Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

CLINICAL RESULTS
The success rate of this flap for reconstruction of congenital unilateral absence of the breast is 100 percent
(2 of 2); for primary reconstruction, 100 percent (2 of 2); and for secondary reconstruction, 100 percent (1 of
1). There have been no functional deficits.
SUMMARY
The gluteal musculocutaneous flap can be used as a free flap for breast reconstruction.
References
1. Fujino T, Harashina T, Aoyagi FL. Reconstruction for aplasia of the breast and pectoral region by
microvascular transfer of a free flap from the buttock. Plast Reconstr Surg 1975;56:178.
2. Fujino T, Harashina T, Enomoto K. Primary breast reconstruction after a standard radical mastectomy by a
free-flap transfer. Plast Reconstr Surg 1976;58:371.
3. Fujino T, Abe O, Enomoto K. Primary reconstruction of the breast by free myocutaneous gluteal flap. Int
Adv Surg Oncol 1981;4:127.

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Chapter 387
Extended Transverse Upper Gracilis Flap in Breast Reconstruction
RYAN REUSCHE
ANITA MOHAN
MICHEL SAINT-CYR
EDITORIAL COMMENT
For small breast reconstruction, the gracilis myocutaneous flap is a reasonable choice. The extended
transverse upper gracilis flap allows for larger breast reconstruction with a reasonable scar at the donor site.
INDICATIONS
The transverse myocutaneous gracilis, also known as the transverse upper gracilis (TUG) flap, has been
utilized in breast reconstruction since its anatomical description in 1992 (1, 2, 3, 4, 5, 6). It can be used in
bilateral reconstruction or stacked for a unilateral reconstruction. A disadvantage of the traditional design is
the lesser volume of harvested tissue compared with abdominal and gluteal flaps, limiting this technique to
small-to midsized breasts. This flap is dependent on body habitus
and sufficient tissue laxity of the upper thighs. Medial thigh tissue correlates well with body mass index, and
therefore a good option if abdominal or alternative donor sites are not available. One modification includes
harvesting the flap from a more posterior location to recruit the bulkier posterior thigh tissue (3, 4, 5). This
technique allows for further tissue recruitment and known as the extended TUG flap. Saint-Cyr et al. (7)
have shown this surgical approach to be appropriate to gain size without increased morbidity.
ANATOMY
The gracilis is a flat type II (Mathes and Nahai) muscle flap of the medial thigh that lies between the adductor
longus and sartorius anteriorly and the semitendinosus posteriorly. In the presence of the adductor longus and
magnus, this muscle is expendable. The dominant pedicle arises from the ascending branch of the medial
circumflex artery or directly from the profunda femoris and enters the muscle belly on its deep surface in the
upper third, at 9 to 12 cm inferior to the pubic tubercle. Usually, two or three vascular pedicles enter the muscle,
the most proximal usually being the dominant pedicle and arising between the adductor longus and brevis before
reaching the muscle. Minor pedicles supply the distal portion of the muscle, arising from the superficial femoral
artery. The dominant pedicle can be up to 6 to 7 cm in length. Upon entering the gracilis muscle, it divides into
ascending, descending, and transverse branches running in parallel with the longitudinal muscle fibers and
commonly anastomosing with the second vascular pedicle. Musculocutaneous perforators generally predominate
in both size and number. The dominant pedicle provides musculocutaneous perforators to the overlying skin in
the proximal third of the muscle and direct fasciocutaneous vessels from the medial circumflex artery, or
superficial femoral artery, in the distal portions of the muscle.
The skin paddle was traditionally designed longitudinally with an unreliable distal perfusion. However, Yousif et
al. (1) showed that perforators had a tendency to travel in a horizontal direction, with perforators posterior to the
gracilis muscle, and this led to redesign of the skin paddle. The potential skin territory is thought to extend from

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the rectus femoris to the biceps femoris. Selective angiographic studies of the dominant pedicles have
demonstrated vascular cutaneous territories of 400 cm2 and a tendency for the perfusion territory to extend more
posteriorly in relation to the gracilis muscle (8). There is concern with regard to skin viability at the margins with a
vertically orientated flap, and this may be somewhat improved with inclusion of a second vascular pedicle (7, 8, 9,
10).
Motor innervation from the anterior branch of the obturator nerve arises on the deep medial surface, superior to
the entry of the dominant pedicle.
FLAP DESIGN AND DIMENSIONS
The adductor longus tendon can be palpated following forced adduction, and a line can be drawn to delineate the
insertion anteriorly from the pubic tubercle to the medial femoral condyle. The central axis of the gracilis muscle is
2 to 3 cm posterior to this line. However, the boundaries of the gracilis muscle can be palpated from the septum
between the adductor longus and gracilis, and the muscle can be marked out as shown in Figure 387.1. The skin
paddle superior border is approximately 1 to 2 cm below the upper thigh crease, which helps to conceal the TUG
flap donor site. Skin paddles can be raised up to approximately 16.5 × 11 cm (Fig. 387.2), but depend on skin
laxity. The maximal anterior extension of the horizontal skin paddle is approximately 5 cm anterior to the gracilis,
or 1 to 2 cm anterior to the lateral edge of adductor longus, avoiding damage to any lymphatics or creating a
noticeable scar. The vertical height of the flap can vary from 5 to 10 cm as determined by skin laxity. Maximal
pinching should be checked in adduction and abduction of the thigh to prevent closing tension. A horizontal pinch
test is undertaken to design the vertical component of the skin paddle if required; 7 cm is usually sufficient for
closure. When combined with a vertical skin paddle, this can create a trilobed (Figs. 387.3 and 387.4), “L”-
shaped skin paddle (Fig. 387.5), or “S”-shaped paddle (Fig. 387.6). Saint-Cyr et al. (12) classified the different
types of TUG flaps, which are categorized in Table 387.1 with a further modification. When designing the trilobed
pattern, it is important to keep the base of each lobe relatively broad, which results in an oval shape at the center
of the flap (Fig. 387.3). When incorporating horizontal and transverse laxity, the authors prefer the “S” design to
avoid the problematic T junction at the donor site resulting from the trilobed design. The vertical incision should
be placed at the anterior border of the gracilis and end at midthigh level. The posterior extension of the flap is
carried out midway between the medial midaxial line and posterior thigh midline. Any extension beyond this point
may increase the risk of fat necrosis, damage to posterior cutaneous nerves, and flap-related complications. With
inclusion of a vertical component, the posterior extension can usually be shortened to the midaxial line. Estimated
additional soft-tissue recruitment through skin undermining can also be marked out preoperatively (Fig. 387.7). A
decision-making
algorithm proposed by Saint-Cyr to choose the appropriate skin paddle and flap design based on patient
characteristics is shown in Figure 387.8.
FIGURE 387.1 Preoperative markings demonstrate surface anatomy of the gracilis muscle and design of a
horizontally oriented skin paddle.

FIGURE 387.2 Preoperative markings demonstrating large posteriorly based transverse skin paddle and planned
area of undermining to reconstruct a larger volume breast and to maximize tissue harvest in an extended TUG
reconstruction.
FIGURE 387.3 Example of preoperative markings and skin paddle design based on a vertical and horizontal
component, which is kept wide over the gracilis muscle, and representative of a trilobed design.
OPERATIVE TECHNIQUE
Flap harvest is performed supine in a lithotomy position with the thighs and legs on extremity boards. The
superior inguinal crease incision is made 2 to 5 cm anterior to the anterior border of the gracilis, extending
posteriorly to the medial midaxial line. The septum is identified between the adductor longus and the gracilis to
locate the pedicle, and adjustments to the skin paddle can be made according to its position (Fig. 387.9). Next,
the inferior skin incision is made. Fattah et al. (3) described undermining the skin inferior to the lower incision to
recruit subcutaneous fat, in a beveled fashion to recruit subcutaneous tissue medially, and posteriorly (Fig.
387.10). However, undermining is limited at the widest portion of the skin paddle to minimize risks of wound
dehiscence. Incorporation of subcutaneous tissue outside the boundaries of the skin paddle should be kept over
the gracilis muscle and posteriorly to gain additional flap volume. The greater saphenous vein should always be
preserved and not incorporated within the flap. However, accessory branches may be ligated (Fig. 387.9), and
there should be minimal disruption of the lymphatics anteriorly. Once the skin paddle is dissected, the gracilis
muscle can be harvested based on the medial circumflex femoral vascular pedicle with maximal possible muscle
length to gain the largest volume. Fat grafting directly into the gracilis muscle distal to the skin paddle can also
increase volume.

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FIGURE 387.4 Flap harvest of an extended TUG flap with trilobed skin pattern. Often, when the anterior skin is
small or narrow, it is often discarded, converting the skin paddle to an “L” shape.
FIGURE 387.5 Flap harvest of an extended TUG flap with “L”-shaped skin paddle.
Once harvested, the flap is folded, or a limb is rotated 180 degrees onto itself to form a “teardrop” and shaped to
become a breast mound (Figs. 387.10 and 387.11). The skin paddle limbs of the extended flaps can be rotated
either clockwise or counterclockwise, yielding the shape desired. The anterior limb, when present, may be tucked
under the flap or beside it to create the deep section of the breast mound, thus providing medial fullness and
better projection. The limbs and shaping of the flap can be tailored to the reconstructive requirements of the
patient. In addition, once the flap is folded, the resultant “dog ear” of skin projecting anteriorly can be used
together with rib cartilage for immediate nipple reconstruction at the time of flap inset.
FIGURE 387.6 When there is adequate vertical and horizontal skin and subcutaneous tissue, design of an “S”-
shaped skin paddle may allow for easier closure and reduce tension on the skin flaps.

TABLE 387.1 CLASSIFICATION OF DIFFERENT TYPES OF GRACILIS FLAPS WITH
SUBCUTANEOUS AND SKIN PADDLE EXTENSIONS AS PROPOSED BY SAINT-CYR ET AL.
(12)
Transverse
Vertical TUG (type II) with adipocutaneous extensions
Extended
TUG with
adipofascial
extension
Vertical
skin paddle
Transverse
+ vertical
“L” skin
paddle
Transverse
+ vertical
“S” skin
paddle
Trilobed skin
paddle
Patient
selection
Nearly all
patients over
35 y should
be considered
first options.
Small
breasts and
minimal
upper thigh
laxity;
patients with
moderate-
sized
breasts with
significant
redundancy
and would
benefit from
thigh lift
Patients with
moderate to
large breasts
and
moderate
upper thigh
laxity: add a
vertical
extension
As for “L”
shaped, but
alternative
method to
combine
vertical and
transverse
skin paddle
and avoid
tight junction
prone to
delayed
healing
Large breasts
and excessive
thigh skin
redundancy
(massive
weight loss
patients);
patients would
benefit from
circumferential
thigh lift.
Flap folding
advantages
90 degrees,
moderate flap
volume,
inconspicuous
scar
Less risk of
lymphatic
damage
45 degrees,
large flap
volume, less
risk of
lymphatic
damage
45 degrees,
large flap
volume, less
risk
lymphatic
damage,
less tension
on wound
closure
45 degrees,
largest flap
volume,
contour
improvement
Disadvantages
Limited flap
volume,
increased
undermining
Conspicuous
scar, small
flap volume
Conspicuous
scar,
increased
undermining
Conspicuous
scar, but
may be
placed more
anterior
Conspicuous
scar,
increased
undermining,
increased risk
to lymphatics,
complication
at T junction
with donor site
healing

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FIGURE 387.7 Preoperative markings demonstrating estimated undermining that is required to recruit greater
amounts of subcutaneous tissue.
CLINICAL RESULTS
The extended TUG flap has consistent vascular reliability, with enough tissue for reconstruction of small- to
moderate-sized breasts. In a retrospective study of 12 extended transverse
gracilis flaps, the average flap weight was 386 g, ranging up to 750 g. Donor site harvest allows for removal
of redundant thigh skin and functional thighplasty. In massive weight loss cases, patients may benefit from a
circumferential thigh lift. Complications, though uncommon, include wound dehiscence, hematomas,
seromas, and fat necrosis. These are not specific to any one surgical technique, and functional loss of the
gracilis muscle is minimal (13, 14). Contraindications specific to this flap include previous liposuction,
previous thighplasty, reconstruction of large breasts, and delayed reconstructions (2, 6, 11, 12).
FIGURE 387.8 The transverse upper gracilis free flap decision-making tree for breast reconstruction as
described by Saint-Cyr et al. to consider variations in skin paddle design based on clinical assessment.

FIGURE 387.9 Identification of the vascular pedicle after dividing the septum between the adductor longus
and gracilis.
FIGURE 387.10 A: Extended TUG flap harvested with undermining of the subcutaneous tissue over the
gracilis and posterior tissue to recruit further tissue for breast reconstruction. B: Flap folded over to create
the shape of the breast mound for inset. C: De-epithelialization of skin around the new proposed nipple-
areolar complex (NAC). D: Final inset of the extended TUG to create the breast mound.

FIGURE 387.11 Example of harvested “L”-shaped extended TUG and demonstration of orientation and size
of the vascular pedicle.
SUMMARY
The TUG flap can reconstruct small to medium breasts particularly when abdominal flaps are not feasible.
The extended TUG can optimize recruitment of posterior and medial thigh subcutaneous tissue but creates a
more conspicuous donor site. The gracilis has consistent anatomy and can be rapidly harvested.
Adaptations to the traditional skin paddle design for the extended TUG provide versatility within the
reconstruction and allow larger-sized breast reconstructions.
References
1. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast
Surg 1992;29:482-490.
2. Arnez ZM, Pogorelec D, Planinsek F, et al. Breast reconstruction by the free transverse gracilis (TMG) flap.
Br J Plast Surg 2004;57:20-26.
3. Fattah A, Figus A, Mathur B, et al. The transverse myocutaneous gracilis flap: technical refinements. J
Plast Reconstr Aesthet Surg 2010;63:305-313.
4. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast
reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008;122:29-38.
5. Schoeller T, Wechselberger G. Breast reconstruction by the free transverse gracilis (TMG) flap. Br J Plast
Surg 2004;57:481-482.
6. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in
autologous breast reconstruction. Plast Reconstr Surg 2004;114:69-73.

7. Saint-Cyr M, Wong C, Oni G, et al. Modifications to extend the transverse upper gracilis flap in breast
reconstruction: clinical series and results. Plast Reconstr Surg 2012;129(1):24e-36e.
8. Whitaker IS, Karavais M, Shayan R, et al. The gracilis myocutaneous free flap: a quantitative analysis of
the fasciocutaneous blood supply and implications for autologous breast reconstruction. PLoS ONE
2012;7:e363-e367.
9. Hallock GG. The conjoint medial circumflex femoral perforator and gracilis muscle free flap. Plast Reconstr
Surg 2004;113:339-346.
10. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap: vascular anatomy and clinical
application. Plast Reconstr Surg 1997;99:1642-1652; discussion 1653-1645.
11. Hamdi M, Andrades P, Thiessen F, et al. Is a second free flap still an option in a failed free flap breast
reconstruction? Plast Reconstr Surg 2010;126:375-384.
12. Saint-Cyr M, Shirvani A, Wong C. The transverse upper gracilis flap for breast reconstruction following
liposuction of the thigh. Microsurgery 2010;30:636-638.
13. Mathes DW, Kenkel JM. Current concepts in medial thigh-plasty. Clin Plast Surg 2008;35:151-163.
14. Fansa H, Schirmer S, Warnecke IC, et al. The transverse myocutaneous gracilis muscle flap: a fast and
reliable method for breast reconstruction. Plast Reconstr Surg 2008;122:1326-1333.

Chapter 388
Microvascular Free Transfer of A Gluteal Musculocutaneous Flap
W. W. SHAW
R. W. LIEBLING
Any breast reconstruction is directed toward restoring natural contour, creating a mound with infraclavicular and
axillary fullness, and reanimating the new tissue with more normal temperature, softness, mobility, sensibility, and
symmetry to the contralateral breast. Moreover, functional and aesthetic morbidity at the donor site should be
kept to a minimum. The buttock region is an abundant source of skin and soft-tissue bulk. In 1975, the use of a
gluteus maximus musculocutaneous free flap to correct a case of congenital aplasia of the breast and pectoral
region was reported (1). This concept was subsequently expanded for breast reconstruction primarily following
radical mastectomy. Recent clinical experience with the gluteus maximus musculocutaneous free flap has
generated further enthusiasm for the use of this method (2, 3).
INDICATIONS
The advantages of a free composite-tissue flap of sufficient volume, such as the gluteus maximus
musculocutaneous free flap, are quite obvious in breast reconstruction. Limited dissection in the axilla
minimizes the possibility of aggravating any lymphedema. A free flap does not borrow any functional tissue
from the adjacent area, but rather adds substantial tissue to the area from a distance. The gluteal free flap
allows much greater freedom in flap design compared to regional pedicled flaps and enables the surgeon to
perform immediate living sculpturing until a gratifying result is obtained. The independent arterial supply of
the free flap allows the patient to undergo radiation as well as further revision and tailoring. Breasts
reconstructed with free musculocutaneous gluteal flaps have proved to be warmer than those reconstructed
by free groin flaps with underlying silicone prostheses. In addition, there has been a considerable return of
sensation, even without sensory neurorrhaphy. A sense of permanence is enhanced, eliminating some of
the disadvantages of silicone implants.
Since the muscle mass taken along with the skin flap is smaller, flap shrinkage becomes minimal, thus
making estimation of breast volume easier. The breast mound achieved is soft to palpation and does not
change in shape or size after the first few weeks. The skin surface of the reconstructed breast is soft and
smooth, unlike the thicker, coarser, and frequently actinic- damaged skin from the back. In the supine
position or with motion, the reconstructed breast has a soft, natural bounce approaching that of a normal
breast, and it is distinctly superior to most breasts reconstructed with implants.
ANATOMY
The gluteus maximus is a broad, fan-shaped type III muscle that is a strong extensor and lateral thigh rotator.
The superior half of the muscle may be used without significant functional loss in the ambulatory patient. It
originates on the gluteal line of the ilium and sacrum and inserts on the greater tuberosity of the femur and the
iliotibial tract. It is innervated by the inferior gluteal nerve on its deep surface. The superior and inferior gluteal
arteries, both separate branches of the hypogastric artery, supply the upper and lower halves of the muscle,
respectively. The muscle may be divided into superior and inferior halves based on these two pedicles, and
there is ample collateralization between these two systems. The superior gluteal artery courses posteriorly above
the piriform muscle. It then gives off a branch to the superior portion of the gluteus maximus muscle. The artery

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then courses laterally to supply the gluteus medius and minimus muscles. The inferior gluteal artery enters the
gluteal region through the sciatic foramen in close proximity to the sciatic nerve. It supplies the inferior portion of
the gluteus maximus muscle.
FLAP DESIGN AND DIMENSIONS
The flap is designed after establishing the extent of the gluteus maximus muscle and locating the origin of the
superior gluteal artery. The cutaneous portion of the flap may be placed anywhere on the muscle and may even
extend beyond it. Skin territories ranging from 8 to 13 cm in width and from 20 to 30 cm in length have been
used.
OPERATIVE TECHNIQUE
The patient is marked in an erect position, so that the inframammary crease can be determined. An ipsilateral
gluteal flap is used. Once the flap is harvested, the donor site is quickly closed, so that the patient can be
brought into a more or less supine position for the microvascular anastomoses on the chest. After completion of
the anastomoses, considerable time is spent in the trimming and setting in of the flap to achieve an optimal
aesthetic result.
The initial incision starts along the superior and lateral borders, exposing the lateral fibers of the gluteus
maximus muscle. After dividing the lateral upper third of the gluteus maximus about 4 cm posterior to the
trochanter, the undersurface of the
muscle is elevated. By following the branches of the superior gluteal artery and vein, the origin of the vessels
can be identified. The skin and muscle incisions are then completed circumferentially. The final stage of
dissection involves tedious detachment of the sacral origin of the gluteal muscle and isolation of the vascular
pedicle. The superior gluteal artery and vein are usually 2 mm or larger, but very fragile. Dissection must be
performed delicately, and small branches should be taken with bipolar forceps at a distance from the main
branch or ligated. A vascular pedicle of 2 to 3 cm is dissected free. The donor vessels may be elongated by
trimming the proximal portion of the muscle and subcutaneous fat without violating the perforating vasculature
within these layers. The donor site is closed after slightly undermining the skin edges just above the fascia over
the remaining gluteus to allow for more natural redraping.
A curved incision is used on the chest, with its lowest portion nearly to the inframammary line. In the case of a
transverse mastectomy incision, this is simply ignored, and the “hockey stick” incision comes all the way down to
the inframammary crease and curves medially. Medial and lateral skin flaps are then raised. If the internal
mammary artery is chosen as the recipient vessel, the fifth rib costal cartilage is identified and resected within the
perichondrium. The perichondrium and deep fascia are then incised longitudinally, starting inferiorly. The internal
mammary vessels are located approximately 1 cm lateral to the edge of the sternum. These vessels are then
dissected free from the surrounding bed, and small vascular branches are cauterized by bipolar forceps or tied.

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FIGURE 388.1 A: Preoperative appearance after a modified radical mastectomy. B: Donor-site scar. C,D:
Postoperative appearance. (From Shaw, ref. 2, with permission.)
If the recipient vein is too small, a vein graft is harvested from the leg and anastomosis to the axillary vein is
performed first. If the patient does not want incisions on the leg and there is no evidence of edema on the arm,
then the cephalic vein can be harvested through two small incisions and brought medially into the wound,
draining into the thoracoacromial access.
Other recipient vessels, such as the thoracoacromial artery, transverse cervical artery, and branches of the
axillary and external carotid arteries (depending on flap geometry and previous zones of irradiation and fibrosis),
may be employed with or without vein grafts, accordingly. Drainage may be facilitated through the axillary,
thoracoacromial, facial, and external or internal jugular venae comitantes.
It is crucial to stabilize the gluteal flap temporarily in its approximate position low at the fascial level just above the
muscle in order to adjust pedicle length correctly. The gluteal flap is placed on its side on the chest, with the skin
facing interiorly and the muscle superomedially. The distal (lateral) part of the skin flap is then brought into the
axilla to fill out the infraclavicular hollow. If the curved skin incision is designed properly, the bending of the
gluteal free flap automatically creates a nice central projection. The medial chest flap is then draped over the
side of the gluteal free flap anteriorly. After placing some holding sutures, the gluteal flap can then be trimmed,
deepithelialized, and shifted around until the overall contour is pleasing. A suction drain is placed underneath the
flap laterally, and the skin is closed (Fig. 388.1).
The patient is allowed to lie on the buttocks immediately. On or about the third day, ambulation is permitted.
About the fifth day, sitting in a chair with full bending of the hip is allowed. Within a week, the patient is generally
walking comfortably, and she is discharged between the seventh and tenth postoperative days.

CLINICAL RESULTS
Up to 13 cm in skin width has been taken from the buttock with fairly tensionless primary closure. The linear
superior gluteal scar is well hidden in bathing suits or shorts. No functional muscle weakness has been
noted, since only a small portion of the upper part of the gluteus muscle is taken with the skin flap. On late
follow-up examination, patients are able to walk up and down stairs, alternately stand on one leg, and jump
rope. There is minimal change in the appearance of the gluteal fold. An unexpected bonus of this particular
donor site is that the superior gluteal area is not only difficult for the patient to see herself, but is also an
area rarely in the conscious minds of most people. Patients have voiced surprising pride and confidence in
feeling that the reconstructed breasts are part of their own bodies.
A disadvantage of microvascular transfer is the increasing complexity requiring specialized equipment and
experience. A second concern is that of long operating time. For free flaps, the only added time is that of
microvascular anastomosis of the artery and vein, adding approximately 1 to 2 hours to the procedure. A fair
amount of time is spent in trimming, insetting, and contouring the flap to achieve the optimal aesthetic result.
A final disadvantage of free-flap reconstruction is possible failure of the anastomoses, resulting in total loss.
However, the current success rate of microvascular free flaps in experienced hands is about 95 percent,
including all types of reconstructions, often in extremely difficult circumstances.
SUMMARY
The gluteus maximus musculocutaneous free flap is used increasingly for breast reconstruction. The extra
operative time is not excessive, and the results in both recipient and donor sites are superior to many of the
other available methods.
References
1. Fujino T, Harashina T, Aoyagi FL. Reconstruction for aplasia of the breast and pectoral region by
microvascular transfer of a free flap from the buttock. Plast Reconstr Surg 1975;56:178.
2. Shaw WW. Breast reconstruction by superior gluteal microvascular free flaps without silicone implants.
Plast Reconstr Surg 1983;72:490.
3. Shaw WW. Microvascular free flap breast reconstruction. Clin Plast Surg 1984;11:333.

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Chapter 389
Microvascular Free Tram Flap
A.-M. FELLER
E. BIEMER
H.-U. STEINAU
EDITORIAL COMMENT
Although technically more involved, the advantages of the free TRAM flap include a decreased incidence of
fat necrosis, as well as better vascularity beyond the hemilateral flap. See also Chapter 391.
Compared to other free-flap procedures for breast reconstruction following radical or modified radical
mastectomy, the free TRAM flap has achieved wide recognition. It provides greater possibilities for breast
contouring and a reliable vascular pedicle.
INDICATIONS
The free TRAM flap was used and reported in two cases of breast reconstruction in 1979 (1), but it did not
achieve extensive use or a significant literature until the years following the report of Hartrampf et al. in
1982 (2).
Indications for the flap are similar to those for other flaps used in breast reconstruction. In patients with
large, ptotic breasts, the flap is the procedure of choice, since the entire transverse flap can be used to
achieve the desired breast volume. Special indications include radiotherapy with destruction of skin and soft
tissue not only over a mastectomy defect, but also over the sternal area, with an expected hypoplastic
vascular system in the internal mammary and superior epigastric vessels.
The free TRAM flap cannot be used in patients with a lower transverse laparotomy with presumably ligated
inferior epigastric vessels. In addition, in extremely obese patients or chronic heavy smokers, the procedure
is quite risky and is not recommended.
ANATOMY
The rectus muscle is covered by the anterior rectus sheath along its entire length; the posterior rectus sheath
ends at the arcuate line. Below this level, the muscle directly overlies a thin layer of transversalis fascia. The
blood supply to the rectus abdominis muscle is derived from the superior and inferior epigastric vessels, and
because of their longer length and greater diameter, these vessels are useful for free-tissue transfer (3).
The free TRAM flap is supplied by one of the deep inferior epigastric vessels, with diameter of the artery
between 2 and 4 mm and that of the vein about 3 mm. Dissection of the inferior epigastric pedicle to the level of
the external iliac vessels provides a vascular pedicle of about 10 to 12 cm.
Generally, the inferior epigastric artery divides into two large branches below the level of the umbilicus. It passes
upward into the muscle to communicate with the superior epigastric system above the level of the umbilicus. The
densest network of larger perforators is located over the middle and medial thirds of the muscle in the

P.1046
paraumbilical region.
To ensure a sufficient blood supply to the free TRAM flap, it is necessary to dissect the rectus muscle from the
arcuate line upward to the umbilical level. Following such dissection, the largest perforators can be included to
guarantee adequate perfusion of the subdermal plexus lateral to the rectus sheath, as well as to the contralateral
side.
FIGURE 389.1 A-C: A 50-year-old woman with modified radical mastectomy on the right side.
FLAP DESIGN AND DIMENSIONS
The flap is designed in a horizontal, elliptical manner, as is the pedicled TRAM flap; in both cases, the umbilicus
must be included in the ellipse. Flap width from the umbilicus to the pubic area depends on the volume of the
contralateral breast. The lateral flap tips are always situated over the iliac crests, allowing easier closure of the
abdominal defect. This also ensures better contouring of the abdominal wall, similar to a regular abdominoplasty.
OPERATIVE TECHNIQUE
The free flap is raised in a manner similar to the pedicled TRAM flap (3, 4, 5, 6); flap dimensions must be
outlined in a standing patient. The patient is then placed in a supine position, with a slightly elevated shoulder on
the mastectomy side. Both arms are abducted.
With two teams working, the scar on the chest wall is excised for histologic examination. The mastectomy defect
is undermined and prepared, and the flap is incised on its inferior rim (Figs. 389.1 and 389.2). One team explores
the axillary region and prepares the recipient vessels, while the other team dissects the inferior epigastric
pedicle. In the axilla, we prefer the lateral thoracic artery and vein; however, if they are not available, the
circumflex scapular or thoracodorsal vessels represent reliable alternatives.
The contralateral rectus abdominis muscle is always taken with the inferior pedicle. The muscle is divided just
above the umbilical level, and the complete free TRAM flap is tethered into the mastectomy defect for
microsurgical revascularization (Fig. 389.3). Whenever possible, end-to-end anastomoses are
used, but the pedicle is usually long enough to reach even the axillary artery and vein for end-to-side
anastomoses.

FIGURE 389.2 The free TRAM flap incised including the umbilical region. The inferior epigastric pedicle will be
harvested from the left side.
Once the microsurgical procedures are completed, the patient is raised to a sitting position of about 45 degrees,
and the abdominal wound is closed. Final orientation and tailoring of the flap are carried out in this position,
allowing the flap to be situated with the desired contour matching that of the contralateral side.
As in all free-tissue transfers, the patient is closely observed postoperatively for adequate flap circulation. To
prevent compromised blood flow in the axilla, special attention is paid to the arm on the repaired side, which
should be slightly abducted (Fig. 389.4).
FIGURE 389.3 The free TRAM flap turned over, ready for transfer to the right thoracic wall. Note the small
amount of rectus muscle and the fairly long pedicle.
CLINICAL RESULTS
Between 1987 and 1988, 12 mastectomy reconstructions with free TRAM flaps have been carried out by us;
none of these flaps failed. None of the patients developed a hernia, probably because of less muscle loss
with this procedure than with the pedicled TRAM flap. A well-contoured, ptotic breast was achieved in only
50 percent of patients, requiring reduction of the contralateral breast. Adjustment of the contralateral breast,
with nipple-areola reconstruction, is performed 6 months after breast reconstruction.
Advantages of the free TRAM flap include (1) availability of large vessels for microsurgical anastomoses, (2)
a long vascular

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pedicle (about 10 to 12 cm), (3) ease in raising the flap, (4) better and more vigorous skin circulation than
with the pedicled TRAM flap, (5) greater freedom in reconstruction, since the entire transverse flap can be
used to achieve the desired breast volume, and (6) avoidance of considerable weakening of the abdominal
wall, since the muscle is taken only between the arcuate line and the umbilical level.
FIGURE 389.4 A,B: Postoperative result 6 months after breast reconstruction and 2 months after
reconstruction of the nipple-areola complex without necessity of breast reconstruction of the contralateral
side. C,D: The patient 6 months after breast reconstruction with acceptable scar of the donor area.
In the hands of surgeons well experienced in microsurgery, the microvascular anastomoses involved in the
procedure present no great difficulties, and with two surgical teams working simultaneously, operative time
is not an issue.
SUMMARY
Even with the requirement of microsurgical technique, the advantages of the free TRAM flap are clear.
Compared with other free-flap procedures for breast reconstruction, this flap provides greater freedom in
breast contouring and a reliable vascular pedicle.
References
1. Holmström H. The free abdominoplasty flap and its use in breast reconstruction. Scand J Plast Reconstr
Surg 1979;13:423.
2. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast
Reconstr Surg 1982;69:216.
3. Boyd BJ, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior

epigastric systems. Plast Reconstr Surg 1984;73:1.
4. Bunkis J, Walton RL, Mathes SJ. The rectus abdominis free flap for lower extremity reconstruction. Ann
Plast Surg 1983;11:373.
5. Friedman JR, Argenta LC, Anderson RA. Deep inferior epigastric free flap for breast reconstruction after
radical mastectomy. Plast Reconstr Surg 1985;76:455.
6. Arnez ZM, Smith RW, Eder E, et al. Breast reconstruction by the free lower transverse rectus abdominis
musculocutaneous flap. Br J Plast Surg 1988; 41:500.

Chapter 390
Microvascular Free Deep Inferior Epigastric Perforator (Diep) Flap
C. HEITMANN
R. J. ALLEN
EDITORIAL COMMENT
This is a major advance in the armamentarium of the plastic surgeon doing breast reconstruction.
Nevertheless, pedicle and prosthetic reconstruction still plays an important role in the care of the post-
mastectomy patient.
The deep inferior epigastric perforator (DIEP) flap arose as a refinement of the conventional transverse rectus
abdominis myocutaneous (TRAM) flap. The DIEP flap can carry the same tissue as the TRAM flap, without the
sacrifice of the rectus muscle or fascia, thereby minimizing donor-site morbidity, including bulge, hernia,
weakness, and length of recovery time (1, 2). The DIEP flap is commonly used for breast restoration to provide a
soft, naturally shaped, long-lasting result.
INDICATIONS
An excellent source of soft tissue for free-flap reconstructions is the lower abdomen in women. Generally
speaking, women who would benefit from an abdominoplasty are possible candidates for a DIEP flap and,
in fact, most women who have had or will have mastectomies for breast cancer are candidates for the DIEP
flap. In cases of breast reconstruction, we prefer to have patients complete any radiation therapy, and a
delay of 6 months, prior to free-flap procedures. Although perforator flaps usually tolerate radiation well,
superior long-term results are typically obtained in reconstructions performed after, rather than before,
chest-wall irradiation [3].
Abdominal scarring is probably the most important risk factor for raising DIEP flaps, and can cause major
problems during the dissection of perforators and epigastric vessels. Intramuscular scarring is not always
diagnosed accurately with preoperative ultrasound, and can spread farther than suspected from the placing
and length of a previous incision. Smoking is considered a relative contraindication to raising a DIEP flap
(4). Smokers who request elective, delayed reconstructions are required to stop smoking at least 3 months
before becoming candidates for surgery. An absolute contraindication for a DIEP procedure in our practice
is a history of previous abdominoplasty or abdominal liposuction.
ANATOMY
The deep inferior epigastric artery arises from the external iliac artery, which is just above the inguinal ligament,
and approaches the rectus abdominis muscle from its lateral side. The artery is accompanied by two venae
comitantes and forms an excellent pedicle for free tissue transfer.
The anatomy of the deep inferior epigastric artery system is quite variable. The average pedicle length is 10.3
cm, and the average vessel diameter is 3.6 mm. Generally, the artery divides into two branches, with a dominant
lateral branch (54%). However, if the deep inferior epigastric artery does not divide, the vessel has a central
course (28%), with multiple small branches to the rectus abdominis muscle and centrally located perforators. If

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the medial branch of the artery is dominant (18%), flow appears to be significantly lower than in a central system
or in patients with a dominant lateral branch.
Previous studies of abdominal-wall vasculature anatomy have noted that one or two perforators per pedicle can
be reliably observed to be greater than 1 mm (5). In addition, all major perforators can usually be found within 8
cm of the umbilicus. The closer a perforator is to the midline, the better the blood supply to zone IV (the area
most distant from the vascular pedicle) will be (6). However, the lateral perforators are often dominant and easier
to dissect, because they run more perpendicularly through the muscle. The sensory nerve that runs with these
perforating vessels is also often much larger. The medial perforators provide better perfusion for the DIEP flap,
but they have a longer intramuscular course and require more elaborate dissection, with extensive longitudinal
splitting of the muscle. Preference is also given to perforators that pass through the rectus abdominis muscle at
the level of the tendinous intersections (7). At this point, the perforators are frequently large and have few
muscular side branches. The
distance from the subcutaneous fat to the deep inferior epigastric vessels is also shorter, simplifying this most
delicate part of the dissection.
FLAP DESIGN AND DIMENSIONS
The patient is usually seen in the office on the day prior to surgery for preoperative markings and Doppler
studies. She should assume a standing position, and an elliptical skin island is drawn on the abdomen. The
borders of a DIEP flap are generally located at the level of the suprapubic crease, the umbilicus, and both
anterior superior iliac spines. A DIEP flap generally measures 12 cm in height and extends 20 to 24 cm from the
midline. However, the tension at the donor site following closure should be estimated, as this ultimately limits the
size of the flap that can be harvested. The side of the abdomen contralateral to the side to be reconstructed is
preferred, as this provides for easier insetting at the time of surgery. With the patient in the supine position, a
Doppler probe is used to identify the main perforators of the deep inferior epigastric artery. This road map of the
largest perforators helps the surgeon make decisions intraoperatively. The superficial inferior epigastric artery
and vein are likewise found with the Doppler and marked. The procedure is performed under general anesthesia,
with the patient in the supine position and the arms positioned beside the trunk. Preoperatively, placement of
intravenous lines, an indwelling urinary catheter, and deep vein thrombosis prophylaxis with low-dose heparin
and sequential pressure hose are recommended
OPERATIVE TECHNIQUE
A two-team approach is used, with simultaneous raising of the flap and preparation of the recipient vessels. For
breast reconstruction, the internal mammary artery (IMA) and vein (IMV) are the recipient vessels of choice and
are used in more than 90% of our cases. The central position of the IMA and IMV in the chest wall makes medial
placement of the flap easier on insetting. The vessels are dissected between the second and third rib spaces. A
distance of 2 to 3 cm in width is sufficient to enable anastomosis. If the rib space is less than 3 cm in width,
removal of a portion of the lower rib is performed.
The thoracodorsal vessels are used alternatively when the internal mammary vessels prevent proper flap
insetting and geometry, such as in cases of partial breast reconstruction. While making the inferior skin incision,
care is taken to preserve the superficial epigastric vein.
If venous drainage of the flap is insufficient or thrombosis of the perforator veins occurs after the anastomosis,
the superficial epigastric vein can be used as an additional venous conduit (8). The vein is dissected over a
length of 4 to 5 cm and ligated with clips to make them easily retrievable later, if needed. If the inferior epigastric
vessels are found to be sufficient in size and quality, they are followed down to their origin from the common
femoral artery, and a superficial inferior epigastric artery (SIEA) perforator flap procedure can be performed.

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For the DIEP flap, the abdominal incisions are continued down to the fascia. Beveling is avoided unless extra
volume is required, as this may later lead to a depressed scar in the abdomen. However, the flap may be
beveled laterally to include more fat and reduce residual dog ears. Dissection of the vascular pedicle of a DIEP
flap can be divided into three different technical stages: suprafascial, intramuscular, and submuscular. The most
demanding stage is the intramuscular dissection of the vascular pedicle.
At first, the abdominal skin island is carefully elevated from lateral to medial until the lateral row of perforators is
encountered. If a large perforator is found, the flap may be based on this vessel. Additional perforators in the
same row may also be dissected and included with the flap for extra perfusion. If no large perforator is found, the
medial row is approached in a similar fashion. If no dominant single perforator is found, two or even three smaller
perforators in the same medial or lateral row may be taken to carry the flap. In cases in which more than one
large perforator is present, the perforator with a more central location to the proposed flap is used. In our
experience, approximately 25% of DIEP flaps are based on one perforator, 50% on two, and 25% on three or
more perforators. We prefer a flap to be based on a single large perforator. The abdominal muscles must be
relaxed at all times and the perforating vessels kept moist with normal saline.
Complete dissection of a perforator helps prevent vessel damage when raising the flap from the contralateral
side. In the case of a unilateral DIEP flap reconstruction, if the medial and lateral row perforators on the initially
approached side of the abdomen are found to be less than optimal, the perforators on the opposite side of the
abdomen are investigated, as the contralateral side often yields a perforator of better quality. Once the
appropriate perforators are chosen, the anterior rectus fascia is incised with a pair of microscissors, following the
direction of the rectus abdominis muscle fibers at the rim of the tiny gap in the fascia through which the
perforating vessel passes. If more than one perforator is dissected, the different gaps can be connected. The
division of the fascia is continued superiorly for a distance of 2 to 4 cm, and inferiorly to the lateral border of the
rectus abdominis muscle.
It is advisable to fully complete the dissection of the DIEP flap on one side before progressing to the other. This
precaution provides a lifeboat in the form of a contralateral DIEP flap, to be used if the perforator is inadvertently
damaged. As dissection progresses, the DIEP flap should be secured to the abdominal wall or carefully held by
an assistant. The rectus abdominis muscle is spread apart in the direction of the fibers, and care is taken to
identify and preserve any intercostal nerves. Dissection continues through the muscle down to the deep inferior
epigastric vessels. By so doing, the perforator is liberated from the muscle by blunt dissection, staying close to
the vessel at all times, as it remains covered by a thin layer of loose connective tissue.
As a general rule, if resistance to dissection is encountered, a side branch or a nerve is identified. Using bipolar
coagulation diathermy and small hemoclips, one continues to ligate all side branches until the inferior epigastric
artery is reached on the posterior surface of the rectus abdominis muscle. If two perforators have been selected
that run in adjacent perimysial planes, the muscle fibers between have to be cut. In a submuscular dissection,
the lateral border of the rectus abdominis muscle is raised to open the plane posterior to the muscle.
The main pedicle of the deep inferior epigastric vessels is exposed and the side branches of the main stem are
ligated. The length of the pedicle can be tailored to meet the needs of different recipient sites, or the demands of
the shape of the flap. If one is certain that the blood flow through the deep inferior epigastric vessels is sufficient,
the remainder of the flap can be raised. The umbilicus is released, and the entire skin flap is raised. The artery
and the veins of the pedicle are then clipped and the pedicle slid out underneath any crossing intercostal nerves.
Sometimes, it is necessary to divide a crossing motor intercostal nerve to release the vascular pedicle. In these
cases, the nerve is repaired with two interrupted 8-0 nylon sutures prior to closure of the abdominal fascia. The
flap is then weighted and transferred to the recipient site. Great care is taken to lay the donor pedicle to the

recipient vessels without any twists or kinks. Although the overall incidence of vascular complication is low,
experience has shown that many cases of venous compromise can be traced to a twisted pedicle. Temporary
stay sutures are placed in the flap with the orientation of 180 degrees with the umbilicus inferiorly. This allows for
the thicker part of the flap to lie medially on the chest wall. The operating microscope is brought into position.
For the venous anastomosis, we use an anastomotic coupling device. The coupling device makes the
anastomosis easier and more rapid, and has the additional benefit of stenting the vein open after the vessels are
joined. The arterial anastomosis is typically performed manually with interrupted sutures. After the anastomosis is
complete, the flap is checked for bleeding and capillary refill.
Insetting and closure are performed over a suction drain, and great care is taken at all times to monitor the
integrity of the pedicle during the insetting of the flap. If a contralateral flap is used, the flap is turned between
approximately 90 and 120 degrees so that the medial portion of the abdominal flap becomes the base of the
reconstructed breast. Excess skin is deepithelialized superiorly and inferiorly, and the flap inset with a visible skin
paddle left in place.
The external Doppler probe is used to identify the locations on the flap with good arterial and venous signals,
and these locations are marked for postoperative monitoring in the postanesthesia care unit (PACU) and on the
floor with a hand-held Doppler probe. For monitoring, it is also possible to use an implantable Doppler probe.
This is especially helpful in cases in which a smaller skin paddle is left, or no dominant point can be found on the
exposed skin portion of an otherwise healthy flap. Also, in nipple-sparing mastectomies in which no skin island is
left, the implantable probe is used. Care must be taken with the placement of these probes. A Doppler sleeve
placed too loosely around the vessel may result in loss of signal, despite the presence of good blood flow,
whereas a tight sleeve or wire connection may kink or otherwise compromise the vessel's patency.
FIGURE 390.1 A: Preoperative view of a patient marked for the deep inferior epigastric perforator (DIEP) flap.
B: Result 1 year after the DIEP flap procedure and nipple-areola reconstruction.
The abdominal fascia is closed and securely tied with a running size 1 absorbable suture. Mesh or other
synthetic materials are not used in abdominal-wall closures. The edges of the umbilicus are tacked down to the
fascia with a 2-0 Vicryl suture. The upper abdominal flap is undermined to the level of the xiphoid and costal
margin. The patient is then flexed and the wound closed in layers over two closed suction drains. As in an
abdominoplasty, the umbilicus is brought out through the abdominal flap and secured in place.
CLINICAL RESULTS
On the basis of our retrospective review and our 10-year experience, we have adopted this method as our

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standard of care for breast reconstruction (Fig. 390.1). We have established smoking and postmastectomy
radiation therapy as primary risk factors. We now require our patients to refrain from cigarette smoking for 4
weeks, and we delay reconstruction for all patients potentially receiving postmastectomy radiation therapy.
Complications are infrequent. In the published series of more than 750 DIEP flap reconstructions (4), 6% of
patients were returned to the operating room for flap-related problems. Partial flap loss occurred in 2.5%
and total flap loss in less than 1%. Problems with the vein or venous anastomosis were almost four times
more likely than problems with the arterial anastomosis. Fat necrosis appeared in 12% of flaps. Seroma
formation at the abdominal donor site was approximately 3.5%, and abdominal hernia occurred in 0.7 % of
cases.
SUMMARY
After more than a decade of experience with the DIEP flap, it has become the preferred choice for breast
reconstruction. Better cosmesis can be achieved with skin and soft tissue, and there is no sacrifice of the
abdominal musculature, which has led to a marked decrease in the hernia rate. With an average unilateral
reconstruction time of 4.66 hours and a bilateral reconstruction time of 7.3 hours, the operative time is not
increased, in comparison with the free TRAM flap. Also in
comparison with the free TRAM flap, the DIEP flap provides a significantly longer pedicle, which allows
tension-free anastomoses. This permits more freedom of design, which results in a centrally located breast
mound, especially with anastomoses to the internal mammary system. As microsurgical experience
increases, we think that the benefit of this flap will outweigh its risks, and the time spent learning
microsurgical techniques will be rewarded with a first-line option for breast reconstruction, affording better
patient satisfaction, decreased donor-site morbidity, and shorter hospital stays.
References
1. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg
1994;32:32.
2. Futter CM, Webster MH, Hagen, et al: A retrospective comparison of abdominis muscle strength following
breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg 2000;53:578.
3. Rogers NE, Allen RJ. Radiation effects on breast reconstruction: a review. Semin Plast Surg 2002;1:19.
4. Gill P, Hunt J, Guerra A, et al: A 10 year retrospective review of 758 DIEP flaps for breast reconstruction.
Plast Reconstr Surg 2004;113:1153.
5. Heitmann C, Felmerer G, Durmus C, et al: Anatomical feature of perforator blood vessels in the deep
inferior epigastric flap. Br J Plast Surg 2000;53:205.
6. Blondeel PN, Morris SF, Hallock GG, Neligan PC: Perforator flaps: anatomy, technique, and clinical
application. St. Louis: Quality Medical Publishing, 2006.

7. Vandevoort M, Vranckx JJ, Fabre B, et al: Perforator topography of the deep inferior epigastric perforator
flap in 100 cases of breast reconstruction. Plast Reconstr Surg 2002;109:1912.
8. Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and blood flow in free transverse rectus
abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000;106:1295.

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Chapter 391
Immediate Microvascular Free Tram Flap
J. C. GROTTING
As experience has been gained in autologous breast reconstruction using the TRAM flap (1, 2, 3, 4), its
suitability for immediate reconstruction has been increasingly recognized. All the advantages of this donor site for
delayed reconstruction are equally applicable in the immediate situation. At present, this flap remains the most
versatile flap for matching the opposite breast in a single procedure without implants.
INDICATIONS
Transferring the TRAM flap as a microsurgical procedure based on the deep inferior epigastric artery and
vein offers several additional advantages (5). First, the greater blood flow through the larger-caliber artery
virtually always irrigates a larger territory of the flap, thereby making more tissue reliably available for the
reconstruction. Second, only a small rectangle of the rectus abdominis muscle need be included in the flap,
just enough to surround the medial and lateral row of perforating vessels from the deep inferior epigastric
pedicle (6, 7, 8).
The free TRAM flap is particularly advantageous in immediate breast reconstruction where the subscapular
axis is readily available following axillary dissection. By using these vessels as recipient vessels,
considerable options are available for folding or molding the flap. In fact, there is less restriction to placing
the flap tissue to create a symmetrical breast. The skin and tissue volume of the mastectomy specimen can
very accurately be replaced.
FLAP DESIGN AND DIMENSIONS
It is unnecessary to take any muscle below the point where the pedicle meets the muscle (Fig. 391.1B). This
allows a strip of medial and lateral rectus abdominis muscle to be left from the semicircular line to the umbilicus.
Above the umbilicus, the entire rectus muscle is left intact and not dissected from its bed. Small twigs of
intercostal motor nerves to the rectus muscle are not divided along the semilunar line, thereby leaving intact
functional rectus muscle laterally.
Because the upper portion of the rectus muscle does not need to be dissected for this flap transfer, the superior
abdominal flap is undermined only as much as necessary to close the donor defect without tension. No tunneling
is required between the abdominal donor site and the mastectomy wound. This markedly reduces the excess
bleeding that can occur during this portion of the conventional TRAM operation. The epigastric bulge produced
by the tunneled rectus muscle that is often persistent after the conventional TRAM flap is also
eliminated. The medial portion of the inframammary fold can be left intact. Therefore, symmetry is improved.

FIGURE 391.1 A: The design of the TRAM flap. B: It is unnecessary to take any muscle below the point where
the pedicle meets muscle.
Immediate breast reconstruction using the free TRAM flap is performed using two surgical teams with separate
operative instrument sets. Planning should include a discussion of incisions to spare as much skin of the breast
as possible. Usually an incision encompassing the nipple-areola complex and the previous biopsy site, if present,
is a sufficient amount of skin to be taken. An oblique extension into the axilla will allow adequate exposure for the
axillary dissection.
The TRAM flap is designed on the lower abdominal wall exactly the same as one designs the conventional flap. I
prefer to design the flap as if doing a standard abdominoplasty, seeking to keep the scar as low and transverse
as possible (Fig. 391.1A). The contralateral rectus muscle is routinely used. This allows the small segment of
rectus muscle to be placed at the point of maximum projection of the newly formed breast and still leaves a
dependable amount of flap available for filling the infraclavicular hollow and to provide fullness inferiorly and
inferolaterally. If chest-wall skin must be replaced high in the infraclavicular area, the ipsilateral rectus muscle
might be a better choice.
OPERATIVE TECHNIQUE
The umbilicus is incised circumferentially down to the rectus fascia. The superior incision is made by beveling
superiorly between the semilunar lines to include a few extra rectus perforators. The ipsilateral side of the flap is
raised at the level of the deep fascia beyond the midline by approximately 1 to 2 cm. Elevation stops when the
medial row of perforators of the contralateral rectus muscle is reached. The contralateral side of the flap is then
raised until the lateral row of rectus perforators is visualized. Inferiorly, the flap is raised to the level of the
semicircular line, which is commonly marked by a large rectus perforator. At this point, the anterior rectus sheath
is incised, forming a rectangle that encompasses the medial, lateral, and inferiormost rectus perforators. The
lateral edge of the rectus muscle is then separated just enough to identify the entry point of the deep inferior
epigastric artery (Fig. 391.2). When this point has been identified, the rectus muscle is split within its fibers just
lateral to this entry point, thereby preserving the lateral row of perforators with the flap. The rectus abdominis
muscle can then be divided just inferior to the point where the deep inferior epigastric pedicle meets the muscle.
The muscle separation is then continued medially, again including the medial row of perforators, but preserving
an intact medial strip of muscle.
Through this window in the muscle deep retractors are placed, and using loupe magnification, the deep inferior
epigastric artery and veins (there are usually two) are dissected to their origin through the lateral pelvic wall.
Usually, only two or three small branches are encountered during this dissection, and these are easily controlled
using small vessel clips.
Before the superior rectus abdominis muscle is cut, the recipient vessels must be explored to determine their

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adequacy for microvascular anastomoses. Usually, the times required to raise the flap and complete the
mastectomy are similar. Therefore, the subscapular axis can be examined following completion of the
mastectomy to identify satisfactory recipient vessels. I prefer to use the thoracodorsal artery and vein proximal to
the serratus branch for end-to-end anastomoses. I believe that this provides the safest inflow with good size
match of vessel caliber and more flexibility
to place the flap in the proper position. Also, axial flow to the latissimus dorsi muscle is maintained by retrograde
flow through the serratus branch if this muscle were ever required for secondary coverage.
FIGURE 391.2 The lateral edge of the rectus muscle is separated just enough to identify the entry point of the
deep inferior epigastric artery.
After adequate inflow has been established, the central remaining portion of the rectus abdominis muscle is
divided superiorly so that the entire flap is allowed to perfuse only on the deep inferior epigastric artery and
accompanying veins. Up to this point, the flap could still be transferred as a conventional TRAM flap. With
warming of the flap, its circulation improves, and after 10 to 15 minutes, it can be safely transferred.
The deep inferior epigastric pedicle is then divided at its origin through the lateral pelvic wall. The flap is
transferred to the mastectomy site. It can be positioned either on the upper arm, allowing the vessels to fall into
the axillary wound, or alternatively, it can be temporarily positioned in the mastectomy wound and the vessels
brought into the axillary defect. It may help to tilt the patient toward the contralateral side to improve the visibility
into the axilla. Also, I prefer to have the anesthesiologist monitor the patient from the foot of the table using long
ventilation tubes. This allows positioning of the microscope and the assistant at the patient's head.
End-to-end microvascular anastomoses are then performed and the flap is allowed to perfuse (Fig. 391.3). A
drain is placed in the axilla, and the latissimus dorsi muscle is sutured to the serratus in order to partially close
the axilla. The axillary skin flap then also can be sutured to close the axilla and help recreate the lateral and
inferolateral aspects of the breast. The small segment of rectus muscle is sutured to the pectoralis major muscle
at the point where maximum projection of the breast is desired. Care is taken to observe the vessels during this
closure to make sure they are under no tension. The flap can then be rotated and folded to replace the tissues
removed with the mastectomy specimen. If abundant breast skin is available, most of the flap can be
deepithelialized, and only a small monitoring disk of skin can be left at the anticipated position of the nipple-
areola complex. Many times the entire flap could be safely used, since zone 4 frequently receives adequate
perfusion. However, in my experience, it has never been necessary to use the entire flap to have enough tissue
for symmetry with the opposite side.

FIGURE 391.3 The flap is anastomosed to the thoracodorsal artery and vein proximal to the serratus branch if
possible.
If a large skin excision is necessary for an adequate mastectomy, it is helpful to make a template of the shape of
the skin excision prior to incising the mastectomy flaps. This template can then be used as a guide to
reapproximation of the mastectomy flaps over the deepithelialized TRAM flap. A second drain is usually left
beneath the flap.
If a reduction or mastopexy is desirable on the opposite side, I prefer to do this prior to molding the TRAM flap. It
is best to have a second team perform the opposite breast correction while the mastectomy is being done or
while the TRAM flap is being raised. I have found that it is easier to match the corrected opposite breast with the
TRAM flap rather than vice versa in a second operation.
The closure of the abdominal wall is straightforward. The anterior rectus sheath and medial and lateral strips of
rectus muscle are easily reapproximated. The umbilicus may be pulled over during this closure but can usually
be easily recentralized by imbricating the fascia on the opposite side. The entire reconstruction is improved if
formal abdominoplasty techniques are used for the abdominal wall closure. This may include correction of a
rectus diastasis superiorly and improvement of the waistline using bilateral external oblique advancement flaps.
The superior abdominal skin and subcutaneous tissue are undermined as much as necessary to allow closure of
the flap donor site without tension. The umbilicus is sutured to the deep fascia and brought through in an
appropriate position. The area around the neoumbilicus is defatted to recreate the periumbilical depression. Two
large suction drains are placed on each side and the wound is then closed.
Molding of the breast is best accomplished with the patient in the sitting position so that symmetry can be
examined. More time spent molding the breast in the initial operation reduces the likelihood of secondary
corrective revisions (Fig. 391.4). Nipple-areola reconstruction is always performed 3 months later unless
chemotherapy has been initiated. In this situation, nipple-areola reconstruction is usually delayed until completion
of chemotherapy.
The patient is transferred directly to a hospital bed with the head elevated 20 to 30 degrees and the knees
elevated slightly as well. The patient is asked to maintain her arm on the side of the reconstruction between 45
and 90 degrees to avoid compression or stretching of the microvascular anastomoses. This is continued for
approximately 10 days. No dextran or other anticoagulants are used with the exception of a single aspirin tablet
daily starting in the postoperative period.
SUMMARY
The free TRAM flap can be molded and adapted to the mastectomy defect to create a soft, well-designed
breast.

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FIGURE 391.4 A: A 35-year-old woman with biopsy-proven carcinoma of the right breast. Subsequent to
this picture, she underwent a modified radical mastectomy and immediate reconstruction with a left free
TRAM flap. B,C: Postoperative result 6 months after the initial procedure and 3 months after nipple-areolar
reconstruction.
References
1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast
Reconstr Surg 1982;69:216.
2. Drever JM. The epigastric island flap. Plast Reconstr Surg 1977;59:343.
3. Robbins TH. Rectus abdominis myocutaneous flap for breast reconstruction. Aust NZ J Surg 1979;49:527.
4. Marino H, Dogliotti P. Mammary reconstruction with bipedicled abdominal flap. Plast Reconstr Surg
1981;68:933.
5. Shaw WW. Microvascular free-flap breast reconstruction. Clin Plast Surg 1984;11:333.
6. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior
epigastric systems. Plast Reconstr Surg 1984;73:1.
7. Carramenha e Costa MA, Carriquiry C, Vasconez LO, et al. An anatomic study of the venous drainage of
the transverse rectus abdominis musculocutaneous flap. Plast Reconstr Surg 1987;79:208.
8. Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric arcade.
Plast Reconstr Surg 1975;55:416.

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Chapter 392
Rubens Flap for Breast Reconstruction
P. M. GARDNER
J. C. GROTTING
EDITORIAL COMMENT
This flap allows for microvascular reconstruction of the breast when a TRAM flap is not available. In many
females, this location affords a generous fatty layer. The drawbacks are the difficulty of dissection and the
need for a meticulous reconstruction of the abdominal wall.
The Rubens flap is particularly useful for patients who require breast reconstruction when a TRAM flap is not
available, either because of a failed attempt or because of previous abdominoplasty.
INDICATIONS
This flap is a soft-tissue free flap found in the peri-iliac area. Described by Hartrampf in 1994 (1), it is useful
for breast reconstruction in women who desire autogenous
reconstruction, but who do not have sufficient tissue in the more conventional donor sites.
ANATOMY
The blood supply to the flap arises from the musculocutaneous perforators of the deep circumflex iliac artery
(DCIA). This artery averages 2 mm in diameter. It originates from the lateral aspect of the external iliac artery just
above the inguinal ligament and almost directly opposite the deep inferior epigastric artery. It has a straight
course laterally along the posterior margin of the inguinal ligament toward the anterior superior iliac spine (ASIS).
Here, it lies between the transversalis fascia and the transversus abdominis muscle.
An ascending branch is found just proximal to the ASIS, which penetrates the internal oblique muscle. Just
beyond this branch, the DCIA pierces the transversalis fascia and travels laterally along the inner lip of the iliac
crest. At this point, it lies in a fibrous tunnel formed by the fusion of the iliacus muscle and transversalis fascia
(2).
The dominant perforator to the Rubens flap arises along the inner lip of the iliac crest 2.5 to 4.0 cm lateral to the
ASIS. A second smaller perforator is usually found 5.5 to 6.0 cm from the ASIS. They travel within millimeters of
the bone but do not pass through. The perforators traverse the adjacent abdominal muscle to supply the skin
and fat of the flap (1).
FLAP DESIGN AND DIMENSIONS
The flap is taken from the skin and fat overlying the iliac crest. The skin island is designed as an ellipse
extending from the ASIS to the posterior axillary line. It parallels the iliac crest superiorly. The inferior extent is
determined by the amount of tissue that can be taken with primary closure of the donor site (Fig. 392.1).
The skin island can be safely designed as a 6- × 12-cm ellipse. A flap up to 9 × 20 cm has been reported (1),

and injection studies on cadavers demonstrate an area of 15 × 30 cm supplied by the DCIA (2). The weight of
the flap depends on the patient's habitus; weights from 520 to 640 g have been reported (1).
OPERATIVE TECHNIQUE
The patient is placed supine with a bean bag beneath the buttock to elevate the pelvis toward the opposite side.
The flap is outlined over the iliac crest with an incision extending anteriorly over the inguinal canal (Figs. 392.1
and 392.2). Dissection of the pedicle begins over the inguinal canal with an incision down to and through the
external oblique aponeurosis. The round ligament is retracted medially and the pedicle (DCIA) is identified. It is
dissected laterally to the ASIS.
Care is taken to avoid the lateral cutaneous femoral nerve, which courses downward medial to the ASIS. The
skin island incisions are then made. The upper half is dissected off the external oblique to within 5 to 6 cm of the
iliac crest. At this point, the external oblique, internal oblique, and transversus abdominis muscles are incised
and taken as a cuff with the flap. The inferior incision is then made and the flap is elevated off the tensor fascia
lata and gluteus medius to the lower border of the iliac crest.
FIGURE 392.1 DCIA pedicle and flap outlined over iliac crest. The two dominant perforators are found after the
ascending branch. The anterior incision is made over the inguinal canal. Five centimeters above the iliac crest,
the dissection goes through the muscles, which are included as a cuff.
Here, the dissection is continued over the lip of the iliac crest directly on top of the periosteum, preserving the
musculocutaneous perforators which run within millimeters of the crest. The muscles and pedicle are dissected
off the inner surface of the iliac crest, taking a cuff of muscle approximately 10 × 3 cm. Laterally, beyond the iliac
crest, the dissection proceeds above the muscles, but below the fascia, to the posterior axillary line (3). The flap
is then transferred to the defect. Microsurgical anastomosis is usually done to the thoracodorsal or internal
mammary vessels.
Careful closure of the donor defect is critical to avoid abdominal-wall herniation. Closure is in layers. First, the
transversalis fascia is approximated to the iliacus muscle and fascia. Next, drill holes are made in the iliac crest,
through which a large suture approximates the transversus and internal oblique muscles to the iliac crest. Finally,
the external oblique is closed over the crest to the tensor fascia lata and gluteal fascia. The inguinal incision is
closed by approximating the external oblique (1, 4).

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CLINICAL RESULTS
The Rubens flap is an excellent secondary flap for autogenous breast reconstruction. After abdominoplasty
or failed TRAM flap, patients usually have a generous amount of tissue in the peri-iliac area. When
harvested, the scar becomes an extension of the abdominoplasty incision. The change in contour of the
waist is usually deemed favorable (Fig. 392.3).
FIGURES 392.2 AND 392.3 Pre- and postoperative views demonstrate Rubens fat pad and cosmetically
acceptable contour of donor site. The dotted lines show the extent of beveling outward from the incisions
(solid lines).
There are several drawbacks to using the Rubens flap. Technically, it is more difficult than the TRAM flap.
In comparison to other alternative flaps for breast reconstruction, it is easier than the gluteal flap, and
probably equal in difficulty to the lateral thigh flap. The donor site can be more painful in the immediate
postoperative period, secondary to drilling the iliac crest during closure (5). Additionally, in order to gain
symmetry, the opposite peri-iliac fat pad requires resection. Finally, shaping the flap is considered a bit
more difficult.
SUMMARY
The options for autogenous breast reconstruction following abdominoplasty or failed TRAM flap are few.
The Rubens flap provides an adequate amount of tissue with a cosmetically acceptable donor site.
Although technically more difficult to harvest and shape, it is an excellent choice for the microvascular
surgeon.
References
1. Hartrampf CR, Noel TR, Dragan E, et al. Rubens fat pad for breast reconstruction: a peri-iliac soft-tissue
free flap. Plast Reconstr Surg 1994;93:402.

2. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: experimental work. Plast Reconstr Surg 1979;64:595.
3. Mathes SJ, Nahai F. Deep circumflex iliac artery (DCIA composite) flap: vascular anatomy. In:
Reconstructive surgery: principles, anatomy, and technique, Vol. 2. New York: Churchill Livingstone,
1994;967.
4. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: clinical work. Plast Reconstr Surg 1979;64:745.
5. Elliott LF. Options for donor sites for autogenous tissue breast reconstruction. Clin Plast Surg
1994;21:177.

Chapter 393
Microvascular Free Superior and Inferior Gluteal Artery Perforator
(Sgap/Igap) Flaps for Breast Reconstruction
M. M. LOTEMPIO
R. J. ALLEN
EDITORIAL COMMENT
Although free gluteal artery perforator flaps may not be the first choice for many surgeons in breast
reconstruction, it is important to have these options available.
Perforator flaps have raised the standard in breast reconstruction. By replacing like with like, permanent natural
results with minimal donor-site deformities can be achieved. Being able to choose from many donor-site options
makes virtually all patients candidates for this method of autogenous reconstruction. The superior or inferior
gluteal artery perforator flap (SGAP, IGAP) was first introduced by our group in 1993. The advantages of the
gluteal flap include preservation of the gluteus maximus muscle and elongation of the pedicle. As with other
perforator flaps, donor-site morbidity is minimal, and no sacrifice of muscle is required.
INDICATIONS
For more than a decade, perforator flaps have allowed the transfer of the patient's own skin and fat in a
reliable manner, with minimal donor-site morbidity (1). They are evidence of the most recent development in
the evolution of flaps for breast reconstruction. Pedicled, axial-pattern flaps, which could reliably transfer
greater amounts of tissue, soon substituted for flaps that relied on a random-pattern blood supply. The
concept of free-tissue transfer allowed an infinite range of possibilities to match donor and recipient sites
appropriately (2).
Women who have undergone mastectomies and wish to have reconstructions with autologous tissue are
candidates for SGAP or IGAP flaps. Those in whom the abdomen cannot be used as a donor site, either
because of previous abdominoplasty or liposuction, or who have more tissue in the buttock area than in the
abdomen, are the best candidates. The buttock has a high fat-to-skin ratio, whereas the abdomen has a
high skin-to-fat ratio. Patients who require mostly fat and little skin may be candidates for SGAP/IGAP flaps.
A significant amount of tissue may be harvested, and, in our experience, the average final inset weights of
our GAP flaps were slightly greater than weights of the mastectomy specimens removed.
Absolute contraindications specific to SGAP/IGAP flap breast reconstruction in our practice include previous
liposuction at the donor site and active smoking within 1 month before surgery. Liposuction of the upper
buttock is rare, so does not often affect harvesting of the SGAP, but liposuction of the saddlebag area can
affect IGAP-flap viability.
ANATOMY
The superior gluteal artery is a continuation of the posterior division of the internal iliac artery. It is a short artery
that runs dorsally between the lumbosacral trunk and the first sacral nerve. It emanates from the pelvis above the
upper border of the piriformis muscle, where it soon divides into both superficial and deep branches. The deep

P.1058
branch travels between the iliac bone and gluteus medius muscle. The superficial branch continues to give off
contributions to the upper portion of the gluteus muscle and overlying fat and skin. Anatomic location is planned
when the femur is slightly flexed and rotated inward; a line is drawn from the posterior superior iliac spine to the
posterior superior angle of the greater trochanter. The point of entrance of the superior gluteal artery from the
upper part of the greater sciatic foramen corresponds to the junction of the upper and middle thirds of this line.
Perforating vessels are found off the superior branch of the superior gluteal artery (3, 4) (Fig. 393.1).
The inferior gluteal artery is a terminal branch of the anterior division of the internal iliac artery and exits the
pelvis through the greater sciatic foramen (5). Landmarks can also be used to identify the location of the
emergence of the inferior gluteal artery outside the pelvis. A line is drawn from the posterior superior iliac spine
to the outer part of the ischial
tuberosity; the junction of its lower with its middle third marks the point of emergence of the inferior gluteal and its
surrounding vessels from the lower part of the greater sciatic foramen (Fig. 393.1). The artery accompanies the
greater sciatic nerve, internal pudendal vessels, and the posterior femoral cutaneous nerve. In this sub-fascial
recess, the inferior gluteal vein will receive tributaries from other pelvic veins.
FIGURE 393.1 The anatomy of the gluteal region. The superior gluteal artery emerges superiorly, and the
inferior gluteal artery emerges inferiorly from the pyriformis muscle. The perforators are identified one-third of the
distance from a line drawn from the posterior iliac spine to the greater trochanter.
The inferior gluteal vasculature continues toward the surface by perforating the sacral fascia. It exits the pelvis
caudal to the piriformis muscle. Once under the inferior portion of the gluteus maximus, perforating vessels are
seen branching out through the substance of the muscle to feed the overlying skin and fat. The course of the
inferior gluteal artery perforating vessels is more oblique through the substance of the gluteus maximus muscle
than the course of the superior gluteal artery perforators, which tend to travel more directly to the superficial
tissue up through the muscle. Thus the length of the inferior gluteal artery perforator and the resultant pedicle
length for the overlying IGAP flap at 7 to 10 cm is greater than that found with an SGAP flap (5 to 7 cm). Because
the skin island is placed inferior to the origin of the inferior gluteal vessels, a longer pedicle is also ensured.
The direction of the perforating vessels can be superior, lateral, or inferior. Perforating vessels that nourish the
medial and inferior portions of the buttock have relatively short intramuscular lengths, between 4 and 5 cm,
depending on the thickness of the muscle. Perforators that nourish the lateral portions of the overlying skin
paddle are observed traveling through the muscle substance in an oblique manner 4 to 6 cm before turning
upward toward the skin surface. By traveling through the muscle for relatively long distances, these vessels are
much longer than their medially based counterparts. The perforating vessels can be separated from the

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underlying gluteus maximus muscle and fascia and traced down to the parent vessel, forming the basis for the
IGAP flap. Between two and four perforating vessels originating from the inferior gluteal artery will be located in
the lower half of the gluteus maximus (6).
After giving off perforators in the buttocks, the inferior gluteal artery then descends into the thigh, accompanied
by the posterior femoral cutaneous nerve, and follows a long course, eventually surfacing to supply the skin of
the posterior thigh (7). The branches of the inferior gluteal nerve (L5, S1-2) supply the skin of the inferior
buttock. A neurosensory flap can be elevated if these nerves are preserved in the dissection of the flap (8, 9).
The superior gluteal nerve arises from the dorsal divisions of the fourth and fifth lumbar and first sacral nerves. It
exits the pelvis through the greater sciatic foramen above the piriformis muscle, accompanied by the superior
gluteal vessels, and divides into both superior and inferior branches. The superior and inferior branches of the
nerves travel with their corresponding arterial branches to end in the gluteus medius, gluteus minimus, and
tensor fasciae latae, respectively.
The inferior gluteal nerve arises from the dorsal divisions of the fifth lumbar and first and second sacral nerves. It
exits the pelvis through the greater sciatic foramen, below the piriformis muscle, and divides into branches that
enter the deep surface of the gluteus maximus. The posterior femoral cutaneous nerve innervates the skin of the
perineum and posterior surface of the thigh and leg. It arises partly from the dorsal divisions of the first and
second, and from the ventral divisions of the second and third sacral nerves, and issues from the pelvis through
the greater sciatic foramen below the piriformis muscle, along with the inferior gluteal artery. It then descends
beneath the gluteus maximus, the fascia lata, and travels over the long head of the biceps femoris to the
posterior knee. Finally, it pierces the deep fascia and accompanies the lesser saphenous vein to the middle of
the posterior leg. Some terminal branches communicate with the sural nerve. All its branches are cutaneous and
distributed to the gluteal region, the perineum, and the posterior thigh and leg.
FLAP DESIGN AND DIMENSIONS
The patient usually is seen in our office 1 day before surgery. The surgical plan is again reviewed with the
patient, and any remaining questions answered. The chest is marked in a sitting position. The midline and the
inframammary crease on both sides are marked. For patients undergoing immediate breast reconstruction,
suggested skin markings are drawn on the
breast, which include marks around the nipple-areolar complex and previous biopsy site. In patients who are
undergoing a nipple-sparing mastectomy, an inframammary, anterior axillary, or lateral incision is made.
FIGURE 393.2 Skin markings are drawn and perforators are located with a Doppler.

For unilateral SGAP flap markings, the patient is placed in a lateral decubitus position. The Doppler probe is
used to locate perforating vessels from the superior gluteal artery. These are usually located approximately one
third of the distance on a line from the posterior superior iliac crest to the greater trochanter. Additional
perforators may be found slightly more lateral from above. It should be noted that perforators located laterally will
produce longer pedicles. The skin paddle is marked in an oblique pattern, from inferior medial to superior lateral,
to include these perforators. On average, the flap height and length is 8 to 10 cm and 20 to 24 cm, respectively,
and the skin paddle may be as large as 12 × 30 cm. For bilateral SGAP planning, the patient is marked in the
prone position (Fig. 393.2).
For the IGAP flap, the gluteal fold is noted with the patient in a standing position. The inferior limit of the flap is
marked 1 cm inferior and parallel to the gluteal fold. The patient is then placed in the lateral position for unilateral
reconstruction and prone for bilateral reconstruction. The Doppler probe is used to find perforating vessels from
the inferior gluteal artery. An ellipse is drawn for the skin paddle to include these perforators, which roughly
parallels the gluteal fold, with dimensions of approximately 8 × 18 cm. For correction of a “saddlebag” deformity,
the skin pattern is shifted laterally (Fig. 393.3).
OPERATIVE TECHNIQUE
For unilateral procedures, the patient is placed in the lateral decubitus position, and a two-team approach is
used. The recipient vessels are prepared, as described earlier, while the SGAP/IGAP flap is harvested. For
breast reconstruction, the internal mammary vessels or internal mammary perforators are preferred, as
anastomosis to these vessels allows easier medialization of the flap when it is inset. The IGAP flap often has a
long enough pedicle to reach to the thoracodorsal vessels; however, the SGAP may be challenging because of a
shorter pedicle. For bilateral simultaneous GAP flap reconstruction, the procedure is started supine. After
mastectomy and recipient vessel preparation, the patient is positioned for flap harvest. Then the patient is
repositioned supine for anastomosis and insetting.
The skin incisions are made, and Bovie electrocautery is used to divide the flap down to the muscle of the
gluteus maximus. Significant beveling is used, as needed, particularly lateral to the muscle superiorly and
inferiorly, to harvest enough tissue for width and volume and to create a natural breast shape. The flap is
elevated from the muscle in the subfascial plane, and the perforators approached beginning from lateral to
medial or medial to lateral. It is preferable to use a single large perforator, if it is present, but several perforators
that lie in the same plane and in the direction of the gluteus maximus muscle fibers can be taken together, as
well. The muscle is then spread in the direction of the muscle fibers, and the perforating vessels are meticulously
dissected free. The dissection continues until both the artery and the vein are of sufficient size to be
anastomosed to the recipient vessels in the chest. The artery usually is the limiting factor in this dissection. The
arterial perforator is visualized and preserved as it enters the main ascending superior gluteal artery or the
descending inferior gluteal artery. The preferable artery and vein diameter for anastomosis is 2.0 to 2.5 mm and
3.0 to 4.0 mm, respectively. When using the IMV perforators as recipient, a shorter pedicle and smaller artery will
suffice, thereby simplifying flap harvest.
Harvesting an in-the-crease IGAP allows more beveling superiorly and inferiorly, because soft-tissue deficiency
in the crease is normal. Laterally, thicker fat from the trochanteric area can be taken, increasing flap volume and
decreasing a saddlebag deformity. When harvesting the IGAP flap, care must be taken to preserve the lighter-
colored medial fat pad that overlies the ischium medial to the gluteus maximus muscle. Preservation of this
specialized fat pad will prevent possible future donor-site discomfort when sitting.
When the recipient vessels are ready, the gluteal artery and vein are divided, and the flap is harvested and
weighed. The skin and fat overlying the gluteus maximus muscle and posterior thigh with the IGAP are elevated
superiorly and inferiorly to allow layered approximation of the fat of the donor site and to prevent a contour

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deformity and give a buttock lift. The donor site is closed in layers over a suction drain with absorbable suture.
Adding a permanent removable skin suture increases the strength of the skin closure.
FIGURE 393.3 Pre- and postoperative pictures of the inferior gluteal artery perforator flap.
The anastomosis is performed to the recipient vessels under the operating microscope. The flap is inset over a
suction drain into the breast pocket, with care taken not to twist or kink the pedicle. To create a spherical flap,
the ends of the ellipse are excised. The flap may be inset horizontally, vertically, or obliquely, depending on the
situation.
CLINICAL RESULTS
In a review of 377 GAP flaps performed by our unit for breast reconstruction, the incidence of complications
was low. The overall take-back rate for vascular complications was 6%. The total flap failure rate was
approximately 2%. Donor-site seroma occurred in 15% of patients, and approximately 20% of patients
required revision of the donor site (4, 5).
SUMMARY
To make these options more available and desirable, there is much room for improvement. The length of
the procedure must be decreased, scars must be improved, and complications must be decreased. With
improvements in technology and technique, these goals can be realized. The in-the-crease IGAP offers
preservation of buttock shape, a scar hidden in a natural crease, and adequate-thickness fat for a youthful,
attractive breast. The SGAP flap procedure has little or no postoperative pain and leaves a scar easily
concealed with swim wear. The contour can be quite good, without taking a flap too large, and by
performing a buttock lift with proper layered closure.
References
1. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg
1994;32:32.
2. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243.

3. Guerra A, Metzinger S, Bidros E, et al. Breast reconstruction with gluteal artery perforator (GAP) flaps: a
critical analysis of 142 cases. Ann Plast Surg 2004;52:118.
4. Strauch B, Yu HL. Gluteal region. In: Strauch B, Yu HL, eds. Atlas of microvascular surgery: anatomy and
operative approaches. New York: Thieme Medical Publishers, 1993;102-119.
5. Roche NA, Van Landuyt K, Blondeel PN, et al. The use of pedicled perforator flaps for reconstruction of
lumbosacral defects. Ann Plast Surg 2000;45:7.
6. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J
Plast Reconstr Aesthet Surg 2006;59:571.
7. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure
sores. Plast Reconstr Surg 1993;91:678.
8. 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;24:253.
9. Blondeel PN. The sensate free superior gluteal artery perforator (S-GAP) flap: a valuable alternative in
autologous breast reconstruction. Br J Plastic Surg 1999;52:185.

Chapter 394
Adipofascial (Anterior Rectus Sheath) Flaps for Breast
Reconstruction
S. SAKAI
I. SUZUKI
H. IZAWA
EDITORIAL COMMENT
This is a reasonably simple technique for breast reconstruction, but will produce only small-volume breasts.
A cranial-based adipofascial (anterior rectus sheath) flap has been developed from immediately below the
inframammary area, for breast reconstruction after subcutaneous mastectomy for removal of a foreign-body or
benign tumor (1).
INDICATIONS
A good candidate for the inframammary adipofascial flap procedure is a patient who underwent foreign-body
injection for breast augmentation about 10 to 20 years previously (e.g., vaseline, paraffin, silicone gel). If the
injected foreign body has infiltrated the breast skin, causing extensive red or brown, hard, inflammatory
changes, the adipofascial flap is not indicated. In such cases, a large latissimus dorsi myocutaneous flap (2,
3) or a rectus abdominis myocutaneous flap (4) is required.
ANATOMY
The flap is supplied by perforators from the pectoralis muscle (Fig. 394.1) (5). During the dissection, it is
essential that these perforators be preserved.
FLAP DESIGN AND DIMENSIONS
With the patient in a standing position, the foreign body or tumor area, the inframammary line, and the donor
area of the adipofascial flap, approximately 7 cm below the inframammary line, are marked (Figs. 394.1A and
2B). A tongue-shaped flap of fat and the anterior sheath of the rectus abdominis muscle, approximately 7 cm in
length, are pulled up, gathered, and inserted for reconstruction of the breast mound.
OPERATIVE TECHNIQUE
The skin incision is made along the inframammary line. After extirpation of the foreign body or benign tumor, the
skin of the inframammary area for the designed flap is undermined in the subcutaneous fat to a depth of 3 or 4
mm. When a depth of 7 cm from the inframammary skin incision is reached, the fat and the anterior sheath of the
rectus abdominis muscle are cut semicircularly in a tongue shape at the previously determined area (Figs. 394.1
and 394.2B). It is difficult to cut the distal end of the flap, because the distance from the skin incision margin is
extensive.
The surgeon grasps the tip of the tongue-shaped flap with forceps and cuts along the edge of the flap and the
anterior sheath with scissors, then pulls it up and releases the flap from the rectus abdominis muscle. If the fat

flap did not include the rectus muscle sheath, the fat would be fragile; thus, it is important to pull it up together
with the muscle sheath. The flap is pulled up by separating the rectus muscle and the anterior rectus sheath as
far as the inframammary line, taking care to preserve a few perforators from the pectoralis major muscle. The flap
is then reflected back to the breast area, where the foreign body or tumor was removed.
The elevated and hinged flap is gathered at the site of the breast-tissue defect, to construct the breast mound,
and is fixed to the chest wall. After modeling the mound with the adipofascial flap, the skin is sutured at the
inframammary line area, and a suction tube or open drain is placed in the undermined area. A soft compress
dressing is placed on the new breast mound, and a tight compress dressing is placed on the undermined
inframammary area.
FIGURE 394.1 Sagittal section of the operative area. A: Subcutaneous resection of foreign body or benign
tumor by an inframammary crease skin incision. Note undermining for the anterior rectus sheath flap. B:
Elevation of the flap. C: Fixation of the flap to the pectoral fascia or muscle, to remodel the breast mound. D:
After skin closure. (From Sakai et al., ref. 1, with permission.)
FIGURE 394.2 A 39-year-old patient who had received a silicone injection 20 years previously. A: Preoperative
frontal view. B: Preoperative markings of the foreign body and inframammary adipofascial flap. C: Appearance 2
years postoperatively. (From Sakai et al., ref. 1, with permission.)

CLINICAL RESULTS
This procedure was performed in seven patients with relatively flat breasts, for reconstruction after
subcutaneous mastectomy to remove foreign bodies. The reconstructed breasts remain soft and retain a
good shape. One patient wanted larger breasts 1 year post flap operation; silicone implants were placed
under the flap. The patient subsequently underwent another procedure to remove the implants.
All other patients were satisfied with the results. There were no complications such as skin or fat necrosis,
or hardening. Two patients complained of tightness of the skin in the inframammary donor area.
SUMMARY
The adipofascial flap is a useful method of reconstruction, especially in patients with relatively small
breasts.
References
1. Sakai S, Suzuki I, Izawa H. Adipofascial (anterior rectus sheath) flaps for breast reconstruction. Ann Plast
Surg 1992;29:173.
2. Maxwell GP, Steuber K, Hoopes JE. A free latissimus dorsi myocutaneous flap. Plast Reconstr Surg
1978;62:462.
3. Sakai S, Omodaka S, Ando K. Breast reconstruction by a latissimus dorsi musculocutaneous flap without a
silicone implant. Asian Med J 1990; 33:353.
4. Sakai S, Takahashi H, Tanabe H. The extended vertical rectus abdominis myocutaneous flap for breast
reconstruction. Plast Reconstr Surg 1989; 83:1061.
5. Jurkiewicz MJ, Hester R. Head and neck reconstruction. In: Mathes SJ, Nahai F, eds. Clinical
applications for muscle and musculocutaneous flaps. St. Louis: C.V. Mosby, 1982;194-217.

Chapter 395
Nipple Reconstruction With The Modified Double-Opposing- Tab
Flap
S. S. KROLL
EDITORIAL COMMENT (CHAPTERS 395-397)
The ability to produce a well-projecting nipple reconstruction from locally available tissue brought nipple
reconstructions into common usage. No longer need the patient worry about loss of another body part for
reconstruction. The following three chapters describe multiple variations.
The modified, double-opposing-tab (MDOT) flap is a method of nipple reconstruction derived from the original
double-opposing- tab flap (1, 2), using two local flaps containing skin and dermofat. The modifications allow
closure of the donor site without a skin graft and increase the blood supply to the flap. The MDOT flap is similar
to the S-flap, differing primarily in the shape of the flap tips (3, 4).
INDICATIONS
The MDOT technique can be used to reconstruct a nipple on virtually any breast mound, regardless of the
original breast reconstruction. It uses two small dermofat flaps to achieve nipple projection, and the only
precondition for its use is the presence of enough skin and underlying fat on the breast, to allow elevation of
the two flaps.
Most modern methods of nipple reconstruction use similar dermofat flaps to achieve nipple projection.
However, unlike most of the other techniques (5, 6), the MDOT procedure uses two flaps instead of one,
thereby doubling the effective flap-base width and blood supply. This increased supply reduces the risk of
flap loss and increases the probability of achieving good projection. The technique also allows for
symmetrical closure of the flap donor sites, reducing distortion of the breast mound and eliminating the need
for skin grafting. Creation of the areola and pigmentation of the nipple itself are achieved with tattooing (7).
The procedure can be easily performed under local anesthesia in the clinic or office.
Contraindications to its use would be the presence of multiple scars cutting across the base of the flaps, or
such a severe shortage of breast skin in all directions that using any of it for creation of a nipple would be
detrimental to the shape of the breast.
FLAP DESIGN AND DIMENSIONS
The location of the nipple-areolar complex (NAC) is selected, with the patient in the upright position, by carefully
noting the position of the NAC on the contralateral breast. The surgeon should attempt to position the NAC, so
that it has the same relationships to the inferior, medial, and lateral borders of the breast, as does the NAC on
the normal side. This is more difficult, if the reconstructed breast has a different shape from the normal one.
Obviously, the surgeon should try to make the reconstructed breast shape as similar as possible to the opposite
breast prior to beginning nipple reconstruction.
The flaps are designed, as shown in Figure 395.1A, with the long axis parallel to any preexisting scar. This will
minimize possible interference with the flap blood supply. If no scars are present, the flaps are oriented in

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whatever direction best improves or maintains breast symmetry. Knowing that the MDOT flaps will tighten breast-
mound skin by 1.8 cm at right angles to the long axis of the flaps, the surgeon orients the flaps horizontally to
reduce breast ptosis, or vertically to maintain ptosis but slightly narrower breast width. The typical dimensions of
the flaps are shown with a width of 1.8 cm; however, flap length or width can be altered slightly, to match an
atypical contralateral nipple, if necessary.
OPERATIVE TECHNIQUE
The flaps are elevated with a No. 15 scalpel, and including some subcutaneous fat, so that total flap thickness is
about 6 mm (Fig. 395.1B). The flap base is freed only enough to allow the flaps to be moved into opposition,
leaving the blood supply as intact as possible. Buried key sutures (4-0 polyglycolic acid) are placed from the
base of one flap to the midpoint of
the opposite one (Fig. 395.1C and D), so that the flaps are brought into opposition like two hands held in prayer.
FIGURE 395.1 A: Plan for nipple-areolar reconstruction with the modified double-opposing-tab flap. Each flap is
generally 1.8 cm in width. B: Flaps are elevated with skin and subcutaneous tissue. C,D: After two key sutures
are tied, the opposed flaps support each other. E,F: Skin closure with 5-0 chromic sutures.
The donor sites are closed primarily with 4-0 polyglycolic acid buried sutures (in a straight line or by W-plasty,
varying with each patient and depending on which closure produces the least distortion). The skin is closed with
5-0 chromic running sutures. The tips of the flaps interdigitate and are closed with 5-0 chromic interrupted
sutures (Fig. 395.1E and F). Bacitracin ointment is then applied to the wound, followed by a gauze dressing to
protect the patient's clothing.
CLINICAL RESULTS
At the end of nipple reconstruction using this technique, nipple projection is usually 10 to 12 mm. Tattooing
can be performed immediately, but we usually prefer to wait 4 weeks for healing to be completed. There is

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usually some early distortion of the breast-mound shape where the flaps have been harvested. This
disappears over the next few weeks, as the weight of the reconstructed breast stretches the skin. Nipple
projection varies, gradually decreasing over the next several months. Some nipples will shrink to a
projection of only 1 or 2 mm; a few will remain excessively long and need to be trimmed; but most will
remain in the 2- to 4-mm range, which is satisfactory to most patients (Fig. 395.2).
If the correct amount of fat was included in the flaps, the nipple can be perfectly round. If too much was
included, closure will be difficult, and the flaps will require thinning intraoperatively. If too little fat was
included, the nipples will have an oval shape; this can be corrected in a second stage. It is best to do any
necessary revision before tattooing the areola, so that its circular shape is not altered.
FIGURE 395.2 Completed nipple-areolar complex, after scar maturation and stabilization of projection.
Loss of part of one or both flaps will lead to poor nipple projection and is more likely in patients who smoke.
The effects of smoking can be mitigated by making the flaps slightly wider than normal, to increase the
blood supply. A tight closure at the flap base can also impede blood supply. If this is noted intraoperatively,
a suture can be removed and the base left open at one side to reduce skin tension, with revision planned
later, as previously described.
Dog-ears at the donor sites and temporary distortion of breast shape are common, but usually disappear
spontaneously with stretching of the breast skin, unless the breast is unusually small and tight.
SUMMARY
The MDOT flap can be used on any type of reconstructed breast and allows primary closure of the donor
site. It creates a projecting nipple with two local flaps containing skin and dermofat.
References
1. Kroll SS. Nipple and areolar reconstruction. In: Kroll SS, ed. Reconstructive plastic surgery for cancer.
Philadelphia: C.V. Mosby, 1996;314-318.
2. Kroll SS, Hamilton S. Nipple reconstruction with the double-opposing-tab flap. Plast Reconstr Surg
1989;84:520.
3. Cronin ED, Humphreys DH, Ruiz-Razura A. Nipple reconstruction: the S flap. Plast Reconstr Surg
1988;81:793.

4. Weiss J, Herman O, Rosenberg L, Shafir R. The S nipple-areola reconstruction. Plast Reconstr Surg
1989;83:904.
5. Little JW. Nipple-areolar reconstruction. Adv Plast Reconstr Surg 1987; 3:43.
6. Anton MA, Hartrampf CR Jr. Nipple reconstruction with the star flap. Plast Surg Forum 1990;13:100.
7. Spear SL, Convit R, Little JW. Intradermal tattoo as an adjunct to nipple-areolar reconstruction. Plast
Reconstr Surg 1989;83:907.

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Chapter 396
Propeller Flap: One-Stage Procedure for Nipple-Areola
Reconstruction
B. TEIMOURIAN
R. B. KARP
S. MALEKZADEH
A single-stage technique for long-term nipple projection is described. It uses a local skin flap that provides a
good color match and satisfactory projection, compared with the contralateral breast (1).
INDICATIONS
Reconstruction of the nipple and areola continues to be a surgical challenge, despite the many procedures
described in the literature over the past 60 years. Free grafts and local skin flaps are the two principal
methods currently in use. Free grafts utilize tissue from another site to create a new nipple; donor sites that
have been described include the opposite nipple, ear lobe, toe, thumb, labia minora, and mucous
membranes (2, 3, 4, 5, 6, 7). Local skin flaps have also produced acceptable results (8, 9, 10, 11, 12, 13).
However, these methods leave a donor-site defect and may require a full-thickness skin graft for closure,
thereby creating a second wound. In addition, these reconstructive techniques are multi-staged procedures.
The primary objectives of nipple-areola reconstruction include: (1) optimal position, symmetry, and color
match with the contralateral breast; (2) a good color match between the nipple and areola; and (3) adequate
nipple projection. Tattooing of the breast-mound skin prior to its elevation in flap reconstruction achieves
these requirements and eliminates the need for skin grafts and donor sites (14). Stable nipple projection
remains the most difficult aspect of the reconstruction.
The use of the propeller flap is indicated in either immediate single-stage breast reconstruction, or as a
second-stage procedure after the breast mound is created. The advantages of the propeller flap, combined
with tattooing for nipple-areola reconstruction, include: 1) the fact that this is a simple one-stage procedure;
2) a secondary procedure after creating the nippleareola complex is eliminated; and 3) a skin graft and
second wound are eliminated. This technique can produce a nipple of adequate size, good color match, and
satisfactory projection.
OPERATIVE TECHNIQUE
With the patient in a semi-Fowler or sitting position, the location of the new nipple and areola are outlined to
match the contralateral side. The proper color dye is selected, and the areola (circle) is tattooed. Tattooing is
performed first, thus eliminating the difficulty of coloring the skin after the papule
has been raised. In the center of the new areola, we draw a smaller circle, approximating the diameter of the
nipple, and two opposing propeller shapes (Fig. 396.1A). The two limbs of the propeller-shaped flap are raised,
leaving the central core undisturbed (9, 15). The central core is elevated after sharp dissection, beveling the
incision away from the center, and thereby creating a broad pedicle base (Fig. 396.1B). The flaps are then
rotated around the center, creating height for the new nipple (10, 12). The donor areas are closed first, and
further tattooing is done to correct the distorted circle (areola) (16, 17) (Fig. 396.1C). The elevated new nipple is
supported with a Keith needle through the base, and a light dressing is applied.

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FIGURE 396.1 A-C: Illustrative steps of the one-stage propeller flap procedure. (From Teimourian, Duda, ref. 1,
with permission.)
FIGURE 396.2 A,B: Six-and-a-half years after nipple-areola reconstruction.
CLINICAL RESULTS
The propeller flap has been used to reconstruct the nippleareola complex in over 200 patients during the
second stage of breast reconstruction with implant placement. Patients have been followed for up to 6.5
years. There have been no complications of skin-flap necrosis, hematoma, or infection. Compared to the
contralateral breast, there is a good color match and satisfactory nipple projection, with minimal changes
during the follow-up period (Fig. 396.2A and B). The amount of nipple created with the propeller flap will
vary with the length and width of the flaps and the amount of pull on the central core. Nipple projection is
produced by a column of
subcutaneous tissue and skin raised above the surface of the breast mound.
The skin flaps of the propeller flap are designed so that the skin defect can be closed first, obviating the
need for a skin graft or a second wound. Complications associated with skin grafts and secondary
procedures are eliminated.
Good color match between nipple and areola and with the opposite breast has been possible with tattooing
(3). This has eliminated the need for a second procedure in the reconstruction of the nipple-areola complex
with the propeller flap.