IDEAS AND INNOVATIONS

Autologous breast reconstruction with the transversemyocutaneous gracilis flap: aesthetic improvements with tissueexpansion before free flap transfer

Nestor Torio-Padron & Steffen U. Eisenhardt &Holger Bannasch & Vincenzo Penna & David Braig

Received: 6 May 2014 /Accepted: 6 June 2014# Springer-Verlag Berlin Heidelberg 2014

Abstract The transverse myocutaneous gracilis (TMG) flapprovides an alternative to commonly used free flaps from thelower abdomen and buttocks for breast reconstruction. Excel-lent aesthetic results can be achieved in primary breast recon-struction after subcutaneous and skin-sparing mastectomy.However, in delayed breast reconstruction after mastectomy,an obvious skin island and conspicuous scars often compro-mise the final appearance. A two-stage approach with tissueexpansion of the skin followed by free deepithelialised TMGflap reconstruction avoids these disadvantages and leads toimproved aesthetic results. We treated two patients who askedfor an autologous breast reconstruction after mastectomy dueto primary breast cancer. Reconstruction with lower abdomi-nal tissue was not feasible in one patient because of a previousabdominoplasty and in the other because of insufficient lowerabdominal tissue. Both patients declined an implant-basedbreast reconstruction as well as a procedure using a flap fromthe buttock, favouring reconstruction with autologous tissuefrom the superior inner thigh. In the first stage, a tissueexpander was inserted endoscopically assisted via atransaxillary approach. The expander was gradually filledover a 3-month period and finally replaced by a freedeepithelialised TMG flap. The postoperative period wasuneventful in both patients. We achieved satisfying results inboth patients with good breast symmetry and uniform colourof the breast skin. Disadvantages and limitations of traditionalone-stage breast reconstructions by free TMG flaps can beavoided by this two-stage approach. This reconstructive pro-cedure leads to inconspicuous scars and a matching skincolour of both breasts.

Level of Evidence: Level V, therapeutic study.

Keywords Breast reconstruction . Autologous breastreconstruction . TMG flap . Transversemyocutaneous gracilisflap . TUG flap . Transverse upper gracilis flap . Tissueexpansion

Introduction

Late cosmetic results after breast reconstruction with autolo-gous tissue are considered superior to implant-based recon-structions in terms of ptosis, texture and fluctuation with bodyweight [1]. Flaps from the lower abdomen have a reliableblood supply and yield excellent aesthetic results as theyprovide sufficient volume and the colour of the skin islandmatches with that of the surrounding native skin. Still, previ-ous surgery to the abdomen or insufficient abdominal softtissue might impede this option [2]. The transversemyocutaneous gracilis (TMG) flap provides an alternative inthese patients. It can be harvested from the inner thigh within ashort operation time with minimal donor site morbidity and awell-hidden scar. It provides sufficient volume to reconstructsmall- to medium-sized breasts and yields excellent cosmeticresults in autologous reconstructions following subcutaneousand skin-sparing mastectomies (Fig. 1a–d) [3]. When used fordelayed reconstruction, in which part of the breast skin enve-lope needs to be reconstructed, aesthetic results are compro-mised by limitations in flap positioning and the visible skinisland which contrasts with the surrounding native skin(Fig. 2a, b) [4]. Thus, the final aesthetic result is often consid-erably inferior to reconstructions with lower abdominal tissue.

Two-stage breast reconstruction with tissue expansion mayprovide superior aesthetic results in secondary reconstructionswith deficient chest skin as it maintains the original breast skin

N. Torio-Padron : S. U. Eisenhardt :H. Bannasch :V. Penna :D. Braig (*)Department of Plastic Surgery, Medical Center - University ofFreiburg, Hugstetter Str. 55, 79106 Freiburg, Germanye-mail: david.braig@uniklinik-freiburg.de

Eur J Plast SurgDOI 10.1007/s00238-014-0978-9

and avoids a visible skin island on the breast [5]. In a first stage,a tissue expander is inserted and gradually filled to create a skinenvelope. The autologous tissue is then inserted in a secondstage, replacing the expander. This technique has been success-fully utilized with transverse rectus abdominis myocutaneous(TRAM) free flaps, deep inferior epigastric artery perforator(DIEP) free flaps [5] and superior gluteal artery perforator (S-GAP) free flaps [6]. In our view, this technique may be espe-cially useful in patients who are candidates for TMG flapreconstruction because it eliminatesmost of the aforementionedflap-inherent disadvantages.

Patients and methods

Patient selection

All patients are routinely assessed for their suitability fordifferent implant-based and autologous reconstructive optionsincluding TRAM/DIEP, S-GAP, inferior (I)-GAP and TMGfree flaps. Patients with contraindications for TRAM/DIEPflaps and small- to medium-sized breasts are further evaluatedfor a two-stage TMG, S-GAP or I-GAP flap reconstructive

approach. Final flap selection is made upon the quality andvolume of soft tissue at both donor sites and patients’ prefer-ence. All patients were counselled in detail on different recon-structive procedures and gave their written informed consentprior to surgery.

Operative technique

In the first step, an expander is placed by a transaxillaryapproach and initially filled with approximately half of itsvolume. The transaxillary approach is chosen in order tominimize implant-related complications. Placement of theexpander is performed endoscopically assisted using alreadyexisting axillary lymphadenectomy scars similar to atransaxillary augmentation mammoplasty [7].

Expansion started 1 week postoperatively at approximately30–50 ml per week until the desired volume is reached.

The expander is replaced in a second stage by a free TMGflap from the contralateral inner thigh. The flap is raised with atransverse skin paddle of approximately 10×30 cm, and thepedicle vessels are subsequently anastomosed to the internalmammary vessels. After shaping the flap as described previ-ously by Wechselberger (Fig. 3a) [8], the skin paddle is

Fig. 1 Bilateral TMG flapreconstruction after subcutaneousmastectomy. a, b Preoperativephotographs of a 42-year-oldwoman with BRCA-2 mutationwho asked for a prophylacticmastectomy with primaryreconstruction. c, d Postoperativephotographs 5 months afterbilateral subcutaneousmastectomy and primaryreconstruction with freedeepithelialised TMG flaps. Flapswere inserted through incisions inthe submammary folds

Fig. 2 Bilateral delayed TMG flap reconstruction after modified radicalmastectomy. a Preoperative photograph of a 49-year-old woman aftermodified radical mastectomy that declined reconstruction with a two-

stage approach. b Postoperative photograph 9 months after traditionalone-stage breast reconstruction with bilateral TMG flaps

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deepithelialised and completely buried under the pre-expanded skin envelope (Fig. 3b). Vascularity of the flap ismonitored via an implantable Doppler probe (Cook Medical)that is placed around the vein of the flap’s pedicle [9].

Results

Two patients underwent a breast reconstruction with theabove-described two-stage approach after mastectomy dueto primary breast cancer.

Patient 1 A 53-year-old woman presented to our departmentand asked for autologous breast reconstruction. Three yearsago, she had a modified radical mastectomy due to invasiveductal carcinoma of her right breast. She was not suitable for

TRAM/DIEP free flap reconstruction because of insufficientlower abdominal soft tissue (Fig. 4a–c) and denied implant-based reconstruction and reconstruction with an S-GAP or I-GAP flap.

In a first stage, a 400-cm3 expander was placedtransaxillary and initially filled with 160 cm3. Weekly expan-sion was started 12 days postoperatively to a final volume of400 cm3. The expander was replaced 3.5 months after its insetby a TMG flap from the upper left thigh. The postoperativeperiodwas uneventful with good vascularity of the flap, whichwas monitored by an implantable Doppler probe. The nipplewas reconstructed by nipple sharing from the contralateralbreast and the areola was tattooed. Due to ptosis of the leftbreast with concomitant breast asymmetry, we performed amastopexy of the contralateral breast 5 months after inset ofthe flap. At 1.5-year follow-up, she is satisfied with theaesthetic result and experiences no limitations in daily life

a b Fig. 3 Operative procedure. aThe shaped and deepithelialisedflap before its inset. b The flap iscompletely buried under the pre-expanded skin envelope. Animplantable Doppler probemonitors flap vascularity (arrow)

a b c

d e

f g h i

Fig. 4 a–c Preoperativephotographs of patient 1, whoasked for an autologousreconstruction after modifiedradical mastectomy.Reconstruction with lowerabdominal flaps was not feasibledue to insufficient soft tissue. d, e1.5-year postoperativephotographs after reconstructionwith free deepithelialised TMGflap. A mastopexy of thecontralateral breast wasperformed to improve symmetry.f, g Preoperative and h, ipostoperative photographs of leftsuperior thigh donor-site

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(Fig. 4d, e). Donor-site scars at the left superior thigh areinconspicuous and well hidden (Fig. 4h, i).

Patient 2 A 41-year-old woman asked for autologous breastreconstruction 1 year after undergoing a nipple-sparing mastec-tomy due to primary breast cancer at the right side. She initiallyunderwent an implant-based reconstruction in an external hos-pital, which failed due to soft tissue necrosis and implantexposure, necessitating its removal. On presentation at ourdepartment, the postmastectomy skin envelope was thin butof good quality (Fig. 5a, b). She previously had anabdominoplasty, which precluded TRAM/DIEP reconstruction.

A 350-cm3 expander was placed by an axillary approachand initially filled with 200 cm3. Expansionwas initiated within

the first week postsurgery and continued weekly to a totalvolume of 430 cm3 (Fig. 5c, d). The expander was replacedby a free TMG flap from the contralateral side 2.5 months afterits placement. Flap vascularity remained stable as evidenced byan implanted Doppler probe. The follow-up at 16 monthsshows good symmetry of both breasts with similar volumeand an inconspicuous donor-site scar (Fig. 5e–h).

Discussion

Microsurgical free tissue transfer is currently the gold standardfor autologous breast reconstruction and various options are

a b

c d

e f

g h

Fig. 5 a, b Preoperativephotographs of patient 2, whopresented to our department aftera nipple-sparing mastectomy witha failed implant-basedreconstruction. c, d Completelyexpanded skin envelope prior toinset of flap. e, f Postoperativephotographs 16 months afterreconstruction with a two-stageTMG approach. g, h Donor-sitescar at the left superior thigh. Notethe scar from the previousabdominoplasty, which precludedreconstruction with lowerabdominal soft tissue

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available. These include the free TRAM flap, DIEP flap,superficial inferior epigastric artery (SIEAP) flap, S- and I-GAP flap, and TMG flap [2].

Still, the most challenging problem remains of how todetermine the most appropriate flap for a particular patient.Various variables such as breast size, mastectomy procedure,availability of soft tissue, scars and patients’ preference needto be considered. Excellent results can be achieved aftersubcutaneous and skin-sparing mastectomies as the originalskin envelope and the submammary fold of the breast remainintact. The flap can thus be inserted in a one-stage procedurewithout pre-expansion of the breast skin envelope [10].

Breast reconstruction after modified radical mastectomyposes additional challenges in that part of the skin envelopeneeds to be reconstructed. Good aesthetic results can thus onlybe obtained if the colour and texture of the flap’s skin paddlematches the surrounding breast skin. Soft tissue from the lowerabdomen is often the most suitable in that its skin is similar tonative breast skin and it provides sufficient volume and a reliablevascularity [1]. Still, abdominal scaring, a previousabdominoplasty or insufficient abdominal soft tissue might pre-clude this option. The inner thigh skin and fat based on thetransverse upper gracilis myocutaneous flap is a favourableoption in these patients. The anatomy is extremely reliable andit creates a well-hidden scar near the groin crease. In addition, nointraoperative repositioning is required, which is in contrast tothe use of gluteal flaps and shortens the operating time [3]. Itprovides sufficient volume to reconstruct small- to medium-sized breasts and is especially useful for primary reconstructionafter subcutaneous and skin-sparing mastectomies (Fig. 1a–d).

Aesthetic results after delayed reconstructions are often notsatisfying as flap positioning is limited and part of the breastskin needs to be reconstructed. The visible skin paddle of theflap is darker and has a different texture and thickness thanbreast skin. It thus often contrasts with the surrounding nativeskin. In addition, the pre-set dimensions of the flap’s skinisland, its short pedicle and the orientation of the mastectomyscar limit flap positioning. Optimal flap positioning is especial-ly difficult in patients with a superior mastectomy scar, as theflap does not provide sufficient skin and soft tissue to recon-struct the whole aesthetic unit, which results in a conspicuousscar that is not hidden in the submammary fold (Fig. 2a, b).

These flap-inherent disadvantages can be bypassed if theflap is deepithelialised and completely buried under the nativebreast skin. This allows for optimal flap positioning, avoids avisible skin paddle and leaves inconspicuous scars as flapinset can be performed through the mastectomy scar or thesubmammary fold.

As the mastectomy skin flaps must be pre-expanded priorto flap inset, it requires a two-stage approach. However, in ourview, this increase in operative effort is surpassed by superioraesthetic outcomes when compared to traditional one-stageTMG flap reconstructions.

A similar two-stage approach with excellent results hasbeen described recently with the use of TRAM/DIEP and S-GAP free flaps [5, 6, 11]. Still, as these flaps usually blendnicely with the surrounding breast skin, patients that mightbenefit from a two-stage approach must be carefully selected.In contrast, in TMG flap reconstructions, the aesthetic resultsof a two-stage approach are clearly superior to those of thetraditional approach. Thus, a two-stage approach should beconsidered for delayed breast reconstruction whenever possiblein patients who are favourable for a TMG flap reconstruction.

In order to reduce the risk of wound healing problems andimplant exposure, we inserted the expander endoscopicallyassisted via a transaxillary approach through already existinglymphadenectomy scars. This additionally allows for earlyand rapid filling of the expander.

Monitoring the completely buried flap with an implantableDoppler probe eliminates the need for a monitoring skinisland. This obviates the need for further operative procedures,as the Doppler probe can easily be removed bedside [12].

Taken together, our two-stage approach greatly improvesthe final aesthetic outcome after breast reconstruction with theTMG flap when compared with traditional one-stage proce-dures. More patients will be needed, to assess safety and long-term results of this approach.

Conflict of Interest None.

Ethical Standards All patients gave their informed consent prior totheir inclusion in the study. Details that might disclose the identity of thesubjects under study were omitted.

References

1. Clough KB, O'Donoghue JM, Fitoussi AD, Vlastos G, Falcou MC(2001) Prospective evaluation of late cosmetic results followingbreast reconstruction: II. Tram flap reconstruction. Plast ReconstrSurg 107(7):1710–1716

2. Yu SC, Kleiber GM, Song DH (2013) An algorithmic approach tototal breast reconstruction with free tissue transfer. Arch Plast Surg40(3):173–180

3. Buntic RF, Horton KM, Brooks D, Althubaiti GA (2011) Transverseupper gracilis flap as an alternative to abdominal tissue breast recon-struction: technique and modifications. Plast Reconstr Surg 128(6):607e–613e

4. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U (2004) Breast recon-struction by the free transverse gracilis (TUG) flap. Br J Plast Surg57(1):20–26

5. Tadiparthi S, Alrawi M, Collis N (2011) Two-stage delayed breastreconstruction with an expander and free abdominal tissue transfer:outcomes of 65 consecutive cases by a single surgeon. J PlastReconstr Aesthet Surg 64(12):1608–1612

6. Gurunluoglu R, Spanio S, Rainer C, Ninkovic M (2003) Skin expan-sion before breast reconstruction with the superior gluteal artery perfo-rator flap improves aesthetic outcome. Ann Plast Surg 50(5):475–479

7. Momeni A, Padron NT, Bannasch H, Borges J, Bjorn Stark G (2006)Endoscopic transaxillary subpectoral augmentation mammaplasty: a

Eur J Plast Surg

safe and predictable procedure. J Plast Reconstr Aesthet Surg 59(10):1076–1081

8. Wechselberger G, Schoeller T (2004) The transverse myocutaneousgracilis free flap: a valuable tissue source in autologous breast recon-struction. Plast Reconstr Surg 114(1):69–73

9. Fernando B, Young VL, Logan SE (1988) Miniature implantablelaser Doppler probe monitoring of free tissue transfer. Ann Plast Surg20(5):434–442

10. Levine SM, Snider C, Gerald G, Tanna N, Broer PN, Stolier A et al(2013) Buried flap reconstruction after nipple-sparing mastectomy:

advancing toward single-stage breast reconstruction. Plast ReconstrSurg 132(4):489e–497e

11. Schwarz K, Tahiri Y (2011) Subcutaneous pre-expansion of mastec-tomy flaps before breast reconstruction with deep inferior epigastricperforator flaps: eliminating the patch-like appearance and improvingaesthetic outcomes. Ann Plast Surg 66(2):124–127

12. Iblher N, Eisenhardt SU, Penna V, Stark GB, Bannasch H (2010) Anew evaluation tool for monitoring devices and its application toevaluate the implantable Doppler probe. J Reconstr Microsurg 26(4):265–270

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