Operative Technique in Plastic Surgery – Kevin C.Chung

■ Superior Gluteal Artery Perforator Flap
■ Markings: See above
■ Harvest of the flap should be done under loupe magnification.
■ Incision of the skin ellipse is made laterally with both superior and inferior
incisions being opened (TECH FIG 1A).
■ If additional fat is desired, beveling is necessary to capture the fat.
■ Above the muscular fascia, the superior cluneal nerves can be identified at
the superior border of the flap. These can be included if large enough to
allow a sensate flap. The superior cluneal nerves are the terminal ends of the
lateral rami of the posterior rami of lumbar spinal nerves L1, L2, and L3.
■ Suprafascial dissection proceeds above the gluteus maximus muscle in the
direction of the fibers until the area around SGAP perforator is encountered.
■ The gluteal fascia is then incised and elevated in a lateral to medial fashion
above the muscle.
■ Once the chosen perforator has been identified, dissection proceeds with the
use of bipolar cautery through the gluteus maximus muscle using standard
perforator dissection techniques.
■ It is important to split the gluteus maximus muscle in the direction of the
fiber along the septum to avoid technical error (TECH FIG 1B).
■ At the deepest point of dissection through the gluteus maximus, the posterior
fascia is encountered, and it must be opened.
■ Once opened, the subgluteal fat pad is exposed, there is a dangerous intricate
vascular network, and the veins in this area tend to be fragile.
■ At this point, Gelpi retractors in the piriformis and gluteus medius are
required to get adequate exposure of the vessel at its origin (TECH FIG 1C).
■ If pedicle length is adequate prior to dissection in the subgluteal fat pad, then
dissection can stop prior to entry.
■ Additional 2 to 3 cm of length can be gained in the subgluteal flat plane.
■ Once the dissection of the perforator back toward the superior gluteal artery
as it emerges between the piriformis and the gluteus medius has been
completed, the remainder of the skin incisions can be made (inferiorly and
medially).
■ The skin paddle is then lifted from the muscle and the flap is isolated on the
perforators.
■ Flaps are then harvested with either tie or double clip in the pelvis and

placed on ice on the back table.
■ Closure of the donor site proceeds in layers and over closed suction drains.
Care is taken to avoid undermining over the iliac crest and greater trochanter
to avoid disruption of periosteal skin ligaments.
■ The patient is then repositioned into the supine position for microsurgical
anastomosis.
TECH FIG 1 • Intraoperative dissection. A.
Intraoperative markings. B. Split of gluteus maximus
muscle during perforator dissection. C. Dissection in
the subgluteal fat plane.
■ Recipient Vessel Exposure
■ Exposure of the recipient vessels proceeds in the standard technique.
■ Rib-sparing and rib-sacrificing techniques have been described and can be
utilized with this flap. 10
PEARLS AND PITFALLS
Physical
findings
■ Preoperative imaging and marking remain the most important part
of the preoperative workup. When marking the skin paddle, make
sure the paddle is centered over the perforators and is oriented in a
45-degree angle with the dog-ear run out into the gluteal crease.
Technique
■ Mark skin paddle without tension to avoid donor-site deformity
and step-offs.
■ Make only superior and lateral incisions first.
■ Dissect in the suprafascial plane until the periperforator area, and

then make fascial incision in the direction of the gluteus maximus
muscle to avoid increased incidence of seroma.
■ Must split the muscle, after fascial incision is made, in the
direction of the fibers to allow careful dissection.
■ When ligating large venous branches in the subgluteal fat plane,
leave minimal length on the branch from the pedicle for risk of
predisposition to venous thrombosis.
■ When closing donor site, close in layers and avoid undermining
superiorly and laterally resulting in contour abnormalities and
functional abnormalities.
Postoperative
■ Patient should be maintained in compression garment 1 month
postoperatively.
Complications
■ High flap loss rates are possible, and donor-site complications
remain the most difficult to handle and can require revision
surgery with scar revision and fat grafting occasionally.
POSTOPERATIVE CARE
■ Patients routinely stay in the hospital for 3 to 4 days postoperatively.
■ Pain control can be augmented with intraoperative subcutaneous bupivacaine
(Exparel) administration in addition to scheduled ibuprofen/Toradol.
■ Patients have routine transcutaneous Doppler checks, and monitoring can be
further augmented by ViOptix technology. The authors prefer flap checks q 15
minutes × 2 hours, q 30 minutes × 1 hour, q 1 hour × 48 -hours, and q 2 hours
until discharge.
■ Postoperatively, sitting can be initiated in patients on POD no. 1 and
ambulation on POD no. 1 or POD no. 2 depending on the patient.
■ Foley is removed on POD no. 2.
■ Patients routinely stay in the hospital for 3 days and then are discharged home
on postoperative aspirin × 30 days.
■ Drains remain in place until less than 30 mL × 24 hours.
OUTCOMES
■ SGAP flap for breast reconstruction provides an adequate reconstruction;
however, the buttock fat is less pliable as compared to a natural breast due to a
developed reticular system. The flap allows for increased projection of the
breast secondary to this quality (FIG 5).
■ The SGAP flap offers a successful reconstruction in 93% to 97% of
patients.11,12

FIG 5 • A–D. Clinical case example.
COMPLICATIONS
■ Donor-site complications remain the most common complications associated
with SGAP flap dissection. These complications include the following:
■ Seroma of which the incidence can be decreased if suprafascial dissection is
undertaken. The incidence of seroma has been seen in as many as 13.5% of
patients.
■ Hematoma can be seen in as many as 1% to 3% of patients.
■ Wound healing problems (including dehiscence and wound infection) can be
seen in as many as 4% to 6% of patients.
■ Total flap loss is a dreaded complication of breast reconstruction with SGAP
flap. There are no large series of SGAP for breast reconstruction in the
literature; however, failure rates are likely between 5% and 8% secondary to
the short pedicle and tedious perforator dissection. These complications can be
associated with arterial or venous thrombosis or difficulty with perforator
dissection. In the largest series describing SGAP, arterial thrombosis occurred
in 3.7% of patients, venous thrombosis occurred in 3.7% of patients, and both
arterial and venous thrombosis occurred in 3.7% of patients.11 Prompt take
back to the operating room is required for either revision of arterial
anastomosis or venous anastomosis in the cases of arterial or venous
insufficiency. These complications routinely present in the first 24 to 48 hours.
■ Fat necrosis in fasciocutaneous flaps for breast reconstruction is
commonplace. However, the fat necrosis rate in SGAP flaps is unknown
secondary to the lack of large series. However, it has been seen in as many as
3% to 6% of patients, which is similar to other fasciocutaneous flaps.11
Treatment of fat necrosis is variable and can include revision with direct
excision or liposuction with fat grafting as an augmentation.
REFERENCES

1. Codner MA, Nahai F. The gluteal free flap breast reconstruction. Making it
work. Clin Plast Surg. 1994;21(2):289-296.
2. Shaw WW. Superior gluteal free flap breast reconstruction. Clin Plast Surg.
1998;25(2):267-274.
3. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for
repair of sacral pressure sores. Plast Reconstr Surg. 1993;91(4):678-683.
4. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap for breast
reconstruction. Plast Reconstr Surg. 1995;95(7):1207-1212.
5. Blondeel PN. The sensate free superior gluteal artery perforator (S-GAP) flap:
a valuable alternative in autologous breast reconstruction. Br J Plast Surg.
1999;52(3):185-193.
6. Georgantopoulou A, Papadodima S, Vlachodimitropoulos D, et al. The
microvascular anatomy of superior and inferior gluteal artery perforator (SGAP
and IGAP) flaps: a fresh cadaveric study and clinical implications. Aesthetic
Plast Surg. 2014;38(6):1156-1163.
7. Fade G, Gobel F, Pele E, et al. Anatomical basis of the lateral superior gluteal
artery perforator (LSGAP) flap and role in bilateral breast reconstruction. J
Plast Reconstr Aesthet Surg. 2013;66(6):756-762.
8. Blum CA, Frank D, Scott S, et al. Composite superior gluteal artery perforator
flaps for unilateral breast reconstruction: a case report. J Reconstr Microsurg.
2015;31(7):541-543.
9. Haddock N, Nagarkar P, Teotia SS. Versatility of the profunda artery
perforator flap: creative uses in breast reconstruction. Plast Reconstr Surg.
2017;139(3):606e-612e.
10. Haddock NT, Teotia SS. Five steps to internal mammary vessel preparation in
less than 15 minutes. Plast Reconstr Surg. 2017;140(5):884-886.
11. Baumeister S, Werdin F, Peek A. The sGAP flap: rare exception or second
choice in autologous breast reconstruction? J Reconstr Microsurg.
2010;26(4):251-258.
12. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with
gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Ann Plast
Surg. 2004;52(2):118-125.

27
CHAPTER
Section VIII: Other Free
Flaps
Profunda Artery Perforator
Flap for Breast
Reconstruction
Katie E. Weichman and Nicholas Haddock
DEFINITION
■ The profunda artery perforator (PAP) flap is a variation of the posterior thigh
myocutaneous flap, which was initially described by Hurwitz1 and further
popularized for reconstruction of burn contractures, pressure sores, and
extremity wounds.2,3 Since its description by Allen et al. in 2010, it has been
recently popularized for use in breast reconstruction.4
■ Although abdominally based free flaps remain the most common choice for
breast reconstruction secondary to sufficient skin and soft tissue, patients may
require alternative donor sites for various reasons. These reasons include lack
of abdominal donor site secondary to prior abdominal surgery or
abdominoplasty, inadequate volume in the abdomen, and patient preference.
ANATOMY
■ The profunda femoris artery originates from the common femoral artery. It
runs deep in the thigh and between the pectineus and the adductor longus and
on the posterior side of the adductor longus.
■ The profunda femoris artery gives off several branches including lateral
circumflex femoral artery, medial circumflex femoral artery, and several
perforating branches that perforate the adductor magnus muscles to the
posterior and medial compartments of the thigh.

■ There are typically three to four perforating arteries originating from the
profunda femoris.
■ First perforating artery passes posteriorly between the pectineus and adductor
brevis and then pierces the adductor magnus close to the linea aspera.
■ Second perforating artery larger than the first pierces the tendons of the
adductor brevis and adductor magnus and divides into anterior and posterior
branches.
■ Third perforating artery is given off below the adductor brevis, and it pierces
the adductor magnus and divides into branches that supply posterior femoral
muscles.
■ The perforating vessels used in the PAP flap have been evaluated in imaging
studies based on both size and location and perfusion.
■ The perforator is consistently found in the upper medial thigh posterior to the
gracilis. The most common location of the perforator in the medial thigh is
exiting the fascia in the vicinity of the adductor magnus about 3.8 cm from the
midline and 5.0 cm below the gluteal fold. The second most common
perforator location is in the vicinity of the biceps femoris and vastus lateralis
at 12 cm from the midline and 5.0 cm below the gluteal fold5 (FIG 1).
■ The thigh has three compartments: anterior compartment, medial
compartment, and posterior compartment. The medial and posterior
compartments are highlighted for profunda artery flap dissection (FIG 2).
■ The medial compartment includes the obturator externus muscle, gracilis
muscle, adductor longus muscle, adductor brevis, and adductor magnus.
■ Gracilis muscle
• Origin: The line on the external surfaces of the body of the pubis, inferior
pubis ramus, and the ramus of the ischium
• Insertion: Medial surface of proximal shaft of the tibia
• Action: Adducts the thigh at the hip and flexes the knee
• Arterial supply: Medial femoral circumflex
• Innervation: Obturator nerve
■ Adductor longus
• Origin: External surface of the body of the pubis (triangular depression
inferior to pubic crest and lateral to pubic symphysis
• Insertion: Linea aspera to middle one-third of the shaft of the femur
• Action: Adducts and medial rotates the thigh at the hip

• Arterial supply: Profunda femoris
• Innervation: Obturator nerve
■ Adductor magnus
• Origin: Ischiopubic ramus
• Insertion: Posterior surface of the proximal femur, linea aspera, and medial
supracondylar line
FIG 1 • Posterior thigh perforator location based on CT
scanning. Described as location from the gluteal fold
and from the midline.

FIG 2 • Cross section of the thigh at the level of the
profunda artery perforators.
• Action: Adducts and medially rotates the thigh at hip joint
• Arterial supply: Profunda femoris
• Innervation: Obturator nerve
■ The posterior compartment has three muscles: biceps femoris, semitendinosus,
and semimembranosus.
■ Biceps femoris
• Origin—long head: Ischial tuberosity
• Origin—short head: Linea aspera on posterior surface of the femur
• Insertion: Both insert onto the head of the fibula as a single tendon.
• Action: Flexion at the knee and extends the hip
• Arterial supply: Profunda femoris artery and perforators of profunda

femoris artery
• Innervation: Sciatic nerve
■ Semitendinosus
• Origin: Ischial tuberosity of the pelvis
• Insertion: Medial surface of the tibia (pes anserinus)
• Action: Flexes the leg at the knee joint and extension of the hip
• Arterial supply: Inferior gluteal artery and perforating arteries from the
profunda femoris
• Innervation: Sciatic nerve (tibial portion)
■ Semimembranosus
• Origin: Ischial tuberosity
• Insertion: Medial tibial condyle
• Action: Flexion of the leg at the knee joint and extension of the hip
• Arterial supply: Profunda femoris and gluteal arteries
• Innervation: Sciatic nerve (tibial portion)
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients present for evaluation for either delayed or immediate breast
reconstruction.
■ This includes patients with a history of breast cancer, patients undergoing
prophylactic mastectomy, patients with congenital abnormalities, and
transgender patients.
■ Physical examination includes examination of the abdomen and posteromedial
thighs to assess availability of excess tissue.
■ Timing of reconstruction should be planned in patients with prior history of
breast irradiation. The authors prefer to wait 6 months after the completion of
radiation therapy prior to completing delayed reconstruction.
■ Smoking status is also assessed.
■ Additionally, tamoxifen should be held 2 weeks prior to surgery and 2 weeks
after surgery.
IMAGING
■ Patients considering PAP flap reconstruction should undergo preoperative
imaging with either computed tomography angiogram (CTA) or magnetic
resonance angiography (MRA) of the pelvis and lower extremity.
■ Imaging is performed in the supine position and coordinated with the

radiologist for appropriate evaluation of images.
■ Perforators should be described as they exit the deep muscular fascia and
described based on location in an x-y axis. The gluteal fold will be set as zero
on the y-axis, and the posterior border of the gracilis will be set as zero on the
x-axis (FIG 3).
FIG 3 • CTA of the lower extremity identifying the
location of the profunda artery perforator behind the
gracilis traversing the adductor magnus toward the
profunda femoris artery.
■ The description of the perforator should include the size of perforator as it
exits the fascia, length of course to the profunda femoris, distance from
midline, and distance from gluteal crease. Additional information includes
location of the perforator in relation to gracilis, adductor longus, adductor
magnus, and semimembranosus.
SURGICAL MANAGEMENT
■ The authors perform PAP flap on patients either undergoing immediate or
delayed breast reconstruction.
■ Additionally, this procedure can be performed on patients who required
multiple flaps secondary to volume and skin deficit and require reconstruction
in a stacked fashion.6,7 This includes both patients having immediate stacked
reconstruction and patients who have autologous reconstruction that require
secondary augmentation in a delayed fashion.
■ Unilateral stacked PAP flaps have been described.8

■ Bilateral stacked deep inferior epigastric artery perforator (DIEP) and PAP
flaps have been described.6
■ PAP and augmenting prior superior gluteal artery perforator flap has also
been described.7
■ The technique has been shown effective on patients with body mass index
between 18.2 kg/m2 and 38.7 kg/m2, and flap weights have been shown
between 172 and 695 g.4,7,9
■ The operation requires loupe magnification for perforator dissection and
microsurgical instruments.
■ Though the microsurgical anastomosis can be performed under loupe
magnification, the authors prefer the use of the operative microscope.
Preoperative Planning
■ Some surgeons prefer to mark the patients in the office on the day prior to
surgery as the marking process is time-consuming.
■ Patients are marked in the standing position (FIG 4).
■ Based on preoperative images, a handheld Doppler can identify the main
perforators. If marked in the standing position, these perforator markings may
shift once positioned in the operating room. Therefore, similar to other
perforator flap elevations, this step may be unnecessary.
FIG 4 • Preoperative markings of profunda artery
perforator flap. An elliptical incision starting medially at
the adductor longus and laterally to the lateral edge of
the gluteal crease. The flap measures 6 to 7 cm in
width, and the perforators are identified with a handheld

Doppler and based on the distance from the gluteal
crease and the distance from midline.
■ The superior margin is marked at or approximately 1 cm below the gluteal
crease.
■ The inferior margin is marked 6 to 7 cm below the superior margin depending
on perforator location and skin pinch.
■ The horizontal markings are started laterally and carried medially in an ellipse
to capture the perforators and traditionally extend 25 to 35 cm.
■ The medial border is the medial border of the adductor longus.
■ The lateral border is the lateral border of the gluteal crease.
■ Additional fat that you would like to capture in the flap harvest should also be
noted during marking.
Positioning
■ Patient is positioned in the frog-leg position.
■ When initially described, patients underwent PAP harvest in the prone
position and then flipped to the supine position, but authors have moved
toward harvest in the supine position based on experience.
■ The entire leg is prepped and sterile sequential compression devices (SCDs)
are routinely placed. This allows manipulation of the leg throughout the
procedure.
Approach
■ Routinely, a two-team approach is required.
■ One team performs recipient artery exposure, internal mammary artery and
vein, thoracodorsal artery and vein, or serratus branches.
■ The second team performs flap harvest. This can be done either ipsilateral or
contralateral depending on comfort.
T E C H N I Q U E S
■ Profunda Artery Perforator Flap
Team 1

■ Harvest of the flap proceeds in a medial to lateral fashion.
■ The incision at the medial tip of the flap is made first. This is overlying the
adductor longus muscle. The flap is raised going laterally in subcutaneous
plane until the gracilis muscle is encountered. Gracilis perforators are often
encountered and if so they should be transected. If large, they can be
maintained until the PAP perforator is identified.
■ The muscular fascia overlying the gracilis is incised vertically (in the
direction of the muscle’s fibers) at the lateral/posterior border of the gracilis
and subfascial dissection continues (TECH FIG 1).
■ The gracilis is then retracted anteriorly, and the fascia overlying the adductor
magnus is identified and also incised.
■ Dissection proceeds in a subfascial plane going laterally/posteriorly until the
perforator is identified.
■ Once the perforator is identified, intramuscular (adductor magnus) perforator
dissection continues in a standard fashion.
■ Dissection stops at the origin on the profunda femoral artery. Occasionally,
dissection may be stopped earlier when the loose areolar plane at the end of
the adductor magnus muscle is encountered. Here, the length and caliber of
the vessels are usually adequate; however, you may dissect the perforator
back to the origin on the profunda femoral artery if inadequate.10
TECH FIG 1 • Profunda artery perforator intramuscular
dissection with staggered approach to maintain
adductor magnus viability and function. This
dissection was performed to the vessel origin.

Team 2
■ Exposure of the recipient vessels proceeds in the standard technique.
■ Rib-sparing and rib-sacrificing techniques have been described.11
PEARLS AND PITFALLS
Physical
findings
■ Preoperative imaging and marking remains the most important
part of the preoperative workup. Be careful with the height of the
markings as this could create tension on the closure. Additionally,
avoid extending the incision outside of the gluteal fold to maintain
a well-hidden scar.
Technique
■ Be prepared for the dominant perforator to be caudal within the
adductor magnus.
■ Pedicle dissection is often performed within a tunnel, and
therefore, great care must be taken to identify and control
posterior branches.
■ If the perforator is deep in the adductor magnus, then a stair-step
dissection can be performed from posterior and then a second
dissection point anterior to the adductor magnus.
Postoperative
■ Patients are maintained in a compression garment for the first
month following surgery.
Complications
■ Postoperative donor-site problems remain the most common
complication.
POSTOPERATIVE CARE
■ Patients routinely stay in the hospital for 3 to 4 days postoperatively.
■ Patients are monitored in a flap unit for the first 48 hours with q 1 hour
vascular checks.
■ Patients have routine transcutaneous Doppler checks, and monitoring can be
further augmented by other technologies based on surgeon preference.
■ Postoperatively, sitting is initiated on POD no. 1 in a beach-chaired position.
■ Patients are discharged home on postoperative aspirin for 30 days.
OUTCOMES
■ Outcomes of breast reconstruction with PAP flap are superior. The flap allows
for great coning of the breast as well as a soft contour on the chest. Patients

who have an abundant posterior thigh tissue and small breasts are the best
candidates for this type of reconstruction. The mean flap weights for this type
of reconstruction are in the mid-400 g (FIGS 5 and 6).
■ The new breast has the shape and feel of a natural breast.
■ The PAP flap offers a successful reconstruction in 97.1% to 99.4% of patients.
FIG 5 • A 39-year-old female with history of left breast
cancer who underwent bilateral mastectomy and
bilateral profunda artery perforator flap followed by
nipple reconstruction and tattooing. A. Preoperative AP
photo. B. Postoperative AP photo. C. Preoperative
posterior view. D. Postoperative posterior view.
COMPLICATIONS
■ Hematomas can occur in either the thigh donor site or the breast. They occur
in 1% to 2% of patients.7,9 If a hematoma occurs in the breast, concern for
venous congestion of the flap should be raised. Patients require reoperations for
hematomas in both the breast and the thigh donor site due to concern for
infection and direct pressure necrosis of the skin.
■ Total flap loss is a dreaded complication of breast reconstruction with PAP
flap. Fortunately, the reported incidences of total flap losses have been seen
between 0.6% and 2.9% of flaps.7,9 These complications can be associated
with arterial or venous thrombosis or difficulty with perforator dissection.
Prompt take back to the operating room is required for either revision of
arterial anastomosis or venous anastomosis in the cases of arterial or venous
insufficiency. These complications usually present in the first 24 to 48 hours.
■ Fat necrosis in fasciocutaneous flaps for breast reconstruction is
commonplace. In PAP flap reconstruction, the incidence has been reported

between 1.3% and 7.0%.7,9 Treatment of fat necrosis is variable and can
include revision with direct excision or liposuction.
FIG 6 • A 44-year-old female with history of right breast
cancer s/p bilateral nipple-sparing mastectomy and
immediate reconstruction with profunda artery
perforator flap. A. Preoperative AP view. B.
Postoperative AP view.
■ The most common complication associated with PAP flap breast
reconstruction remains donor-site complications. Dehiscence of the closure as
well as infection can occur at the donor site and occurs between 3.6% and
8.2% of donor sites. Treatment of these complications ranges from healing by
secondary intention to revision of donor-site scar closure in a secondary
procedure.
REFERENCES
1. Hurwitz DJ, Walton RL. Closure of chronic wounds of the perineal and sacral
regions using the gluteal thigh flap. Ann Plast Surg. 1982;8(5):375-386.
2. Angrigiani C, Grilli D, Siebert J, Thorne C. A new musculocutaneous island
flap from the distal thigh for recurrent ischial and perineal pressure sores. Plast
Reconstr Surg. 1995;96(4):935-940.
3. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept
based on the septocutaneous artery. Br J Plast Surg. 1984;37(2):149-159.
4. Allen RJ, Haddock NT, Ahn CY, Sadeghi A. Breast reconstruction with the
profunda artery perforator flap. Plast Reconstr Surg. 2012;129(1):16e-23e.

5. Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator location on
preoperative imaging for the profunda artery perforator flap. Microsurgery.
2012;32(7):507-511.
6. Mayo JL, Allen RJ, Sadeghi A. Four-flap breast reconstruction: bilateral
stacked DIEP and PAP flaps. Plast Reconstr Surg Glob Open. 2015;3(5):e383.
7. Haddock N, Nagarkar P, Teotia SS. Versatility of the profunda artery
perforator flap: creative uses in breast reconstruction. Plast Reconstr Surg.
2017;139(3):606e-612e.
8. Blechman KM, Broer PN, Tanna N, et al. Stacked profunda artery perforator
flaps for unilateral breast reconstruction: a case report. J Reconstr Microsurg.
2013;29(9):631-634.
9. Allen RJ Jr, Lee ZH, Mayo JL, et al. The profunda artery perforator flap
experience for breast reconstruction. Plast Reconstr Surg. 2016;138(5):968-
975.
10. Haddock NT, Gassman A, Cho MJ, Teotia SS. 101 Consecutive profunda
artery perforator flaps in breast reconstruction: lessons learned with our early
experience. Plast Reconstr Surg. 2017;140(2):229-239.
11. Haddock NT, Teotia SS. Five steps to internal mammary vessel preparation in
less than 15 minutes. Plast Reconstr Surg. 2017; 140(5):884-886.

28
CHAPTER
Transverse Upper Gracilis
Flap for Breast
Reconstruction
Adeyiza O. Momoh
DEFINITION
■ The transverse upper gracilis (TUG) flap is a medial thigh–based
musculocutaneous flap option for breast reconstruction.
■ It serves as a second- or third-line autologous flap option in patients who lack
abdominal donor tissue necessary for breast reconstruction (FIG 1).
■ The TUG flap is typically used to reconstruct small to moderate-sized breasts
based on limitations of medial thigh soft tissue volume.
ANATOMY
■ The flap is based on the medial circumflex femoral vessels, which branch off
the profunda femoris vessels.
■ The ascending branch of medial circumflex femoral reliably perfuses the
gracilis muscle and skin/adipose tissue of the upper medial thigh, extending
from just medial to the femoral neurovascular bundle to the midline of the
posterior infragluteal region.
■ The flap pedicle is located at the anterior border of the gracilis and can be
found approximately 8.5 cm inferior to the pubis.1
■ The pedicle length is relatively short averaging 6.7 cm, with an average
arterial diameter of 2.2 mm and average venous diameter of 2.3 mm.
■ Anterior to the gracilis muscle, the pedicle runs deep to the adductor longus
muscle and comes off the profunda femoris just anterior to the adductor longus.
■ A transverse skin paddle measuring 30 × 10 cm is possible2; a vertical skin
paddle extension positioned directly over the central aspect of the gracilis can
be included to gain additional volume1 (FIG 2).

PATIENT HISTORY AND PHYSICAL FINDINGS
■ A detailed medical history is necessary given that there is a potential for a
lengthy operation under general anesthesia.
■ The surgeon should be aware of all medications that might have an impact on
the operation and recovery such as anticoagulants, tamoxifen, and
chemotherapeutic medications; also important to assess is the patient’s
smoking history and the presence of hypercoagulable conditions.
■ The history should then focus on details of the patient’s breast pathology and
reasons for mastectomy. This should also include information on neoadjuvant
or planned adjuvant treatment following mastectomy in the setting of
immediate reconstruction.
■ Prior treatments to the breast and chest wall including radiation therapy and
the time from the last treatment should be discussed in cases of delayed breast
reconstruction.
FIG 1 • A–F. Patient with left breast cancer who is to
undergo bilateral mastectomies with immediate
autologous breast reconstruction. She has limited tissue
for an abdominal-based flap reconstruction. Her thigh
soft tissue is a good option for small-sized breast
reconstructions.

FIG 2 • Illustration demonstrating the flap skin paddle
design and vascular anatomy.
■ Information on prior operations to the chest or breast and the potential donor
sites (in this case the thighs) should be elicited.
■ In addition to the breast examination assessing breast size, degree of ptosis,
and base width, the patient should be asked about her desired breast size
postreconstruction.
■ With an appreciation of the patient’s desired size, the medial thighs/posterior
thigh can be assessed, palpating and gently pinching to determine the
possibility of achieving the desired volume.
IMAGING
■ There is limited value to routine preoperative imaging of recipient vessels or

the flap vasculature in the absence of a history that suggests potential
compromise. CT angiography is currently the imaging modality of choice for
recipient or donor-site vascular studies.
SURGICAL MANAGEMENT
■ The author performs immediate breast reconstruction with two teams, the
oncologic and reconstructive team, working simultaneously. Flap harvest is
performed while the mastectomies are performed.
■ The goal of the first operation is the free tissue transfer to establish the breast
mound. In cases of unilateral breast reconstruction, contralateral procedures for
symmetry are performed in a subsequent procedure.
Preoperative Planning
■ Appropriate referrals and consultations should be made for clearance and
patient optimization prior to surgery based on the history and physical.
■ The risks and benefits of breast reconstruction using tissue from the medial
thighs should be discussed, including the risk for flap loss, medial thigh scars
that drift low onto the thighs and that could widen.
■ Preoperative markings of the breasts and thighs are performed prior to
returning to the operating room.
■ Markings of breast landmarks including the midline and inframammary folds
and the planned incisions for mastectomy are performed with the patient
sitting.
■ The thighs are marked with the patient standing to visualize the inguinal and
gluteal crease. The patient also externally rotates the thigh to aid with the
markings. The upper marking is approximately 1 cm inferior to the inguinal
and gluteal crease. A pinch test is performed just posterior to the gracilis to
determine how far inferior the lower marking can be made over the medial
thigh. This marking extends anterior and posterior, tapering to end medial to
the femoral neurovascular bundle (anteriorly) and the midline of the posterior
thigh.
Positioning
■ The entire procedure is performed with the patient in supine position. The
arms are extended and secured to arm boards.
■ To aid with space for the two-team approach, the operating table is turned 180
degrees such that the patient’s head is furthest from the anesthesiologist.

Approach
■ Flap harvest is performed from an anterior to posterior approach, and the hips
are flexed and externally rotated (frog legged) for portions of the case as
needed (FIG 3).
FIG 3 • Positioning of the hip in flexion and external
rotation to provide exposure of the medial thigh for flap
harvest.
T E C H N I Q U E S
■ Flap Harvest
Dissection
■ An incision is made along the anterior half of the superior skin paddle
markings.
■ Bovie electrocautery is then used to dissect through the dermis and
subcutaneous tissue down to the muscles of the medial thigh. The gracilis
muscle and the adductor longus (just anterior to the gracilis) are identified.
■ Once the gracilis is identified, dissect inferiorly along its anterior border to
identify the circumflex femoral vessels (TECH FIG 1A).
■ With identification of the vascular pedicle, the inferior skin paddle incision
for the anterior half of the flap is completed with a scalpel. A Bovie is then
used to dissect down to the muscle fascia inferiorly.

■ The flap is then elevated from anterior to posterior in the suprafascial plane
until the saphenous vein is encountered. The saphenous vein is preserved and
the dissection plane deepened posterior to the vein and over the adductor
longus muscle.
■ At the anterior border of the gracilis, the adductor longus muscle is retracted
anteriorly with Army-Navy retractors, and dissection of the vascular pedicle
identified earlier is performed.
■ Vessel branches from the pedicle to the underside of the adductor longus are
isolated, ligated with clips, and divided (TECH FIG 1B).
■ Additional dissection of the flap pedicle is performed from the anterior
border of the adductor longus, exposing the pedicle all the way to the
profunda femoris.
Flap Elevation
■ With the flap pedicle completely dissected out, elevation of the posterior half
of the skin paddle can then be performed.
■ The hip is flexed providing exposure of the posterior thigh, and incisions
along the superior and inferior markings for the posterior half of the flap are
made.
■ A Bovie is then used to elevate the flap from the posterior toward the
anterior aspect of the flap. All fat superficial to the semimembranosus and
semitendinosus muscles is captured from the posterior thigh region, which is
where most of the volume of the flap resides.
■ Elevation over the adductor magnus to the posterior border of the gracilis
ends the posterior flap elevation.
■ Dissection underneath the gracilis muscle is then performed bluntly.
■ Suprafascial dissection over the gracilis is performed distally toward the
knee for the desired length of the gracilis to be harvested with the flap.
■ On the more distal anterior border of the gracilis, the minor pedicle to the
gracilis is identified, ligated with hemoclips, and divided.
■ The gracilis is then divided distally underneath the medial thigh skin and
proximally through the superior incision.
■ At this point, the flap is fully elevated and only tethered to the thigh by its
vascular pedicle (TECH FIG 2).
■ The artery and veins (two venae comitantes) are ligated with clips just distal
to the takeoff from the profunda femoris, and the vessels are divided with
tenotomy scissors.

TECH FIG 1 • A. Early identification of the circumflex
femoral vessels through a limited superior incision
prior to proceeding with additional incisions and flap
elevation. B. Isolation of the length of the circumflex
femoral vessels as they run underneath the adductor
longus muscle (retracted).
TECH FIG 2 • Fully elevated flap with division of the
proximal and distal gracilis muscle.
Flap Preparation and Placement
■ The flap is taken to a back table, where it is flushed with copious amounts of
heparinized saline from the arterial end.
■ Shaping of the flap is then performed on the back table, folding the superior
border of the skin flap on itself and creating a circular-appearing flap (TECH
FIG 3A–C).

■ Flap skin edges are approximated with interrupted deep dermal sutures.
■ The internal mammary vessels (the author’s preferred recipients) are
exposed with excision of the medial cartilaginous segment of the 3rd or 4th
rib (see chapter on recipient vessel exposure).
■ The flap is positioned on the chest wall such that the gracilis muscle will be
inset in the superior pole of the breast. The flap is temporarily secured to the
chest wall skin with Vicryl sutures (TECH FIG 3D,E).
■ With the aid of an operating microscope, the veins are coupled and the
arteries hand-sewn in an end-to-end fashion.
■ Once reperfused, the flap is advanced into the mastectomy defect and
secured to the pectoralis fascia with interrupted Vicryl sutures to avoid
traction on the short pedicle.
Completion
■ De-epithelialization of the flap skin is performed as needed, a drain is placed
within the mastectomy defect, and skin edges are approximated in layers.
■ A Doppler signal is identified and marked with a 5-0 Prolene suture.
■ The donor site is then irrigated and a drain is placed in the upper thigh
defect.
■ Closure of the thigh donor site is performed in layers. Colles fascia
(superiorly) is approximated to the deep fascia of the skin flap at the inferior
border of the defect. The deep dermis and subcuticular layers are then
approximated (TECH FIG 4).
■ Skin glue is then applied to the donor-site incision to minimize dressings that
have to be placed in this region of the thighs.

TECH FIG 3 • A–C. Shaping of the harvested flap to
create a circular and conical mound that mimics the
excised breast tissue. D,E. An option for positioning of
the shaped flap on the chest wall for the microvascular
anastomosis. The flap is placed within the
mastectomy defect in this orientation with the distal
gracilis muscle placed in the upper pole of the breast.

TECH FIG 4 • A,B. On table result after inset of flaps
and closure of thigh donor sites.
PEARLS AND PITFALLS
Harvest
technique
■ Early identification of the gracilis and the flap pedicle through the
superior incision allows for rapid subsequent flap elevation.
Microsurgery
■ As the flap pedicle is relatively short, plan on providing exposure
of at least the entire length of the internal mammary vessels
between two adjacent ribs.
■ To address the expected arterial size mismatch (medial circumflex
femoral artery smaller than the IMA), consider exposure of the
IMA at the 4th rib instead of the 3rd.
■ Plan on spatulating the flap artery to account for the size mismatch.
Donor site
■ Efforts should be made to anchor the inferior thigh skin flaps to the
Colles fascia to avoid inferior scar migration and widening.
Skin paddle
■ The TUG flap skin paddle is at times darker than breast skin and
may grow hair in some patients.
■ The darker color may obviate the need for tattooing in cases of
immediate reconstruction where the skin paddle is used for nipple
reconstruction.
■ Laser therapy might be needed to limit hair growth.
POSTOPERATIVE CARE

■ The head of the bed and consequently the patient’s breasts are placed in slight
elevation of 30 degrees or greater.
■ Patients are transferred from the OR to the postanesthesia care unit and
subsequently to a surgical floor where monitoring can be performed.
■ Prior to leaving the operating room, flap monitoring is initiated with
continuous near-infrared spectroscopy (NIRS) tissue oximetry. This is
continued for 72 hours postoperatively.
■ Serial Doppler assessments are also performed in addition to standard flap
physical examinations (color, temperature, capillary refill) every hour for the
first 24 hours. Flap evaluations are then spaced out to every 2 hours and 4
hours on postoperative days 2 and 3, respectively.
■ Daily aspirin and DVT prophylaxis (subcutaneous injections) are the only
forms of anticoagulation used routinely.
■ Diet is advanced from clear liquids to a regular diet on postoperative day
(POD) 1 with restrictions to caffeine intake.
■ Patients are assisted out of bed to a chair on POD 1 and ambulate on POD 2;
Foley catheters, intravenous fluids, and medications are discontinued on POD
2.
■ Patients are discharged home on POD 3 to POD 5 with outpatient follow-up
scheduled a week after discharge.
OUTCOMES
■ Success rates ranging from 96% to 100% have been reported in larger series in
the literature.2–5
■ Soft and aesthetically pleasing breast reconstructions are achieved with the
TUG flap (FIG 4).
■ A good number of flaps, however, require some fat grafting to address contour
abnormalities and volume deficiencies (FIG 5).
■ Satisfaction with TUG flap reconstructed breasts from the patient’s perspective
is high; patient satisfaction with the donor site is similarly high, even when
scars are visible5 (FIG 6).
COMPLICATIONS
■ Thigh donor-site wound dehiscence, delayed wound healing, and suture
fistulae are common complications, particularly when the limits of skin paddle
width are pushed.5
■ Inferior displacement of donor-site scars results in scars that cannot be hidden

(FIG 7); revisions might be necessary to reposition scars, anchoring the soft
tissue to Colles fascia or the periosteum of the pubis.
■ Pain along the scar, posterior thigh hypesthesia, and traction on the labia
majora are also noted donor-site complications that have an impact on quality
of life and sexuality.5
■ Donor-site seromas are possible with disturbance of the upper thigh
lymphatics but can be avoided by staying medial to the neurovascular bundle
with the anterior flap elevation.
FIG 4 • A–D. Postoperative result after immediate TUG
flap reconstruction with subsequent fat grafting and
nipple reconstructions.

FIG 5 • A–D. Patient with right breast cancer who
underwent a right mastectomy with immediate TUG flap
reconstruction. Volume deficiencies at the superior and
superolateral poles of the breast will require autologous
fat grafting.

FIG 6 • A,B. Upper thigh donor-site scars that are
visible in undergarments.
FIG 7 • A,B. Significant inferior displacement of an
upper thigh donor-site scar.
REFERENCES
1. Wong CS, Mojallal A, Bailey SH, et al. The extended transverse
musculocutaneous gracilis flap: vascular anatomy and clinical implications.
Ann Plast Surg. 2011;67:170-177.
2. 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.
3. 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.
4. Vega SJ, Sandeen SN, Bossert RP, et al. Gracilis myocutaneous free flap in
autologous breast reconstruction. Plast Reconstr Surg. 2009;124:1400-1409.
5. Graggs B, Vanmierlo B, Zeltzer A, et al. Donor-site morbidity following
harvest of the transverse myocutaneous gracilis flap for breast reconstruction.
Plast Reconstr Surg. 2014;134:682-691.

29
CHAPTER
Skate Flap for Nipple
Reconstruction
Katie E. Weichman
DEFINITION
■ Nipple-areolar reconstruction is the final stage of postmastectomy
reconstruction. This procedure has been shown to positively influence overall
satisfaction with breasts and outcomes in several series and transforms the
mound to a breast.1,2
■ The skate flap is a commonly performed technique in both implant and
autologous reconstruction.
■ This local flap was first described by J. W. Little in 1994 for nipple
reconstruction after mastectomy and breast reconstruction.
■ Further modifications of this flap have been described by Cordeiro for
primary use in implant reconstruction and Hammond for use in autologous
reconstruction.3,4
■ Although there are several additional iterations of the skate flap, the author
prefers these two techniques.
■ The Cordeiro modification to the skate flap has two main advantages.
■ It avoids elevating the body of the flap with a central wedge of subcutaneous
fat as initially described by Little. The central wedge of subcutaneous fat
creates a defect that requires primary closure, resultant fat undermining, and
significant deformation of the remaining areola. The Cordeiro technique
incises through only the epidermis, dermis, and subcutaneous fat without any
undermining, resulting in a central subcutaneous stalk for volume without a
secondary defect.
■ A tripoint stitch to the dermal platform is used when the two skate wings are
sutured together at the 6 o’clock position.
■ Hammond’s modification to the skate flap provides the ideal nipple

reconstruction for autologous reconstruction. This technique provides a nipple
with adequate bulk and long-term projection but uniquely allows for primary
closure of the donor site with minimal distortion of the breast.
■ This technique requires experience with the purse-string technique in breast
reduction and mastopexy.
ANATOMY
■ The skate flap is a local flap with a pedicle of epidermis, dermis, and
subcutaneous fat centered at the site of the desired future nipple. The skate flap
is named based on skin flaps that are shaped like wings of a skate fish (FIG 1).
■ Blood supply
• Subdermal plexus
• Subcutaneous plexus
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients undergoing skate flap nipple reconstruction have reached the end of
the reconstructive process.
■ Indications: A history of breast cancer requiring mastectomy, prophylactic
mastectomy, congenital abnormalities, and transgender patients who have had
mastectomy with complications associated with silicone injection
■ History of radiation therapy or need for further radiation therapy should be
considered when deciding timing of nipple reconstruction.
■ Patients should not be actively smoking for at least 3 months prior to surgery.
■ Patients should have a final breast mound without need for further revision.
■ Nipple reconstruction should be performed when the breast has taken its final
form and has adequately settled to prevent malposition.
■ This timing is least 3 months to 6 months after either the direct to implant
reconstruction, tissue expander exchange for implant, or the autologous
reconstruction. All revisions of the breast mounds should be performed prior
to nipple reconstruction.
■ Revision of autologous reconstruction can often be performed synchronously
with nipple reconstruction; however, assuring correct nipple position can be
more challenging with an increased incidence of nipple malposition requiring
further revision.
SURGICAL MANAGEMENT
■ The authors perform skate flaps for nipple-areolar reconstruction when the

nipple-areolar complex is absent.
■ Patients who desire larger nipples and agree to harvest of full-thickness skin
graft from a secondary donor site (abdomen, inner thigh, or lateral chest wall
roll) should be considered for the Cordeiro modification. Patients with
autologous reconstruction should be considered for the Hammond
modification.
FIG 1 • A. Skate fish. B. Skate flap centered on breast
mound. D represents the diameter of nipple and pedicle
of nipple; H represents the desired height of the nipple.
The length of the flap wings measures at least 3D, and
the height of wings measures 2H.

FIG 2 • A. Traditional landmarks for nipple position.
Sternal notch to nipple distance of 19 to 21 cm.
Distance from midline to nipple measuring 9 to 11 cm.
Distance from nipple to inframammary fold measuring 7
to 8 cm. B. Ideal nipple position in asymmetric breasts.
Maintain ratios of nipple in relation to the medial breast
border, lateral breast border, inframammary fold, and
superior breast extent.
■ A 50% reduction of the nipple projection should be anticipated, and therefore,
skate flap should be designed accordingly based on patient preference and
contralateral nipple size in unilateral reconstructions.5,6
Preoperative Planning
■ Patients are marked in the standing position with shoulders relaxed in the
preoperative holding area.
■ Nipple position should be centered on the breast at the point of maximal
convexity and projection. Additionally, it should be symmetric to the
contralateral nipple in unilateral reconstructions. In bilateral reconstructions,
nipple position is often easier to match, and the location is less critical as long
as it is symmetric and located on the center of the breast.
■ Specific landmarks are often helpful in determining the correct position of the
nipple-areolar complex on the breast. These include the level of the
contralateral nipple-areolar complex, the position at the Pitanguy point
(reflection of the inframammary fold), and triangle from the sternal notch to
nipple/midsternal line (FIG 2A).
■ When breasts are asymmetric, the surgeon should try to maintain the ratios of
the nipple to the breast footprint. This includes midline, lateral breast, superior
breast, and inframammary fold (FIG 2B).
Positioning
■ The patient is positioned in supine position. Surgery should be performed in
the operating room because a full-thickness skin graft is needed to cover the
nipple site.

T E C H N I Q U E S
■ Cordeiro Modification of the Skate Flap
Flap Design
■ Generally, the desired diameter of the nipple is designed to be 1 cm. The
nipple is marked based on the above guidelines and is confirmed by both the
surgeon and the patient as being in an acceptable position.
■ The use of an EKG lead, as a surrogate for the nipple-areolar
reconstruction, is routinely used in the preoperative area (TECH FIG 1A).
■ In unilateral reconstruction, the diameter of the areolar is matched to the
contralateral breasts and is generally 38, 42, or 48 mm. A cookie cutter
template is used to create a perfect circle (TECH FIG 1B).
■ In bilateral reconstruction, choice between 38 and 42 mm is made by the
surgeon and patient, and the cookie cutter template is used to create a perfect
circle.
■ The axis of the skate flap is designed so that the mastectomy scar does not
cross either the wings or body of the flap.
■ A horizontal line is then drawn cephalad or cranial to the desired nipple
location depending on the mastectomy scar to form a hemicircle that will be
de-epithelialized and the opposite hemicircle that will be used to construct
the skate flap.
■ Based on this, the nipple reconstruction will be superiorly or inferiorly
oriented based on the mastectomy scar (TECH FIG 1C,D).
■ The body of the skate flap is the 1- x 1-cm square outlining the nipple
centrally.
■ The wings of the skate flap are the two triangles just outside the body
peripherally.
■ Full-thickness skin graft is designed using the same 38-, 42-, or 48-mm
cookie cutter template used in skate flap design.
■ Donor sites include groin, abdomen, and lateral chest wall dog-ear. The
groin has been shown to have the best areolar color match; however, donor
site can be unacceptable to some patients.4

TECH FIG 1 • A. Preoperative use of ECG leads to
confirm desired nipple-areolar position. B. Design of
Cordeiro modification of the skate flap. Nipple position
is marked with 1-cm diameter circle at the appropriate
point. D represents the diameter of the areola, and the
areolar is marked using a cookie cutter template of
appropriate size (38, 42, or 48 mm) based on
contralateral side. Base of the flap is the 1-cm

representation on the line cranial to the nipple
measuring the diameter of the circle. The superior
hemicircle (yellow) is de-epithelialized, and the inferior
hemicircle (blue) is elevated in the subcutaneous
plane to become the skate flap. C,D. Position of
nipple-areolar complex in relation to mastectomy scar.
(C) Cranial scar position resulting in superiorly based
skate flap. (D) Caudal scar position resulting in
inferiorly based skate flap.
Elevating and Insetting the Flap
■ The hemicircle that is opposite the base of the skate flap is incised and de-
epithelialized (TECH FIG 2A).
■ The wings of the skate flap are then incised and raised in the deep dermal
plane until the peripheral margin of skate body is reached and then the plane
is deepened into the subcutaneous plane (TECH FIG 2B).
■ Subcutaneous fat is included to improve nipple projection.
■ Once the skate body is fully elevated, the wings of the skate flap are
wrapped around the skate body to form a cylinder 1 cm in height, with a
diameter of 1 cm, using 4-0 chromic sutures (TECH FIG 2C).
■ The cap of the nipple is then closed, and excess dog-ears are excised and
closed using 4-0 chromic sutures (TECH FIG 2D).
■ Full-thickness skin graft is marked in situ to proper positioning of 12, 3, 6,
and 9 o’clock and the center of the graft.
■ Adequate preparation and thinning of the full-thickness skin graft is
necessary for complete skin graft take.
■ The full-thickness skin graft is then sewn down onto the areolar bed using a
running 5-0 Prolene suture (TECH FIG 2E).

TECH FIG 2 • Intraoperative steps of skate flap
elevation. A. De-epithelialization of superior
hemicircle. B. Raising skate flap wings in
subcutaneous plane. C. Wrapping of skate flap wings
to create the nipple. D. Folding cap over nipple and
trimming of lateral dog-ears. E. Securing full-thickness
skin graft into place over areolar bed. F. Delivery of
nipple through areolar skin graft. G. Irrigation with
angiocatheter under pie-crusted full-thickness skin
graft.
■ A circular hole is then made in the center of the skin graft to allow the
delivery of the nipple through the areolar graft (TECH FIG 2F).
■ The nipple is then sewn down to the graft with 4-0 chromic suture.
■ Pie crusting of the graft is then performed with either small sharp scissors or
a no. 11 blade scalpel.
■ Irrigation with saline and a flexible 20-gauge angiocath is then performed to
remove any debris (TECH FIG 2G).
■ A bolster-type dressing is created and placed.
■ Hammond Modification of the Skate Flap
Flap Design
■ The desired nipple diameter is generally 1 cm, and the flap is drawn with the
measured vertical height designed to be 2 times the projection of the opposite
nipple based on an approximate loss in projection in the long term of 50%7

(TECH FIG 3A).
■ The diameter of the skate flap (or horizontal width) is measured to provide
the desired areolar diameter, usually between 40 and 50 mm.
■ The vertical cap is drawn as a smooth oval and the height is generally equal
to the vertical height of the skate flap wings (generally 1 cm) to allow this to
come over the top of the flap without tension (TECH FIG 3B).
■ The inferior areolar skin is marked from the midpoint of the skate flap wings
at 90 degrees with the radius of the desired areolar diameter (eg, radius is 21
mm in a 42-mm desired areola)
■ A gentle arc connects the point to the medial and lateral limits of the width
of the skate flap.
■ The superior areolar skin is marked from the center of the cap extending
superiorly with the same radius (eg, radius of 21mm in a 42-mm desired
areola).
■ Again, the gentle arc connects the superior extent to the medial and lateral
limits of the width of the skate flap.
Elevating and Insetting the Flap
■ All incisions are made full thickness through the dermis (TECH FIG 4A).
■ The skate flap wings are elevated with an even layer of fat; usually only 1 to
2 mm of fat are included (TECH FIG 4B).
■ The central cap of the skate is elevated just at the level of the dermis.
■ The superior and inferior areolar skin islands are then further released and
closed using 3-0 Monocryl sutures (TECH FIG 4C).
■ The wings of the skate flaps are de-epithelialized or trimmed, depending on
the desired amount of projection, and are then wrapped around the base and
sutured together using 4-0 chromic sutures (TECH FIG 4D).
■ The cap is then closed over the top and closed using 4-0 chromic sutures
(TECH FIG 4E).
■ Using a CV-3 Gore-Tex suture on a Keith needle, a purse-string suture is
placed within the deep dermis of the surrounding peripheral edges of the
periareolar pattern.
■ The knot requires at least 10 throws and must be buried.

TECH FIG 3 • A. Design of Hammond flap
modification. Routinely, the radius (R) is measured to
be 21 mm and the diameter (D) is marked at 42 mm.
The projection (P) is generally marked at 1 cm. In
most instances, C (cap length) will equal the
projection of the nipple to allow for a tension-free
closure. Redundant flap is crossed out. The center of
the nipple is indicated in red. B. Intraoperative
markings of Cordeiro modifications of skate flap with
abdominal harvest of full-thickness skin graft.
TECH FIG 4 • Intraoperative steps of Hammond
purse-string skate flap elevation. A. Full-thickness
incisions of construct, excluding base of skate flap. B.

Skate flap wing elevation in the subcutaneous plane.
C. Primary closure of superior and inferior areolar skin
islands after elevation of skate flap wings. D. Wrap of
skate flap wings to the midline and closure. E. Cap
closure. F. Closure of periareolar purse string. G.
Dressing with eye patch and adhesive dressing.
■ After the purse-string sutures have been drawn closed, the skin is closed
with a running, subcuticular 4-0 absorbable monofilament suture with a taper
needle (TECH FIG 4F).
■ Usual dressings are placed over the skin incisions, and the nipple
reconstruction is covered with an eye patch and an adhesive dressing (TECH
FIG 4G).
PEARLS AND PITFALLS
Physical
findings
■ Nipple position on asymmetric breasts remains a great challenge.
■ Obtain breast symmetry PRIOR to nipple-areolar reconstruction.
■ Radiation proves challenging, and nipple reconstruction should be
only undertaken if there was resolution of acute radiation changes,
no evidence of late radiation changes, and appropriate thickness of
mastectomy skin flaps.8
Technique
■ Preoperative marking in the standing position with shoulders
relaxed is pivotal and the most important part of a successful
operation. If markings are made with shoulders abducted, the
nipple-areolar complex may be displaced superiorly and laterally,
and if made with the shoulders hunched, the nipple will be too
high postoperatively.
■ Preoperative markings must LOOK right. Proper appearance
should supplant measurements.
■ It is far better for nipple position to be low and lateral rather than
high or medial.
■ The axis of the skate flap must be designed so that the
mastectomy scar does not cross the wings or the body of the flap.
■ Full-thickness skin grafts must be appropriately thinned for best

take.
■ In the Hammond technique, using the Gore-Tex for the purse
sutures requires at least 10 knots and buried knots.
■ Subcuticular running layer should be done with TAPER needle so
as not to cut the Gore-Tex suture.
■ Tension-free closure of donor site is imperative and prevents both
nipple flattening and distortion of breast mound.
Postoperative
■ The Cordeiro modification with full-thickness skin graft requires
compressive bolster dressing to remain watertight and partial graft
loss is possible.
■ Projection loss is estimated to be about 50%; therefore, nipples
are often designed to be overprojecting. Occasionally, a minor
revision in the office setting is necessary if the reconstructed
nipple maintains too much projection.
Complications
■ Postoperative donor site problems remain the most common
complication.
■ Early dressing changes and showers after 48 h are recommended.
FIG 3 • This 47-year-old woman had cancer of the right
breast and underwent right mastectomy with tissue
expander reconstruction followed by breast
reconstruction with the Cordeiro modification of the
skate flap. A. Preoperatively. B. After mastectomy and
implant exchange. C. Eight months after skate flap
reconstruction of right breast.
POSTOPERATIVE CARE
■ Patients routinely have occlusive dressings in place for 5 to 7 days.

■ Avoid compression to the NAC, which can affect ultimate projection of the
nipple.
OUTCOMES
■ Skate flaps for nipple reconstruction provide good projection with minimal
complications in patients undergoing nipple reconstruction after mastectomy.
■ Overall decrease in projection is noted to be between 50% to 75% over time.4
■ Patients undergoing the Cordeiro modification have good long-term results
and projection (FIG 3).
■ Similarly, patients undergoing the Hammond purse-string modification have
good long-term results and symmetry (FIG 4).
■ Secondary revision in patients with too much projection is possible and
requires a small in-office procedure to decrease the projection.
COMPLICATIONS
■ Cordeiro modification complications
■ Major complications are possible but very rare and include
• Complete necrosis of nipple or skin graft
• Infection of the implant
• Implant extrusion
■ In the Cordeiro modification, rates of minor complications are low and seen
in around 7%.
• These include donor site complications (dehiscence, infection, and cyst
formation).
• Recipient complications are very rare and include partial graft loss.
■ Hammond modification complications
■ Donor site dehiscence and local wound problems can occur.
■ Additionally, the desired areola may become ovoid instead of round
secondary to tension on the closure and tissue underneath. The tattoo can help
with the problem.

FIG 4 • This 43-year-old woman had cancer of the left
breast and underwent bilateral mastectomy and DIEP
flap reconstruction followed by Hammond flap
reconstruction. A. Preoperatively. B. After mastectomy
and DIEP flap. C. Eight months after skate flap breast
reconstruction.
REFERENCES
1. Momoh AO, Colakoglu S, de Blacam C, et al. The impact of nipple
reconstruction on patient satisfaction in breast reconstruction. Ann Plast Surg.
2012;69(4):389-393.
2. Wellisch DK, Schain WS, Noone RB, Little JW 3rd. The psychological
contribution of nipple addition in breast reconstruction. Plast Reconstr Surg.
1987;80(5):699-704.
3. Hammond DC, Khuthaila D, Kim J. The skate flap purse-string technique for
nipple-areola complex reconstruction. Plast Reconstr Surg. 2007;120(2):399-
406.
4. Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection
using the modified skate flap for nipple-areolar reconstruction in a series of
422 implant reconstructions. Ann Plast Surg. 2009;62(5):591-595.
5. Hallock GG, Altobelli JA. Cylindrical nipple reconstruction using an H flap.
Ann Plast Surg. 1993;30(1):23-26.
6. Little JW 3rd, Munasifi T, McCulloch DT. One-stage reconstruction of a
projecting nipple: the quadrapod flap. Plast Reconstr Surg. 1983;71(1):126-
133.
7. Yang JD, Ryu JY, Ryu DW, et al. Our experiences in nipple reconstruction
using the hammond flap. Arch Plast Surg. 2014;41(5):550-555.

8. Draper LB, Bui DT, Chiu ES, et al. Nipple-areola reconstruction following
chest-wall irradiation for breast cancer: is it safe? Ann Plast Surg.
2005;55(1):12-15.

30
CHAPTER
C-V Flap for Nipple
Reconstruction
Katie E. Weichman
DEFINITION
■ Nipple-areolar reconstruction is the final stage in the process of
postmastectomy reconstruction.
■ This procedure has been shown to positively influence overall satisfaction with
breasts and outcomes in several series and transforms the mound to a breast.1,2
The C-V flap is the most commonly performed technique in both implant and
autologous reconstruction.
■ This local flap was first introduced in 1994 by Bostwick for use in nipple
reconstruction after mastectomy and breast reconstruction.3 Long-term results
with this technique were further shown by Losken and Bostwick in 2001.4
■ The C-V flap evolved from the skate flap but uniquely allows primary closure
of the donor site.
■ The main advantage of this technique is that the full-thickness skin graft is not
required.
■ The main limitation is maintenance of projection of the C-V flap, as the
thickness of the subcutaneous tissue and dermis is the main determinant of
nipple projection. The loss of intraoperative volume has been shown to be up
to 50%.5
■ Further modifications of this flap to maintain and increase projection have
been described and include using rolled triangular dermal fat flaps, a “Swiss
roll” flap, V-V flap, CC-V flap, and C-V-M flap.6–10
ANATOMY
■ The C-V flap is a local flap with a pedicle of epidermis, dermis, and
subcutaneous fat centered at the site of the desired future nipple. The basic

concept of the C-V flap is that the nipple consists of three flaps: 2 V flaps and 1
C flap.
■ Blood supply
• Subdermal plexus
• Subcutaneous plexus
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients undergoing C-V flap nipple reconstruction have reached the end of the
reconstructive process.
■ Patients having a history of breast cancer requiring mastectomy, prophylactic
mastectomy, and congenital abnormalities and transgender patients who have
had mastectomy with complications associated with silicone injection are
indicated for the procedure.
■ History of radiation therapy or need for further radiation therapy should be
considered when deciding timing of nipple reconstruction.
■ Patients should not be actively smoking at least 3 months prior to surgery.
■ Patients should have a final breast mound without need for further revision.
■ Nipple reconstruction should be performed when the breast has taken its final
form and has adequately settled to prevent malposition.
■ This timing is least 3 to 6 months after either the direct to implant
reconstruction, tissue expander exchange for implant, or the autologous
reconstruction. All revisions of the breast mounds should be performed prior
to nipple reconstruction.
■ Revision of autologous reconstruction can often be performed synchronously
with nipple reconstruction; however, ensuring correct nipple position can be
more challenging with an increased incidence of nipple malposition requiring
further revision.
SURGICAL MANAGEMENT
■ The authors perform C-V flaps for nipple-areolar reconstruction when the
nipple-areolar complex is absent.
■ A 50% reduction of the nipple projection should be anticipated, and therefore,
C-V flap should be designed accordingly based on patient preference and
contralateral nipple size in unilateral reconstructions.4,5
Preoperative Planning
■ Patients are marked in the standing position with shoulders relaxed.