Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, e1ee6

Bilateral simultaneous breast reconstructionwith transverse musculocutaneous gracilisflaps

Frederic Bodin*, Thomas Schohn, Caroline Dissaux,Alexandre Baratte, Caroline Fiquet, Catherine Bruant-Rodier

Department of Plastic Surgery, Strasbourg Academic Hospital, Strasbourg, France

Received 7 August 2014; accepted 22 September 2014

KEYWORDSTransversemusculocutaneousgracilis (TMG) flap;Transverse uppergracilis (TUG) flap;Bilateral breastreconstruction;Prophylacticmastectomy;Microsurgery

* Corresponding author. Service de CStrasbourg Cedex, France. Tel.: þ33 3

E-mail address: frederic.bodin@ch

http://dx.doi.org/10.1016/j.bjps.2014.01748-6815/ª 2014 British Association of P

Summary Background: A transverse musculocutaneous gracilis flap provides good autologousreconstruction for small- and medium-sized breasts. Although the procedure is well adaptedfor bilateral breast reconstruction, no publication has specifically addressed simultaneousbilateral cases.Methods: From 2010 to 2014, the authors performed seven simultaneous bilateral breast re-constructions using transverse musculocutaneous gracilis flaps. The results with respect tooperative data, immediate complications, second-stage reconstruction, and patient satisfac-tion after >1 year of follow-up were studied retrospectively.Results: The mean operative time was 7 h and 48 min (range, 6e9 h). Three minor complica-tions occurred: two cases of limited flap necrosis and one case of donor-site wound dehis-cence. Surgical revision was not required, and there was no flap failure. A second-stageoperation was performed in 71% of the patients to improve the aesthetic results and flap vol-ume. On average, 167 cm3 of fat was injected per breast. After a mean follow-up of 27 months,the satisfaction rate was 86% without significant functional deficits.Conclusions: A transverse musculocutaneous gracilis flap is an effective and safe option forsimultaneous bilateral reconstruction. The operating time is shorter than that for other autol-ogous procedures with similar complication rates and high patient satisfaction levels.ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

hirurgie plastique et reconstructrice e Hopital civil e 1, Place de l’hopital e B.P. N� 426 e 6709188116197; fax: þ33388115188.ru-strasbourg.fr (F. Bodin).

9.047lastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Table 1 Operative parameters.

Parameters Value (minemax)

Operation duration 468 min (360e540)Ischemic duration 37 min (26e55)Flap weight 356 g (270e487)Skin paddle length 22.6 cm (18e30)Skin paddle width 9.3 cm (7e10)Artery diameter 2.0 mm (1.5e2)Coupler size 2.4 mm (1.5e3.5)Length of TMG vascular pedicle 5.8 cm (4.5e7)

e2 F. Bodin et al.

Introduction

Several autologous reconstruction procedures are availableto provide natural and sustainable breasts after mastec-tomy. The deep inferior epigastric perforator (DIEP) flap isthe most commonly used procedure.1 However, pedicledlatissimus dorsi flaps, gluteal perforator flaps, and trans-verse musculocutaneous gracilis (TMG) flaps are oftenpreferred, especially when the patient does not have suf-ficient abdominal skin. The recently developed TMG flapwas originally described by Wechselberger and Schoeller in2004 for breast reconstruction.2 Previous studies haveshown a high level of patient satisfaction for small- andmedium-sized breast reconstructions with low donor-sitemorbidity.3 The main consistent vascular pedicle of thegracilis muscle provides the blood supply for the flap.4 Theelliptical transversal skin paddle provides sufficient volumefor breast reconstruction with concealed scars in the nat-ural folds. The procedure is particularly well adapted forbilateral breast reconstruction that offers a symmetricaesthetic appearance in the upper inner thigh.5 However,no study has yet specifically analyzed the results of simul-taneous bilateral cases.

Materials and methods

Between November 2010 and January 2014, 36 patientsunderwent 44 TMG breast reconstructions performed by thesame leading surgeon in our surgical department. Of these,seven cases of primary bilateral simultaneous breast re-constructions were identified and analyzed. Approval toconduct this study was obtained from the ethics committeeof the academic hospital, and all patients provided writteninformed consent.

Patients

The mean age of the patients was 39.4 years (range, 20e48)with a mean body mass index of 25 kg/cm2 (range,18.1e31.6). Mastectomies were performed as curativebreast cancer therapy (50%) or prophylactically as skin-sparing mastectomies (50%). The flaps were transferred inthe immediate (50%) or delayed setting (50%). Fifty percentof the patients had previously received radiation therapy orchemotherapy. None of the patients presented significantcomorbidities, and none of them were active smokers.

Surgical procedure

The surgical procedure was performed as previouslydescribed by Schoeller et al.5 The TMG flaps were harvestedfrom the inner thigh and transferred to the opposite breastusing a systematic double-team approach. The pedicle ofthe flap was end-to-end anastomosed to the internalthoracic vessels in the third intercostal space. A portionbelow or above the rib cartilage was removed if necessary.Microanastomoses were performed using hand-sewn 9/0 or8/0 nylon sutures for the artery and a mechanical couplerdevice for the veins (Synovis Micro Companies Alliance Inc.,St Paul, MN, USA). The skin flap was folded onto itself into a

cone shape and partially deepithelialized. The remainingskin was placed on the major breast surface in delayedbreast reconstruction, but was reduced to the areola inimmediate breast reconstruction with skin-sparing mas-tectomy. The gracilis muscle was rolled underneath to in-crease breast projection.

Retrospective evaluation protocol

Operative data on operative time, ischemic time, weight ofthe flap, skin paddle dimension, and vascular pediclecharacteristics (diameter and length) were studied. Thelength of hospital stay and immediate complications werecollected and analyzed. After 1 year of follow-up, second-stage operations were recorded, focusing on the lip-omodeling process and the volume of fat injected in eachbreast. Patient satisfaction was measured using a four-point Likert scale (very disappointed, disappointed, satis-fied, and very satisfied).

Results

On average, the operative timewas 7 h 48min (range, 6e9 h)with an ischemic time of 37min (range, 26e55min). The flapcharacteristics are presented in Table 1. No major compli-cations occurred in the immediate postoperative period. Nosurgical revisions were required, and no flap failuresoccurred. The mean postoperative hospital stay was 6.4days, ranging from 6 to 8 days. Three minor complicationsoccurred after surgery (21% of the reconstructed breasts).One patient had a limited 3-cm2 flap necrosis necessitatingwound healing for 2 months, and another patient sufferedfrom cytosteatonecrosis. The third complication, a 5-cmwound dehiscence, occurred at the donor site.

After a mean follow-up period of 27 months, rangingfrom 12 to 37 months, five women underwent surgery undergeneral anesthesia for a second-step reconstruction (71%).Monitoring of skin excision, flap modeling, nipple areolacomplex reconstruction, and lipomodeling were the mainprocedures used. Bilateral fat volume injection was per-formed on all patients with a mean volume of 167 cm3 perbreast (range, 60e260 cm3). Only one woman described apersistent sensation of tightness on the left thigh duringforced abduction.

Patient satisfaction regarding the bilateral reconstruc-tion was high, with a satisfaction rate of 86% (Figures 1e4).Four patients were very satisfied (57%), two were satisfied

Figure 1 First clinical case. Bilateral prophylactic mastectomy and reconstruction using double TMG flaps. During the secondsurgical step, 260 cm3 of fat was injected into each breast. Above: prior to surgery. Below: postoperative aesthetic result.

Bilateral TMG flap e3

(29%), and the one was disappointed because of an asym-metrical result. She underwent an immediate reconstructionafter prophylactic mastectomy on the left side, whereas theright sidewas treatedwith radicalmastectomy and radiationtherapy before delayed reconstruction. A third operativestep was proposed to improve the aesthetic outcome.

Figure 2 Second clinical case. Prophylactic mastectomy on the l(right) breast reconstruction using double TMG flaps. During the sbreast, and 180 cm3 was injected into the right breast. Above: pri

Discussion

Bilateral breast reconstruction after cancer should beexamined separately from unilateral procedures because ofspecific problems. The magnitude of the procedure and theoperating duration are substantially higher6e8; however,

eft side associated with bilateral immediate (left) and delayedecond surgical step, 240 cm3 of fat was injected into the leftor to surgery. Below: postoperative aesthetic result.

e4 F. Bodin et al.

breast symmetry is easier to achieve when the same pro-cedure is employed for both sides.9 Furthermore, theincidence of bilateral breast reconstruction has recentlyincreased because prophylactic mastectomies are widelyrecommended for BRCA mutation carriers.10 In the currentstudy, 50% of the breast reconstructions were performedimmediately after the risk-reducing mastectomy. The TMGflap procedure has proved to be effective for bilateralsmall- and medium-sized breast reconstructions,2 but, todate, no specific evaluations have been conducted.

In the largest TMG flap series, Schoeller et al. performed26 bilateral breast reconstructions. Unfortunately, thesurgical evaluation did not separate unilateral and bilateralcases.5 The same is true for the studies by Fattah et al. (fivebilateral cases),11 Vega et al. (six bilateral cases),12 Bunticet al. (12 bilateral cases),13 and Fansa et al. (12 bilateralcases).14 Three of these groups simply reported a meanoperative time of 6.7, 6, and 5.4 h for bilateral flaps.Recently, Pulzl et al. reported their experience with TMGflaps for tertiary breast reconstruction or breast augmen-tation following capsular contracture. Seventeen caseswere bilateral procedures with an operative time of 5 h.15

Locke et al. performed eight double TMG flaps with sevenbilateral breast reconstructions. The operative time wasnot mentioned, but the average length of hospital stay was8.6 days.16 The follow-up revealed one flap failure (6.3%),four additional procedures with either a DIEP flap or a

Figure 3 First clinical case. Anterior and posterior appearance oaesthetic result.

silicone implant (25%), and eight second-step lipomodelingprocedures (50%).

In the current series, we specifically evaluated primarybilateral simultaneous autologous breast reconstructionusing TMG flaps. The operative time of 7 h 48 min wassomewhat longer than previously published results. Nomajor complications occurred, and there were no surgicalrevisions or cases of flap loss, indicating the reliability ofthis procedure. The postoperative hospital stay remainedstable at approximately 6.4 days. During the follow-upperiod, 71% of patients underwent surgery for a second-stage procedure. Bilateral fat volume injections improvedaesthetic results by correcting irregularities and increasingbreast volume. The patient satisfaction rate was high, at86%.

Alternative procedures to achieve bilateral autogenousbreast reconstruction have been shown to require longeroperative times than that required for double TMG flaps.According to the literature, the operative time for thesimultaneous bilateral DIEP flap procedure ranges from 7 h18 min to 10 h 54 min (Table 2).17e20 Similarly, bilateralinferior and superior gluteal artery perforator (IGAP andSGAP) flap transfers require 9 he10 h 26 min.18,21e23 Onlyone publication has reported an operative time of 6 h36 min with bilateral pedicled transverse rectus abdominismyocutaneous (TRAM) flaps.24 Therefore, we concludedthat the TMG flap is one of the fastest autologous

f the donor site. Above: prior to surgery. Below: postoperative

Figure 4 Second clinical case. Aesthetic results of the donor site 6 months following flap harvesting.

Table 2 Systematic review of the literature on simultaneous autologous bilateral breast reconstruction.

Author Year Flap Numberofpatients

Follow-up(months)

Operating time(min)

Hospitalstay (days)

Globalcomplicationrate

Flapfailure

Surgicalrevision

Partial flapnecrosis

Hamdi et al.17 2004 DIEP 49 NA 570 (420e780) 9 (6e20) NA 1% NA 0%Guerra et al.18 2004 DIEP 140 14.6 (6e76) 438 (300e720) 3.9(2e9) 35.60% 0% 6.40% 14.30%Drazan et al.19 2008 DIEP 55 NA (4e52) 476 (396e600) 8 (7e11) 27.30% 0% 7% 1.80%Chun et al.28 2010 DIEP 58 28 NA NA NA 2% NA 19.80%Venkat et al.20 2012 DIEP 54 32 (6e101) 654 (462e834) 3(2e8) 34.0% 0% 7.60% 2%Baldwin et al.24 1994 pTRAM 28 NA 396 7.6 NA 0% NA 20%Paige et al.26 1998 pTRAM 130 18 (1e64) NA NA 26.9% 0% NA 13.80%Chun et al.28 2010 pTRAM 105 74 NA NA NA 0% NA 11.80%Guerra et al.18 2004 SGAP 6 NA 570 NA 33.0% 0% 16.60% 16.60%Dellacroce et al.21 2005 SGAP 20 NA 626 4 15.0% 0% 0% 5%Levine et al.22 2009 IGAP 22 23 (7e42) 540 (450e660) 4 (4e5) 36.3% 0% 9% 5%Flores et al.23 2012 SGAP 23 12.5 570 (306e7032) 5.3 (3e24) NA 0% 13% 10.80%Hankins et al.27 2008 LD 37 NA NA NA 29.7% 0% NA 4%Losken et al.29 2010 LD 83 27.6 NA NA NA 1.8% NA 4.80%

DIEP, deep inferior epigastric perforator flap; pTRAM, pedicled transverse rectus abdominal myocutaneous flap; SGAP, superior glutealartery perforator flap; IGAP, inferior gluteal artery perforator flap; LD, latissimus dorsi flap with or without implant. NA, not available.

Bilateral TMG flap e5

procedures for simultaneous breast reconstruction, mostlikely due to easy flap harvesting, and only one requiredsurgical positioning. The operative time played an impor-tant role because Hofer et al. proved that unilateral free-flap breast reconstructions exceeding 8 h resulted insignificantly more complications.25

The global complication rate of bilateral autologousbreast reconstructions is approximately 30% (Table 2). Asystematic review of the literature showed complicationrates of 27.3e35.6% for bilateral DIEP flaps, 15e36% forbilateral gluteal flaps, 26.9% for bilateral pedicled TRAMflaps,26 and 29.7% for bilateral latissimus dorsi flaps withimplant.27 The revision rate ranged from 6.4% to 16.6% in afree-flap series, and flap necrosis occurred in 2e20% ofpatients across all techniques (Table 2). Regarding patientsatisfaction, the satisfaction level among bilateral TMGpatients was almost as high as that in the bilateral DIEP flapseries. According to Chun et al., 92.6% of patients werevery satisfied.28 In a study conducted by Drazan et al., thesatisfaction level was good or excellent in 96.2% ofwomen.19

To inform and help women who consider bilateralautologous breast reconstruction, several benefits relative

to the bilateral TMG flap can be highlighted. The scars arewell concealed in natural folds, and functional donor-sitedeficits are limited.3 Bilateral flap harvesting providesupper inner thigh symmetry with skin lifting. The procedureis feasible even if the body mass index is low and there is noskin or fatty tissue excess. Finally, in cases with insufficientvolume, the breast can be easily enlarged with bilateral fatgrafting.

Conclusion

The TMG flap is an effective and safe option for primarysimultaneous bilateral reconstruction. The mean operativeduration was 7 h 48 min and was lower than that for mostbilateral autologous procedures, most likely because of thequick flap harvesting and unique surgical position. Thecomplication rate was close to that of bilateral perforatorflaps without significant functional sequelae at the donorsite. After at least 1-year follow-up, 71% of patients hadundergone a second-stage operation, with a mean fatgrafting volume of 167 cm3 per breast. The high patient

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satisfaction level of 86% was almost as high as that in thebilateral DIEP flap series.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Funding

None.

Ethical approval

The Ethical Committee of the Strasbourg Academic Hospitalapproved this study.

Acknowledgments

The authors wish to thank Professor Thomas Schoeller forhis instruction on TMG flaps.

References

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