a segment of the proximal gracilis muscle and a 25×10 cm skin paddle oriented transversely. The vascular pedicle of the TUG flap is the ascending branch of the medial circumflex femoral artery with two venae comitantes. The pedicle length is 6 cm and the diameter of the artery is 1.6 mm. In the year 2002, seven patients had breast reconstruction by the free TUG flap. There were three primary and four secondary reconstructions. Five flaps totally survived, two flaps were lost (in the same patient). TUG flap is indicated in women who seek primary autologous reconstruction after a skin sparing mastectomy, have small or moderately large breasts, do not accept scars on the abdomen, back or gluteal region, who are large in hips and thighs and want a thigh lift. The vascular pedicle although short, permits easy anastomosis of matching vessel diameters to the internal mammary vessels. The main possible complication, other than thrombosis at the anastomosis, is wound dehiscence on the thigh with secondary wound healing. This can happen when the flap is wider than 10 cm.