Phẫu Thuật Tạo Hình (Tập 5): Tuyến Vú – Neligan (2018)

356
SECTION II
CHAPTER 20.4 • The free TRAM flap
20.4.3). It is critical to ensure that the location and caliber
of the perforating vessels are sufficient to safely perfuse
the required flap volume. In the event that the perfora-
tors are deemed inadequate, a muscle-sparing free
TRAM is usually performed to capture more perfora-
tors. It is explained during the initial consultation that
most outcome studies have demonstrated no clinically
relevant functional difference between the free TRAM
and DIEP flaps (Table 20.4.4). Patients are told that a
unilateral free TRAM flap may take 4–6 h and a bilateral
free TRAM may take 6–8 h to complete; however, these
times are variable and based on surgeon and hospital
experience. Patients are usually hospitalized for 3 days
following free TRAM reconstruction and instructed to
refrain from strenuous activity for 6 weeks.
Patient markings
Patients are marked in the standing position (Figs.
20.4.10 & 20.4.11). The breast markings include the
sternal midline and the inframammary folds bilaterally.
The mastectomy incisions depend on whether mastec-
tomy is skin-sparing or nipple-sparing as well as
whether the reconstruction is immediate or delayed.
With delayed reconstruction, the prior mastectomy scar
likelihood of radiation therapy exceeds 50%, the
delayed-immediate approach using a tissue expander is
considered. Conversion to an autologous microvascular
reconstruction is performed 6–12 months following
radiation. This time interval is recommended because
of the perivascular inflammation that may be present
along the recipient vessels following radiation therapy.
The topic of complications is discussed and reviewed
with all women.14–24 Following free TRAM flap recon-
struction, success rates typically range from 97% to 99%.
Factors related to anastomotic or flap failure includes
vascular thrombosis, poor vessel quality, and iatrogenic
injury. The risk of an abdominal bulge following a free
TRAM flap ranges from 3–5% following a unilateral and
5–7% following a bilateral reconstruction. This is related
to various factors that include the amount of anterior
rectus sheath excised, residual muscle innervation, and
the use of mesh reinforcement. The use of a synthetic
mesh to reinforce the closure is sometimes used at the
initial operation and may be necessary for the correction
of an abdominal bulge.
The decision to perform a DIEP or free TRAM flap is
based on an intraoperative assessment of the perfora-
tors, flap volume, and abdominal characteristics (Table
Table 20.4.2  The effect of prior abdominal incisions on the vascularity of the abdominal flaps
Scar
n
SIEA disruption
DIEA disruption
Perforator disruption
Laparoscopy
20
None
None
None
Open appendectomy
20
All (ipsilateral)
None (ipsilateral)
Medial row of DIEA
Pfannenstiel
35
Medial branch (30/35)
None
NR
Paramedian
3
All (ipsilateral)
All (ipsilateral)
All (ipsilateral)
Open choly
1
None
None
None
Midline
17
None
None
Crossover
(Reproduced with permission from Rozen W, et al. Clinical Anatomy. 2009;22:815–823.)
Table 20.4.3  Personal algorithm for abdominal flap selection
based on flap volume, number of perforators, and abdominal
lipodystrophy
Factor
Free TRAM
DIEP
SIEA
Breast volume requirement
  <800 cc
±
+
±
  >800 cc
+
±
−
Abdominal fat
  Mild−moderate
±
+
±
  Severe
+
±
−
Perforators >1.5 mm
  0
+
−
−
  >1
±
+
±
Table 20.4.4  Adverse events comparing the free TRAM to the
DIEP flap
Factor
DIEP (%)
Free TRAM (%)
Fat necrosis
7.30
7.10
Venous congestion
4.50
2.70
Flap failure
2.70
1.80
Abdominal bulge
  Unilateral
4.50
5
  Bilateral
6.50
21
Sit-ups
  Unilateral
100
97
  Bilateral
95
83
(Reproduced with permission from: Nahabedian MY, et al. Plast Reconstr Surg.
2005;115:436.)

357
Patient selection
is usually delineated. With immediate reconstruction in
the setting of skin-sparing mastectomy, the areolar
border is delineated. With immediate reconstruction in
the setting of nipple-sparing, it is the author’s prefer-
ence to use a laterally based incision that extends to the
lateral edge of the areola. On occasion, the incision may
be extended through the areola or around the areolar
border by 90–180 degrees. This provides excellent expo-
sure for the mastectomy and the exposure of the internal
mammary artery and vein. Some surgeons prefer an
inframammary incision for the mastectomy and for
access to the recipient vessels.
Important markings for the free TRAM flap include
the anterior superior iliac spine (ASIS), midline, and
proposed incisions (Fig. 20.4.12). The midline of the
abdomen from the xiphoid to the pubic bone is delin-
eated. The proposed upper and lower transverse inci-
sions are delineated and communicated laterally at the
ASIS. The proposed lower abdominal incision is an
approximation. The final location is determined intra-
operatively when the patient is flexed about 30° to
ensure that the abdomen can be closed. Sometimes the
proposed incision has to be elevated above the pubic
hairline in order to ensure closure of the abdomen. The
design of the free TRAM flap should incorporate the
aesthetic units of the abdomen such that the final scar
will be positioned as low as possible extending supero-
laterally towards the ASIS.
Recipient vessels
Recipient vessels for the free TRAM flap include the
internal mammary and the thoracodorsal artery and
vein.25,26 Anatomic studies of the internal mammary
vessels at the level of the 4th rib have demonstrated
a diameter of 0.99–2.55 mm for the artery and
Fig. 20.4.10  The standard elliptical marking of the free TRAM flap with the
vascular zones.
Fig. 20.4.11  Actual preoperative marking of a patient that will have bilateral
skin-sparing mastectomies and a bilateral free TRAM flap.
Fig. 20.4.12  Illustrated preoperative marking of a free TRAM flap (black)
demonstrating the rectus abdominis muscle (red), intercostal innervation (green),
and the inferior epigastric artery (red) and vein (blue).

358
SECTION II
CHAPTER 20.4 • The free TRAM flap
mastectomy in the setting of immediate reconstruc-
tion.27,29 In the setting of a skin-sparing mastectomy with
excess skin, it should be debrided to fit the flap. When
the excision pattern is periareolar, the circular excision
pattern can be further excised and adjusted to fit the
desired skin paddle of the flap with a purse-string
suture technique. An alternative option is to partially
inset the flap medially and then excise the lateral mas-
tectomy skin such that a laterally based “lollipop”
pattern is created. With nipple-sparing mastectomy, it is
important to ensure that enough donor tissue is present
to fill the skin envelope.
In women considering delayed reconstruction with a
free TRAM, there are several factors to consider.30–33
When radiation therapy has been completed prior to the
reconstruction, adequate time must elapse to allow the
tissues and vascularity to recover. This is typically 6–12
months. In patients who will receive radiation therapy
following reconstruction, consideration to the type of
reconstruction being performed is important. Known
long-term consequences of radiation are fat atrophy and
distortion. To eliminate these effects, many reconstruc-
tive surgeons have adopted the delayed-immediate
approach as a means to avoid radiation damage to the
flap. With this technique, a subpectoral tissue expander
is placed immediately following the mastectomy and
becomes the target for the radiation. Following radia-
tion, the device is removed and replaced with autologous
tissue. Most tissue expanders are placed totally or par-
tially behind the pectoralis major muscle. When these
devices are removed, the pectoralis major muscle should
be returned to its normal position on the chest wall such
that the flap is positioned on top of the muscle. This will
optimize aesthetics and prevent animation or distortion
0.64–4.45 mm for the vein. The diameter of the thora-
codorsal vessels ranges from 1.5 to 3.0 mm for the
artery and 2.5 to 4.5 mm for the vein. Blood flow rates
of the inferior epigastric, internal mammary, and tho-
racodorsal arteries have been evaluated with flow rates
of 11 mL/min (range, 5–17), 25 mL/min (range, 15–35),
and 5 mL/min (range, 2–8), respectively. Studies have
demonstrated that either vessel is suitable for micro-
vascular anastomosis and that success rates using the
internal mammary or thoracodorsal vessels range from
97% to 99%.25
The mastectomy skin flaps
In cases of immediate breast reconstruction, the quality
of the mastectomy will impact the quality of the recon-
struction.27 Mastectomies are performed using either
skin-sparing techniques or nipple areolar sparing tech-
niques. With both approaches, the vascularity of the
remaining mastectomy skin flaps must be maintained.
Incisional approaches for the mastectomy may be apical,
inframammary, or lateral areolar (Fig. 20.4.13). When
there has been extensive undermining of the mastec-
tomy flaps, the natural borders are re-established by
suturing the inframammary and lateral mammary folds
back to the chest wall. If the vascularity of the mastec-
tomy skin flaps is compromised, the edges are excised
until normal bleeding is observed. The use of fluorescent
angiography can assist the surgeon with the decision-
making process regarding tissue perfusion.28 With all of
these approaches, free TRAM reconstruction can be
performed with excellent aesthetic outcomes.
An important and sometimes overlooked aspect of
achieving ideal breast aesthetics is to make the neces-
sary adjustments to the skin envelope following
Fig. 20.4.13  Mastectomy planning. (A) A standard mastectomy incision via an ellipse that is oriented either obliquely or transversely. (B) A skin-sparing mastectomy via
periareolar incision which may be supplemented with an extension for better access to the tail and axilla. (C) A Wise pattern mastectomy or (D) vertical reduction pattern
– both are useful for macromastia in which the reconstruction will be smaller than the preoperative state.
$
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359
Surgical technique
perforator. In the event that these imaging studies are
inconclusive or the intraoperative assessment does not
correlate with the preoperative imaging studies, a free
TRAM can be considered
Surgical technique
Preparing for surgery
Following the markings, patients are transported to the
operating room and placed in the supine position under
general endotracheal anesthesia. Pneumatic compres-
sion devices are applied to both legs, and a Foley catheter
is inserted. All patients receive a dose of intravenous
antibiotics before making the incision. The anesthesiolo-
gist is asked to avoid vasoconstricting medication
because of the risk of vascular spasm and flap failure.
Fluid resuscitation with crystalloid, colloid, or blood is
preferred. Muscle relaxation is necessary in all patients
to safely dissect the free TRAM flap. The operation is
performed using loupe magnifying glasses for the flap
dissection. An operating microscope is preferred for the
microvascular anastomosis.
Harvesting the flaps
Following the initial upper abdominal incision, the dis-
section proceeds to the anterior rectus sheath (Fig.
20.4.14A). The anterior rectus sheath is a vascularized
lattice of collagen fibers that should be preserved as
much as possible. It is important to note that sensory
nerves usually pass through the fascia as neurovascu-
lar bundles en route to the skin. These nerves should
be identified and divided. Clipping these sensory
nerves should be avoided to prevent a painful neuroma.
Once a network or island of perforators is visualized
on the anterior sheath, it is outlined and incised
(Fig. 20.4.14B). The dimensions of the fascial excision
typically range 1–2 cm in width and 2–4 cm in length.
Incising the anterior rectus sheath is not without
consequence, as it disrupts the normal lattice of
fibers that is considered one of the primary support
systems of the anterior abdominal wall. Under normal
with contraction of the pectoralis major muscle. Severely
radiated tissues that have been damaged or fibrotic are
usually excised. In these cases, the inferior edge of the
flap usually becomes the upper aspect of the inframam-
mary fold.
The free TRAM flap
The free TRAM is considered by many plastic surgeons
to be the most reliable of the free tissue transfer
procedures for breast reconstruction because it has
excellent blood supply, does not require a meticulous
intramuscular dissection, and is usually easier to
harvest. Although a DIEP flap may be the primary
choice for many surgeons and patients, a free TRAM
flap is considered when the quality of perforators is
deemed inadequate for a DIEP flap (<1.5 mm in diam-
eter) or when the flap volume requirements exceed
800 g (see Table 20.4.3). When considering the spec-
trum of free TRAM flaps, a muscle-sparing free TRAM
(MS-1 or MS-2) is performed in the majority of cases.
The MS-0 variant is rarely performed because it dis-
rupts the continuity of the rectus abdominis muscle.
The advantage of the free TRAM flaps over the DIEP
flap is that multiple perforators can be included that
may minimize the incidence of fat necrosis or vascular
compromise.
The decision regarding whether to perform a free
TRAM or DIEP flap is ultimately based on the presence
and quality of the abdominal wall perforating vessels.5,18
Knowledge of these perforators can be assessed either
pre- or intraoperatively (Table 20.4.5). Preoperative
assessment of perforators is usually obtained using
computerized tomography (CT) or magnetic resonance
(MR) angiography.34,35 With either modality, the location
and caliber of the perforating vessel or vessels, as well
as the intramuscular course of the source vessel, can be
adequately determined. The advantage of these imaging
modalities is that the “guesswork” as to whether a
perforator is present or suitable is essentially eliminated
and the harvesting of a DIEP flap can be more reliably
performed. In addition, the CT or MR angiogram can
alert the surgeon as to the subfascial course of the
Table 20.4.5  Comparison of the various imaging modalities with respect to radiation exposure, contrast requirements, caliber
assessment, location, course, flow, and accuracy
Test
Radiation
Contrast
Caliber
Location
Flow
Course
Accuracy
Doppler
No
No
No
Yes
No
No
Low
Color duplex
No
No
No
Yes
Yes
No
Moderate
CTA
Yes
Yes
Yes
Yes
No
Yes
High
MRA
No
Yes
Yes
Yes
No
Yes
High

360
SECTION II
CHAPTER 20.4 • The free TRAM flap
A
B
C
D
E
Fig. 20.4.14  (A) Elevation of the adipocutaneous component of the free TRAM
being elevated off of the anterior rectus sheath extending to an island of perforators.
(B) The fascial incision around the island of perforators. (C) Preservation of the
lateral intercostal innervation to the rectus abdominis muscle. (D) The internal
mammary artery and vein are prepared as the recipient vessels. (E) The double
approximating vascular clamps are applied to the internal mammary and inferior
epigastric veins in preparation for the anastomosis.
circumstances, as intra-abdominal pressure increases,
the lattice will tighten to maintain contour. It is impor-
tant to preserve as much of the anterior rectus sheath
as possible and to adequately close all layers during
the closing phase.
In contrast to the DIEP flap dissection, the anterior
rectus sheath is elevated off the surface of the rectus
abdominis muscle medially and laterally. The muscle is
undermined, and the location of the inferior epigastric
artery is visualized and palpated. This maneuver will
facilitate the dissection of the free TRAM and minimize
the chance of injury to the perforators or primary source
vessel. The rectus abdominis muscle is divided along
the desired segments using a fine-tip mosquito clamp
and an electrocautery device. When the perforators are
located in the central segment of the rectus abdominis
muscle, a MS-2 free TRAM is harvested. When the
perforators are predominately over the medial or lateral

361
Surgical technique
F
G
H
I
K
J
(F) The venous anastomosis is being completed with
interrupted monofilament sutures. (G) Following elevation of bilateral MS-2 free
TRAM flaps, the anterior rectus sheath is closed in two layers. (H) Following
elevation of bilateral MS-1 free TRAM flaps, a biologic mesh is used to replace the
missing segment of the anterior rectus sheath. (I) A synthetic mesh is occasional
placed only to further reinforce a primary fascial repair. (J) A contour abnormality
may arise following primary fascial repair. This patient has a rectus diastasis with
bulging of the upper abdomen. (K) Following plication, normal contour of the
abdomen is restored.
Fig. 20.4.14, cont’d
Continued

362
SECTION II
CHAPTER 20.4 • The free TRAM flap
recipient vessels, properly aligned, and divided (Fig.
20.4.14E). The lumen is irrigated with a dilute heparin
solution. The anastomosis is completed using 8-0 sutures
placed in an interrupted manner or continuous manner
(Fig. 20.4.14F). Many surgeons prefer to use a vascular
coupler for the venous anastomosis and to hand sew the
artery. Following completion of the anastomosis, a
Doppler is used to assess arterial and venous patency.
The cutaneous Doppler location is marked with a suture
for postoperative monitoring.
Closing the abdomen
Abdominal closure requires proper technique, attention
to detail, and appropriate use of supplemental materials
when necessary.36–39 It is important to approximate the
medial and lateral segments of muscle when an MS-2
or MS-3 flap has been performed to minimize the inci-
dence of lateralization of the muscle that may occur
with contraction and intra-abdominal pressure. Proper
closure of the anterior rectus sheath is the most impor-
tant predictive aspect of outcome. With the MS-3 flap,
fascial approximation is performed using an absorbable
or non-absorbable monofilament suture placed in an
interrupted figure-of-8 fashion (Fig. 20.4.14G). All
lamellae of the anterior sheath are closed to ensure
stability. A second row of sutures is placed in a running,
continuous fashion for additional reinforcement. Mesh
reinforcement is rarely necessary except when the fascia
is weak or tears with suture placement. When an MS-0,
MS-1, or MS-2 free TRAM flap has been performed,
primary fascial closure without mesh is possible when
there is enough laxity or redundancy of the fascia. In
situations where it is not, the use of a biologic or
aspect of the muscle, then an MS-1 free TRAM is har-
vested. The lateral intercostal innervation is preserved
when possible to ensure muscle contractility (Fig.
20.4.14C). Each of these flaps requires a myotomy or
segmental excision of muscle. There are crossover motor
nerve branches that will be encountered. These nerves
are usually divided sharply without clips to permit
axonal sprouting and neurotization of the medial
segment of the rectus abdominis.
Maximal preservation of the rectus abdominis muscle
and the anterior rectus sheath will usually improve
functional outcomes related to the anterior abdominal
wall. All variations of myotomy or myomectomy of the
rectus abdominis will limit the contractility of the muscle
because the contractile sarcomeres are replaced by scar.
Loss of continuity of the muscle (MS-0 free TRAM) will
result in a non-functional muscle; therefore MS-3, MS-2,
and MS-1 flaps are preferred.1,2,22–24 Limiting the amount
of anterior rectus sheath excision will minimize contour
abnormalities of the abdomen.
Microsurgery
Following exposure of the recipient vessels and eleva-
tion of the flap, the microscope is positioned along the
patient (Fig. 20.4.14D). In some cases where the recipi-
ent and donor vessels are large (>2.5 mm), surgical
loupes can be considered. Prior to division of the free
TRAM flap from its source, 3000–5000 units of heparin
is administered intravenously. The loose adventitia is
cleared from the donor and recipient vessels under the
microscope. In some patients a venae comitans is
present. The distal recipient vessels are clipped. The
microvascular clamps are placed on the donor and
L
M
(L) Postoperative monitoring is often achieved using a near infrared spectroscopy probe. (M) The unit displays the transcutaneous oxygen saturation
(68%) in a time-dependent fashion and the signal quality strength (84%).
Fig. 20.4.14, cont’d

363
Surgical technique
flex the patient approximately 45° to assess the position,
symmetry, contour, and projection of the breast.3,4,29,41
In cases of a skin-sparing mastectomy, the skin territory
to be exteriorized is delineated and the remainder of the
flap is de-epithelialized. When a nipple-sparing mastec-
tomy has been performed, a Doppler is used to identify
an arteriovenous signal and delineated with a 2 cm
circle. The remainder of the flap is de-epithelialized, and
the skin paddle is exteriorized. The vascular pedicle
must be visualized with insetting to ensure that it is
not twisted or kinked. With delayed reconstruction,
the lower mastectomy skin is usually excised or de-
epithelialized and the inferior edge of the autologous
flap is used to recreate the inframammary fold.
Shaping the free TRAM flap
There are several shaping advantages using free flaps
for breast reconstruction when compared with pedicle
flaps.3,4,29 Pedicle flaps are tethered to the donor site
muscle that often limits proper positioning of the flap.
The free TRAM, however, permits optimal positioning
on the chest wall because it is not tethered. With bilateral
reconstruction, the abdominal donor tissue is bisected
at the midline. The weight of the mastectomy specimen
is less relevant because the volume of flap is fixed and
limited to the hemi-abdomen. The medial edge of the
flap (zone 2) is usually positioned along the sternal
border, and the lateral aspect of the flap is positioned
on the lateral chest wall. Suturing of the flap to the chest
wall is sometimes necessary with immediate reconstruc-
tion, especially when the footprint of the old breast is
larger than the footprint of the flap. These absorbable
sutures can be placed superomedially, inferomedially,
and laterally. With delayed reconstruction, the dimen-
sions of the created subcutaneous pocket are usually
made to match that of the flap, so internal suturing is
usually not necessary.
With a unilateral reconstruction, the goal is to achieve
symmetry with the opposite breast. Assessment of
patient expectations is critical because it is important to
know if the opposite breast will be reduced, augmented,
or left as is. The opposite breast is sometimes used as a
template for the reconstruction, especially if the volume
of the free TRAM is sufficient to match the volume of
the breast. Typically with a unilateral reconstruction,
zones 1–3 and sometimes zone 4 are utilized, depending
on the amount of tissue required and the perfusion
characteristics of the flap. Because there is more tissue
available for the unilateral flap (zones 1–3) compared
with the bilateral flap (zones 1–2), shaping options are
increased. The flap can be folded in a conical fashion or
it can be folded laterally such that apical portion (zone
synthetic mesh may be necessary (Fig. 20.4.14H,I). The
purpose of the mesh is to minimize tension on the fascial
closure and to decrease the likelihood of dehiscence
or attenuation. The mesh can be placed as an inlay
when there is a fascial deficit and as an onlay when the
fascial closure needs additional reinforcement. The use
of a mesh has been necessary in approximately 10% of
patients.
Following fascial closure, additional plication of the
superior or midline fascia is considered to achieve ideal
contour. With unilateral breast reconstruction, contra-
lateral plication can balance and flatten the anterior
abdominal wall and will centralize the umbilicus. With
bilateral reconstructions, the supraumbilical fascia is
often plicated along the midline to prevent an upper
abdominal bulge (Fig. 20.4.14J,K). These sutures are
usually monofilament and also placed in a figure-of-8
fashion. Infraumbilical midline sutures are also some-
times useful to achieve ideal contour.
Skin closure is the final stage of abdominal closure
and includes the umbilicus and the incisions. The inset-
ting of the umbilicus is an important step to achieve
ideal abdominal aesthetics. Various skin incision pat-
terns are possible that include circular, oval, and ‘U’
designs. A technique that has demonstrated success is
the 2-dermal flap umbilical transposition flap.40 With
this technique, the umbilicus is invaginated to shorten
the umbilical stalk and yields a very natural appear-
ance. Skin closure is always performed in three layers
including Scarpa’s fascia, dermis, and epidermis.
Closure of Scarpa’s layer is important to prevent separa-
tion of the fat resulting in an involuted scar. When
closing in obese women, the subscarpal fat may be
excessive and require excision. This layer is often less
vascularized than the subcutaneous fat located above
Scarpa’s fascia. The thickness of the upper and lower
adipocutaneous layers of the abdominal wall should be
similar to prevent any step-off deformity. The slight
depression of the midline anterior abdominal wall can
be recreated by excision of a few millimeters of fat along
the midline of the adipose layer. This maneuver will
provide a more natural abdominal contour. Monofila-
ment sutures are used for the dermis and subcuticular
layers. Lateral “dog-ears” should be identified at time
of closure and addressed. This will lengthen the abdomi-
nal incision but improve overall abdominal contour.
Two closed suction drains are always used to minimize
the occurrence of a fluid collection.
Flap insetting
When insetting the free TRAM flap following a unilat-
eral or bilateral reconstruction, it is recommended to

364
SECTION II
CHAPTER 20.4 • The free TRAM flap
Complications
Factors that may increase the risk of flap failure can be
divided into two groups: those that are within the
control of the surgeon and those that are not. Factors
that can be controlled by the surgeon are often related
to meticulous technique, knowledge of the relevant
anatomy, and attention to detail. Flap failure is the most
serious complication and can be due to arterial or venous
factors (Fig. 20.4.16). Venous occlusion due to clot,
kinking, or twisting of the vascular pedicle is the most
common and characterized by a flap that becomes
congested, edematous, and tense (Fig. 20.4.17). Arterial
occlusion is less common and may be due to the same
factors but is characterized by a flap that is pale, ashen,
and soft (Fig. 20.4.18). Both situations require a return
to the operating room.
Operative exploration requires a return to the operat-
ing room where the flap sutures are removed and the
flap is exteriorized. The anastomosis and vascular
pedicle are inspected. With venous occlusion, the vein
is tense and dilated and may be filled with clotted blood.
In some cases, the pedicle may have a kink or twist and
realignment of the pedicle is all that is needed to restore
circulation. When the etiology is a true thrombosis,
management includes takedown of the anastomosis,
embolectomy of the venous limb, and irrigation of the
lumen with heparin. If clot is suspected in the flap or
the muscle, thrombolytic therapy is indicated. Success
with this technique depends on the elapsed time interval
and is more effective when occlusion has been less than
2 h. If the flap demonstrates sluggish venous outflow,
medicinal leech therapy can be considered following
exploration.
With arterial occlusion, there is no pulse and the veins
are usually flat. The anastomosis is taken down and
inspected for thrombin clot or intimal damage. In some
cases, the vessels are trimmed and the anastomosis is
performed again. When there is persistent disruption of
flow, vascular spasm, or a clotting disorder is suspected,
4% lidocaine or papaverine HCl may be used along the
adventitia of the vessel to promote vasodilation. If the
flap is deemed unsalvageable, then it is removed and
sometimes replaced with a tissue expander.
There are other factors that can also influence
the success of microvascular breast reconstruction.
Advanced patient age and its relationship to microvas-
cular success have demonstrated success rates similar
to non-elderly patients and range from 97% to 99%.42,43
ASA status and length of the operation are significant
predictors of postoperative morbidity.42 Clinical studies
related to glycemic status have demonstrated that
patients with diabetes mellitus are not at increased risk
2) of the flap is tucked under zone 1, with zone 3 of the
flap being positioned along the sternal border. With
both maneuvers, the goal is to provide better projection
and contour. Suturing the flap laterally is usually neces-
sary, and suturing the flap along the medial border is
occasionally necessary.
Another aspect of shaping depends on the location of
the recipient vessels. When the anastomosis is to the
internal mammary vessels, the flap can be positioned
anywhere on the chest wall. When the anastomosis is to
the thoracodorsal vessels, the flap may not reach the
medial border because the thoracodorsal vessels are
laterally based. This is less likely with unilateral recon-
struction because of the inclusion of zone 3; however,
with bilateral flap reconstruction, a medial deficiency
may be noted. Thus, one advantage of the internal
mammary recipient vessels is that there is ample length
of the vascular pedicle such that the flap can be posi-
tioned, shaped, and contoured without impediments.
Postoperative care
Following the operation, patients are transported to the
recovery room where diligent monitoring is performed.
Patients will typically be monitored using a hand
held Doppler and a near infrared spectrometer (Fig.
20.4.14L,M). Other monitoring methods include capil-
lary refill, turgor, color, and temperature. Flap monitor-
ing occurs every 15 min for the first 4 h, hourly for the
next 20 h, and then every 2–4 h for the next 48 h. Patients
are typically started on aspirin 325 mg daily for 2 weeks.
Heparin is administered intraoperatively but not
postoperatively.
Outcomes, prognosis,
and complications
The free TRAM is capable of achieving excellent aes-
thetic outcomes that are reproducible and predictable.
Because of the excellent vascularity, fat and partial
necrosis is uncommon. In addition, greater volumes of
fat can be perfused because of the different perforators
perfusing different angiosomes. Abdominal outcomes
are maintained from a functional and aesthetic perspec-
tive (see Table 20.4.4). The ability to perform sit-ups is
higher following unilateral free TRAM flap reconstruc-
tion compared with bilateral. Fig. 20.4.15A–D illustrates
a woman following bilateral skin-sparing mastectomy
and immediate reconstruction with MS-2 free TRAM
flaps. Fig. 20.4.15E–H shows another woman follow-
ing bilateral skin-sparing mastectomy and immediate
reconstruction with an MS-1 free TRAM flap.

365
Outcomes, prognosis, and complications
A
B
C
D
Fig. 20.4.15  (A) A preoperative image of a patient scheduled for bilateral skin-sparing mastectomy and immediate reconstruction with free TRAM flaps. (B) Preoperative
left lateral view. (C) Postoperative view of the breast and abdomen following the bilateral MS-2 free TRAM flaps, at the 2-year follow-up. (D) Postoperative left lateral view
at the 2-year follow-up.
for flap failure, abnormal healing of the anastomosis, or
intolerance to an ischemic challenge, as long as a eug-
lycemic state is maintained in the preoperative period.9
Hemoglobin A1c levels >7 are associated with increased
complications such as delayed healing, incisional dehis-
cence, and infection. Connective tissue disorders such
as lupus and psoriatic arthritis are often thought to
increase complications following breast reconstruction;
however, studies have demonstrated that perioperative
complication rates are similar to patients without con-
nective tissue disorders.44
There are other factors that can lead to partial or total
flap failure.8,14,19,20 Inadequate outflow of the internal
mammary system can lead to venous congestion,
Continued

366
SECTION II
CHAPTER 20.4 • The free TRAM flap
can result in flap failure. In the author’s experience,
anastomotic failure is usually due to venous occlusion
and is responsible for return to the operating room and
flap necrosis in the majority of cases. Two factors com-
monly associated with anastomotic and flap failure are
delayed reconstruction and postoperative hematoma.
partial necrosis, fat necrosis, or total flap failure. Radia-
tion damage to the recipient vessels can be the source
of progressive inflammation and lead to vascular
thrombosis. Some women will have undiagnosed
hypercoagulability states and form clots at the anasto-
moses. Postoperative bleeding and hematoma formation
E
F
G
H
(E) Preoperative image of a patient scheduled for bilateral skin-sparing mastectomy and immediate reconstruction with free TRAM flaps.
(F) Preoperative right lateral view. (G) Postoperative view of the breast and abdomen following the bilateral MS-2 free TRAM flaps at the 1.5-year follow-up.
(H) Postoperative right lateral view at the 1.5-year follow-up.
Fig. 20.4.15, cont’d

367
Outcomes, prognosis, and complications
Fig. 20.4.16  Severe venous congestion of a flap demonstrating total flap failure.
Fig. 20.4.17  Mild venous congestion of a flap with brisk capillary refill requiring
operative exploration.
Fig. 20.4.18  Arterial occlusion of a flap demonstrating the pale and ashen color
requiring operative exploration.
Fig. 20.4.19  Postoperative abdominal bulge is demonstrated following a bilateral
free TRAM flap.
Donor site complications include, but are not limited
to, contour abnormalities, complex scars, delayed
healing, seroma, pain, and infection.1,2,21–24 Contour
abnormalities include abdominal bulge and hernia and
with the free TRAM occur more often with bilateral
reconstruction (Fig. 20.4.19). Abdominal hernia is rare,
and abdominal bulge occurs in the vast majority of
cases. The incidence ranges from 3–10% for unilateral
cases and 5–15% for bilateral cases. Abdominal fluid
collections such as a hematoma or seroma are rare and
typically occur in 1–2% of cases. Delayed healing may
include incisional necrosis or dehiscence, umbilical
necrosis, or soft tissue and fat necrosis (Fig. 20.4.20).
This can be the result of prior abdominal incisions,
obesity, poor perfusion, excessive tension, or patient
comorbidities. Chronic pain may be the result of
neuroma formation due to hemoclips placed on the
sensory nerves or nerve entrapment.

368
SECTION II
CHAPTER 20.4 • The free TRAM flap
is a common method that has achieved success. The
placement of fat along the breast and chest wall is an
excellent method to improve contour in the upper and
medial pole of the breast (Fig. 20.4.21). Fat grafting has
also been used in radiated breasts where skin damage
or volume deficiency is present. The ability of fat and
stem cells to regenerate, hydrate, and revascularize
damaged skin is well accepted. When reconstruction
with a free TRAM results in a breast that is too ptotic,
the technique of burying the flap has demonstrated
success. The skin territory of the flap is outlined with
an elliptical extension and de-epithelialized. The mas-
tectomy skin flaps are undermined superiorly and
inferiorly and then re-approximated. Fig. 20.4.22 illus-
trates a woman with secondarily buried bilateral free
TRAM flaps.
For the reconstructed breast that is deficient in
volume, two methods of correction are commonly
employed.45–47 The first is to fat graft the parenchyma of
the flap, and the second is to place a small implant
under the flap. Fat grafting using a small cannula has
been effective when placed within the flap itself.
Volumes of 100–200 cc are possible because the tissues
are soft and supple. When an implant is used to augment
flap volume, it is usually saline and ranges in volume
from 80 to 125 cc. This is because there is usually scar
tissue present that prevents excessive fill volumes ini-
tially. In women with a history of chest wall radiation,
the device is placed in the prepectoral position; whereas
in women without a history of radiation therapy, the
device is placed is the subpectoral position. Radiated
patients typically have a fibrotic pectoralis major muscle
that may increase the incidence of capsular contracture
or device malposition.
Secondary procedures
Secondary revisions are often necessary following
autologous reconstruction with the free TRAM as well
as most autologous flaps.11,17,38 This may be to restore
volume, contour, and position and include both flaps
in the setting of a bilateral reconstruction as well as
the ipsilateral and contralateral breast in the setting of
a unilateral reconstruction. Various techniques are
available for the reconstructed breast including soft-
tissue recontouring, fat grafting, burying the flap, and
implant placement. Achieving symmetry with the
contralateral or non-reconstructed breast can be accom-
plished via augmentation, mastopexy, or reduction
mammaplasty.
The reconstructed breast
The most common method of revision is by direct exci-
sion of skin and fat as well as tissue rearrangement.15,29
The goal may be to reduce the volume, improve the
shape, reposition the breast on the chest wall, or to
better define the inframammary or lateral mammary
folds. The technique of autologous fat grafting to
correct contour deformities and to improve skin quality
Fig. 20.4.20  Delayed healing and skin necrosis of the abdominal skin in a patient
using tobacco products.
Fig. 20.4.21  The technique of fat grafting is illustrated as a means of secondary
contouring of the flap.

369
Secondary procedures
Fig. 20.4.22  (A) Preoperative image of a patient scheduled for bilateral skin-sparing mastectomy and immediate reconstruction with free TRAM flaps. (B) Preoperative
markings are illustrated for the skin-sparing mastectomy and the flap. (C) Postoperative image following an MS-2 bilateral MS-2 free TRAM flap. The patient has bilateral
breast ptosis. (D) Postoperative image following excision of the skin territory of the flap in an elliptical fashion with undermining of the mastectomy skin flaps and primary
closure. Nipple areolar reconstruction has been completed; 1-year follow-up.
A
B
C
D

370
SECTION II
CHAPTER 20.4 • The free TRAM flap
absence, weakness, or denervation of the rectus abdomi-
nis muscle. Imaging studies are usually not necessary
with a bulge. With the free TRAM flaps, the bulge is
usually located in the lower abdomen and is usually on
the side of the flap harvest. When preparing for repair,
the area of the bulge is delineated with the patient
standing. During the operation, the lower transverse
incision is opened and the upper adipocutaneous layer
elevated. The bulge is identified and plicated in two
vertical layers using a non-absorbable monofilament
suture in a figure-of-8 fashion, as well as a continuous
suture. The use of a synthetic mesh is usually considered
to further reinforce the anterior abdominal wall and
typically extends from the costal margin superiorly, the
pubic region inferiorly, and the anterior axillary lines
laterally. The sutures are usually absorbable monofila-
ment and placed around the periphery of the mesh and
centrally to anchor it to the anterior rectus sheath.
Abdominal hernia
The repair of a true hernia differs from that of the bulge
(Figs. 20.4.23 & 20.4.24). Given that there is a facial
defect, the repair mirrors that of a ventral incisional
hernia with the main difference being that the rectus
abdominis muscle is altered. The initial phase of the
repair includes defining the fascial edges of the defect,
followed by excision of the hernia sac. An intra-
abdominal approach to the repair is required. Mesh
Nipple reconstruction is usually the final procedure
that is performed. Common methods of nipple areolar
reconstruction include various local flaps that include
the CV, star, and skate flaps. These are usually performed
at the time of secondary procedures. Areolar tattooing
is usually performed 3 months following the nipple
reconstruction. Nipple reconstruction is usually not
advised in women who have had radiation to the free
TRAM flap. Many women are choosing to have 3D
nipple areolar tattooing performed.
The non-reconstructed breast
In unilateral reconstructions, the non-reconstructed
breast is sometimes modified to achieve symmetry.15,48
Options include unilateral augmentation with an
implant, mastopexy, or reduction mammaplasty.
Implant selections is facilitated by volumetric analysis
using 3D imaging. Standard breast augmentation
methods are used. When breast volumes are similar but
the natural breast is ptotic, a mastopexy is sometimes
performed. This is usually via a periareolar or circum-
vertical approach; however, in some cases, the inverted-T
technique is performed. When the reconstructed breast
is smaller than the natural breast, reduction mamma-
plasty is considered. This can be performed using a
variety of techniques that include short scars when the
difference is mild to moderate, as well as inverted-T
scars when the difference is moderate to severe.
Correcting postoperative
abdominal abnormalities
There are several postoperative abnormalities that can
occur, and these include abdominal bulge, abdominal
hernia, persistent pain, delayed healing, and chronic
fluid collection.1,2,11,17,21,36,37 Many of these can be managed
conservatively; however, operative intervention is
sometimes necessary. The first step is to address the
patient concerns by performing a history and physical
examination. Areas of abnormal contour, pain, indura-
tion, fluid, and delayed healing are noted. Abnormal
contour may be secondary to edema, excess skin, and
fascial compromise. It is important to differentiate
between a bulge and hernia. A hernia will have a true
facial defect that can be palpated, whereas a bulge will
not. Pain is usually self-limiting but sometimes chronic
due to neuroma formation. Fluid collections are rare but
may be secondary to seroma or hematoma.
Abdominal bulge
An abdominal bulge is most often due to attenuation of
the anterior rectus sheath. It can be exacerbated by
Fig. 20.4.23  Preoperative image of a patient following right breast reconstruction
with a free TRAM flap with a left abdominal contour abnormality.

371
Correcting postoperative abdominal abnormalities
Pain
Chronic pain following abdominal flap reconstruction
may be due to scar formation along the anterior rectus
sheath or a neuroma.17 Neuromas usually occur follow-
ing placement of a surgical clip that has been placed
along a sensory branch of the intercostal neurovascular
bundle as it traverses through the anterior rectus sheath
to the adipocutaneous layer. Other etiologies may
include entrapment of the ilioinguinal and iliohypogas-
tric nerves as well as the use of an onlay synthetic mesh.
Conservative management is usually recommended for
reinforcement is often necessary and can be used as an
underlay or onlay fashion. Both synthetic and biologic
meshes can be considered. Underlay and onlay mesh
should span as much of the anterior abdominal wall as
possible. Absorbable monofilament sutures are usually
used to anchor the mesh to its surface. The fascial edges
are re-approximated when possible using non-absorbable
monofilament sutures in an interrupted figure-of-8
fashion followed by a running continuous suture placed
along the linea alba. In complex situations associated
with recurrence and loss of domain, the use of tissue
expanders can be considered to repair a true hernia.
A
B
Fig. 20.4.24  (A) Intraoperative image of a left fascial defect consistent with an abdominal hernia. (B) The hernia sac is excised, and the remaining layers of the anterior
rectus sheath are closed in 2-layers. (C) A biologic mesh is placed in an onlay fashion to further reinforce the abdominal wall. (D) Postoperative view of the abdomen at the
3-month follow-up.
C
D

372
SECTION II
CHAPTER 20.4 • The free TRAM flap
catheter via interventional radiology. Operative evacu-
ation may be considered when refractory to conventional
maneuvers.
Conclusion
The free TRAM flap is an excellent option for autologous
reconstruction in properly selected patients. The vascu-
larity and perfusion characteristics are predictable and
capable of sustaining large flap volumes. The flap can
be elevated with variable amounts of the rectus abdomi-
nis muscle and classified as MS-0, 1, or 2. Success rates
for the free TRAM range from 97% to 99%. Its utility in
the setting of skin- and nipple-sparing mastectomy is
excellent, and its complication profile is acceptably low.
Donor site morbidity is low, and patients usually retain
almost all of their preoperative function. Aesthetic
outcomes can be excellent and rival those of the other
abdominal flaps.
the first 6 months because most of these symptoms are
self-limiting. Surgical management is often recom-
mended when the pain persists beyond 6 months and
interferes with activities of daily living. Specific man-
agement techniques include excision of the neuroma
with burial of the nerve stump into the underlying
muscle, as well as partial or total removal of synthetic
mesh when responsible.
Fluid collections
Fluid collections following abdominal flap reconstruc-
tion can occur and may be due to premature drain
removal, damage to the loose areolar layer of the ante-
rior rectus sheath, and body habitus. Seroma is the most
common followed by hematoma. Many of these fluid
collections are small and self-limiting; however, when
large and persistent, intervention is usually recom-
mended. Invasive maneuvers include office procedures
such as serial aspiration or by placing an indwelling
5. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction
with the free TRAM or DIEP flap: patient selection, choice of flap,
and outcome. Plast Reconstr Surg. 2002;110:466–475. The authors
review their early experience with 163 free TRAM or DIEP flap breast
reconstructions performed on 135 women. Selection of the free TRAM or
DIEP flap should be made on the basis of patient weight, quantity of
abdominal fat, and breast volume requirement, and on the number, caliber,
and location of the perforating vessel. Adverse events were similar for the
two groups.
10. Hseih F, Kumiponjera D, Malata CM. An algorithmic approach to
abdominal flap breast reconstruction in patients with pre-existing
scars: results from a single surgeon’s experience. J Plast Reconstr
Aesthet Surg. 2009;62:1650–1660. The authors review their experience
with pre-existing abdominal scars in 30 patients scheduled for TRAM
flaps demonstrating that pre-existing scars are not an absolute
contraindication to abdominal flap breast reconstruction. They provide an
algorithm for decision-making.
11. Nahabedian MY. Factors to consider in breast reconstruction.
Womens Health (Lond). 2015;11:325–342. This paper reviews essential
elements for all types of breast reconstruction with an emphasis on patient
selection, reconstructive technique, and outcomes.
21. Chang E, Chang E, Soto-Miranda MA, et al. Comprehensive
analysis of donor-site morbidity in abdominally based free flap
breast reconstruction. Plast Reconstr Surg. 2013;132:1383–1391. The
authors review 89 of 1507 patients who developed an abdominal bulge/
hernia following free abdominal flaps. Contour abnormalities were more
likely to occur following full width muscle harvest. There was no
difference between MS free TRAM and DIEP patients in the unilateral or
bilateral setting.
23. Nelson JA, Guo Y, Sonnad SS, et al. A comparison between DIEP
and muscle-sparing free TRAM flaps in breast reconstruction: a
single surgeon’s recent experience. Plast Reconstr Surg.
2010;126:1428–1435. The authors review their early outcomes in 144
patients following DIEP or free TRAM flap breast reconstruction,
demonstrating that the choice of flap should be made intraoperatively,
based on anatomic findings on a patient-by-patient basis.
31. Mirzabeigi MN, Smartt JM, Nelson JA, et al. An assessment of the
risks and benefits of immediate autologous breast reconstruction in
patients undergoing postmastectomy radiation therapy. Ann Plast
Surg. 2013;71:149–155. This study reviews outcomes in 407 women
following autologous reconstruction and radiation therapy. There was a
higher incidence of fat necrosis and volume loss in the radiation cohort.
Other adverse events were not increased.
36. Mennie JC, Mohanna PN, O’Donoghue JM, et al. Donor-site hernia
repair in abdominal flap breast reconstruction: a population-based
cohort study of 7929 patients. Plast Reconstr Surg. 2015;136:1–9. This
study reviews hernia rate in 7929 women who had a DIEP or TRAM flap
breast reconstruction. The hernia repair rate was 2.45% after 3 years.
Mean time to hernia repair following a DIEP or TRAM flap was 17.7
months. The only independent risk factor for hernia repair was age greater
than 60 years.
39. Patel KM, Shuck J, Hung R, et al. Reinforcement of the abdominal
wall following breast reconstruction with abdominal flaps: a
comparison of synthetic and biologic mesh. Plast Reconstr Surg.
2014;133:700–707. This study reviews 818 patients that had synthetic
mesh (n-61) or biological mesh (n-36) to reinforce the abdominal wall.
Overall complication rates for the synthetic and biologic cohorts were
6.5% and 5.5%, respectively. Both meshes behave similarly for abdominal
reinforcement.
45. Kaoutzanis C, Xin M, Ballard TN, et al. Autologous fat grafting
after breast reconstruction in postmastectomy patients:
complications, biopsy rates, and locoregional cancer recurrence
rates. Ann Plast Surg. 2016;76:270–275. The authors review 108 women
and 167 reconstructions following autologous fat grafting for revision. A
total of 53 (31.7%) breasts underwent imaging after autologous fat
grafting. Suspicious findings requiring biopsy were noted in four (2.4%)
breasts, and clinically palpable masses combined with suspicious imaging
findings requiring biopsy occurred in four (2.4%) breasts.
48. Nahabedian MY. Managing the opposite breast: contralateral
symmetry procedures. Cancer J. 2008;14:258–263. A review of various
options for managing the contralateral breast following breast
reconstruction is provided.
Access the complete reference list online at

372.e1
References
References
1. Nahabedian MY, Manson PN. Contour abnormalities of the
abdomen following tram flap breast reconstruction: a multifactorial
analysis. Plast Reconstr Surg. 2002;109:81–87.
2. Nahabedian MY, Dooley W, Singh N, et al. Contour abnormalities
of the abdomen following breast reconstruction with abdominal
flaps: the role of muscle preservation. Plast Reconstr Surg.
2002;109:91–101.
3. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Plast Reconstr Surg. 2009;123:455–462.
4. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Part II—breast reconstruction after total mastectomy. Plast
Reconstr Surg. 2009;123:794–805.
5. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction
with the free TRAM or DIEP flap: patient selection, choice of flap,
and outcome. Plast Reconstr Surg. 2002;110:466–475. The authors
review their early experience with 163 free TRAM or DIEP flap breast
reconstructions performed on 135 women. Selection of the free TRAM or
DIEP flap should be made on the basis of patient weight, quantity of
abdominal fat, and breast volume requirement, and on the number, caliber,
and location of the perforating vessel. Adverse events were similar for the
two groups.
6. Nahabedian MY. Breast reconstruction: a review and rationale for
patient selection. Plast Reconstr Surg. 2009;124:55–62.
7. Han E, Johnson N, Glissmeyer M, et al. Increasing incidence of
bilateral mastectomies: the patient perspective. Am J Surg.
2011;201:615–618.
8. Endara M, Nahabedian MY. Free flap breast reconstruction in the
hypercoagulable patient with a concomitant bleeding diathesis.
Plast Reconstr Surg. 2013;132:180e–181e.
9. Nahabedian MY. Microvascular breast reconstruction in the diabetic
patient. (Discussion). Plast Reconstr Surg. 2007;119:46–48.
10. Hseih F, Kumiponjera D, Malata CM. An algorithmic approach to
abdominal flap breast reconstruction in patients with pre-existing
scars: results from a single surgeon’s experience. J Plast Reconstr
Aesthet Surg. 2009;62:1650–1660. The authors review their experience
with pre-existing abdominal scars in 30 patients scheduled for TRAM
flaps demonstrating that pre-existing scars are not an absolute
contraindication to abdominal flap breast reconstruction. They provide an
algorithm for decision-making.
11. Nahabedian MY. Factors to consider in breast reconstruction.
Womens Health (Lond). 2015;11:325–342. This paper reviews essential
elements for all types of breast reconstruction with an emphasis on patient
selection, reconstructive technique, and outcomes.
12. Albino FP, Patel KM, Nahabedian MY. Aesthetic outcomes
following immediate and delayed autologous breast reconstruction.
Arch Plast Surg. 2014;41:265–270.
13. Patel KM, Albino FP, Fan K, et al. Microvascular autologous breast
reconstruction in the context of radiation therapy: comparing two
reconstructive algorithms. Plast Reconstr Surg. 2013;132:251.
14. Nahabedian MY, Momen B, Manson PN. Factors associated with
anastomotic failure following microvascular reconstruction of the
breast. Plast Reconstr Surg. 2004;114:74–82.
15. Nahabedian MY. Symmetrical breast reconstruction: analysis of
secondary procedures following reconstruction with implants and
with autologous tissue. Plast Reconstr Surg. 2005;115:257–260.
16. Nahabedian MY, Momen B, Tsangaris T. Breast reconstruction with
the muscle sparing (MS-2) free TRAM and the DIEP flap: is there a
difference? Plast Reconstr Surg. 2005;115:436–444.
17. Nahabedian MY. Secondary operations of the anterior abdominal
wall following microvascular breast reconstruction with the TRAM
and DIEP flaps. Plast Reconstr Surg. 2007;120:365–372.
18. Nahabedian MY, Schwartz J. Autologous breast reconstruction
following mastectomy. Handchir Mikrochir Plast Chir.
2008;40:248–254.
19. Rao SS, Stolle EC, Sher S, et al. A multiple logistic regression
analysis of complications following microsurgical breast
reconstruction. Gland Surg. 2014;3:226–231.
20. Masoomi H, Clark EG, Paydar KZ, et al. Predictive risk factors of
free flap thrombosis in breast reconstruction surgery. Microsurgery.
2014;34:589–594.
21. Chang E, Chang E, Soto-Miranda MA, et al. Comprehensive
analysis of donor-site morbidity in abdominally based free flap
breast reconstruction. Plast Reconstr Surg. 2013;132:1383–1391. The
authors review 89 of 1507 patients who developed an abdominal bulge/
hernia following free abdominal flaps. Contour abnormalities were more
likely to occur following full width muscle harvest. There was no
difference between MS free TRAM and DIEP patients in the unilateral or
bilateral setting.
22. Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing
the functional impact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: Part II. Bilateral reconstruction.
Plast Reconstr Surg. 2010;126:1438–1453.
23. Nelson JA, Guo Y, Sonnad SS, et al. A comparison between DIEP
and muscle-sparing free TRAM flaps in breast reconstruction: a
single surgeon’s recent experience. Plast Reconstr Surg. 2010;126:
1428–1435. The authors review their early outcomes in 144 patients
following DIEP or free TRAM flap breast reconstruction, demonstrating
that the choice of flap should be made intraoperatively, based on anatomic
findings on a patient-by-patient basis.
24. Selber JC, Nelson J, Fosnot J, et al. A prospective study comparing
the functional impact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: Part I. Unilateral
reconstruction. Plast Reconstr Surg. 2010;126:1142–1153.
25. Nahabedian M. The internal mammary artery and vein as recipient
vessels for microvascular breast reconstruction. Ann Plast Surg.
2012;68:537–538.
26. Lorenzetti F, Kuokkanen H, von Smitten K, et al. Intraoperative
evaluation of blood flow in the internal mammary or thoracodorsal
artery as a recipient vessel for a free TRAM flap. Ann Plast Surg.
2001;46:590–593.
27. Patel KM, Hill LM, Gatti ME, et al. Management of massive
mastectomy skin flap necrosis following autologous breast
reconstruction. Ann Plast Surg. 2011;69:139–144.
28. Gurtner GC, Jones GE, Neligan PC, et al. Intraoperative laser
angiography using the SPY system: review of the literature and
recommendations for use. Ann Surg Innov Res. 2013;7:1.
29. Nahabedian MY. Achieving ideal breast aesthetics with autologous
reconstruction. Gland Surg. 2015;4:134–144.
30. Fosnot J, Fischer JP, Smartt JM, et al. Does previous chest wall
irradiation increase vascular complications in free autologous breast
reconstruction? Plast Reconstr Surg. 2011;127:496–504.
31. Mirzabeigi MN, Smartt JM, Nelson JA, et al. An assessment of the
risks and benefits of immediate autologous breast reconstruction in
patients undergoing postmastectomy radiation therapy. Ann Plast
Surg. 2013;71:149–155. This study reviews outcomes in 407 women
following autologous reconstruction and radiation therapy. There was a
higher incidence of fat necrosis and volume loss in the radiation cohort.
Other adverse events were not increased.
32. Clemens MW, Kronowitz SJ. Current perspectives on radiation
therapy in autologous and prosthetic breast reconstruction. Gland
Surg. 2015;4:222–231.
33. Kronowitz SJ. Delayed-immediate breast reconstruction: technical
and timing considerations. Plast Reconstr Surg. 2010;125:463–474.
34. Ghattaura A, Henton J, Jallali N, et al. One hundred cases of
abdominal-based free flaps in breast reconstruction. The impact of
preoperative computed tomographic angiography. J Plast Reconstr
Aesthet Surg. 2010;63:1597–1601.
35. Chae MP, Hunter-Smith DJ, Rozen WM. Comparative analysis of
fluorescent angiography, computed tomographic angiography and
magnetic resonance angiography for planning autologous breast
reconstruction. Gland Surg. 2015;4:164–178.
36. Mennie JC, Mohanna PN, O’Donoghue JM, et al. Donor-site hernia
repair in abdominal flap breast reconstruction: a population-based
cohort study of 7929 patients. Plast Reconstr Surg. 2015;136:1–9. This
study reviews hernia rate in 7929 women who had a DIEP or TRAM flap
breast reconstruction. The hernia repair rate was 2.45% after 3 years.
Mean time to hernia repair following a DIEP or TRAM flap was 17.7
months. The only independent risk factor for hernia repair was age greater
than 60 years.

372.e2
SECTION II
CHAPTER 20.4 • The free TRAM flap
37. Wan DC, Tseng CY, Anderson-Dam J, et al. Inclusion of mesh in
donor-site repair of free TRAM and muscle-sparing free TRAM
flaps yields rates of abdominal complications comparable to
those of DIEP flap reconstruction. Plast Reconstr Surg. 2010;126:
367–374.
38. Nahabedian MY. Achieving ideal donor site aesthetics with
autologous breast reconstruction. Gland Surg. 2015;4:145–153.
39. Patel KM, Shuck J, Hung R, et al. Reinforcement of the abdominal
wall following breast reconstruction with abdominal flaps: a
comparison of synthetic and biologic mesh. Plast Reconstr Surg.
2014;133:700–707. This study reviews 818 patients that had synthetic
mesh (n-61) or biological mesh (n-36) to reinforce the abdominal wall.
Overall complication rates for the synthetic and biologic cohorts were
6.5% and 5.5%, respectively. Both meshes behave similarly for abdominal
reinforcement.
40. Rozen SM, Redett R. The two-dermal-flap umbilical transposition: a
natural and aesthetic umbilicus after abdominoplasty. Plast Reconstr
Surg. 2007;119:2255–2262.
41. Nahabedian MY, Patel K. Maximizing the use of the handheld
Doppler in autologous breast reconstruction. Clin Plast Surg.
2011;38:213–218.
42. Chang EL, Vaca L, DaLio AL, et al. Assessment of advanced age as
a risk factor in microvascular breast reconstruction. Ann Plast Surg.
2011;67:255–259.
43. Girotto JA, Schreiber J, Nahabedian MY. Breast reconstruction in the
elderly: preserving excellent quality of life. Ann Plast Surg.
2003;50:572–578.
44. Shuck J, Patel KM, Franklin B, et al. Impact of connective tissue
disease on outcomes following breast surgery and reconstruction.
Ann Plast Surg. 2016;76:635–639.
45. Kaoutzanis C, Xin M, Ballard TN, et al. Autologous fat grafting
after breast reconstruction in postmastectomy patients:
complications, biopsy rates, and locoregional cancer recurrence
rates. Ann Plast Surg. 2016;76:270–275. The authors review 108 women
and 167 reconstructions following autologous fat grafting for revision. A
total of 53 (31.7%) breasts underwent imaging after autologous fat
grafting. Suspicious findings requiring biopsy were noted in four (2.4%)
breasts, and clinically palpable masses combined with suspicious imaging
findings requiring biopsy occurred in four (2.4%) breasts.
46. Delay E, Guerid S. The role of fat grafting in breast reconstruction.
Clin Plast Surg. 2015;42:315–323.
47. Roehl KR, Baumann DP, Chevray PM, et al. Evaluation of outcomes
in breast reconstructions combining lower abdominal free flaps and
permanent implants. Plast Reconstr Surg. 2010;126:349–357.
48. Nahabedian MY. Managing the opposite breast: contralateral
symmetry procedures. Cancer J. 2008;14:258–263. A review of various
options for managing the contralateral breast following breast
reconstruction is provided.

SECTION II • Reconstructive Breast Surgery
21.1 
Introduction to alternative free flaps for
breast reconstruction
Maurice Y. Nahabedian
Gluteal flaps
Many surgeons consider the gluteal free flaps to be
among the most complex flaps for the microsurgeon
(see Chapter 21.2).1–4 Gluteal flaps can be raised with or
without the gluteus maximus muscle. There are two
perforator flaps that are derived from this region that
include the superior (SGAP) and inferior (IGAP) gluteal
artery perforator flaps. Gluteal flaps can be performed
in women with a variety of body types, ranging from
short to tall and thin to obese.
For some surgeons, the gluteal flaps are the second
choice following the abdomen. Preoperative imaging
with computed tomography (CT) or magnetic resonance
imaging is useful to identify the caliber and position of
the perforating vessels. The superior gluteal vessels are
located above the piriformis muscle within the greater
sciatic foramen, and the inferior gluteal vessels are
located below the piriformis muscle within the lesser
sciatic foramen. The vascular pedicle of these flaps is
typically shorter and the vessel caliber is thinner than
the free transverse rectus abdominis myocutaneous or
deep inferior epigastric artery perforator flaps. Gluteal
flaps are usually less voluminous than flaps from the
abdominal region and range from 300 to 600 g. Follow-
ing closure, the scars are located along the upper gluteal
region (SGAP) or along the infragluteal crease (IGAP).
Medial thigh flaps
The medial thigh donor site provides another alterna-
tive donor site and has demonstrated success for breast
reconstruction (see Chapter 21.3).5–7 Flaps such as the
transverse upper gracilis (TUG), diagonal upper graci-
lis (DUG), and transverse musculocutaneous gracilis
(TMG) have been described. For some surgeons, the
medial thigh is the preferred second choice when the
abdomen is not suitable because the vascular pedicle
is more predictable based on length and caliber. The
caliber of the gracilis vascular pedicle ranges from 1.5 to
2.5 mm. The volume of these medial thigh flaps ranges
from 150 to 550 cc.
Candidates for medial thigh flaps include women
with insufficient abdomen skin and fat, who prefer not
to use the abdomen, and have a moderate amount of
skin and fat in the medial thigh. Other indications
include bilateral reconstructions in which the mastec-
tomy volume approximates the volume of the medial
thigh or meets the expectation of the patient. DUG and
TUG flaps are similar except that the orientation of the
flap is oblique and posterior and parallel to Langer’s
lines.8 The reason for this modification is to minimize
disruption to the superficial lymphatic vessels and to
conceal the incision when viewed from the frontal and
lateral side. Potential adverse events associated with the
TUG flaps include postoperative lymphedema, complex
scarring, and thigh distortion.
Posterior thigh flaps
The PAP flap is becoming the preferred second option
for many surgeons.9,10 This flap is based off the profunda
femoris artery and vein that has several associated
perforators within the posterior compartment of the
thigh (see Chapter 21.4). This flap is often considered as

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SECTION II
CHAPTER 21.1 • Introduction to alternative free flaps for breast reconstruction
2006;59:614–621. The authors describe the technique of harvesting SGAP
and IGAP flaps and demonstrate that these flaps are safe and reliable for
breast reconstruction.
5. 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. A
retrospective review of 111 patients and 154 TMG flaps for breast
reconstruction. Based on excellent outcomes, the authors feel that this flap
may surpass the abdomen as a primary donor site.
6. Vega SJ, Sandeen SN, Bossert RP, et al. Gracilis myocutaneous free
flap in autologous breast reconstruction. Plast Reconstr Surg.
2009;124:1400–1409. The authors review their experience with 27 gracilis
flaps for breast reconstruction. Outcomes included a flap success rate of
100% with an average operating time of 4.9 h for unilateral and 6.7 h for
bilateral flaps.
7. 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. The
authors describe their experience with the TMG flap in 32 patients. Mean
operating time was 3.7 h for unilateral and 5.4 h for bilateral cases. The
vascular pedicle is constant, and the soft tissue component resembles
native breast.
8. Dayan E, Smith ML, Sultan M, et al. The diagonal upper gracilis
(DUG) flap: a safe and improved alternative to the TUG flap. Plast
Reconstr Surg. 2013;132:33–34. This abstract describes the diagonal
upper gracilis flap. The advantages are that the scar is better concealed
and the risk of lymphatic disruption is minimized.
9. Allen RJ, Haddock NT, Ahn CY, et al. Breast reconstruction with the
profunda artery perforator flap. Plast Reconstr Surg. 2012;129:16e–
23e. The authors review their experience with 27 PAP flaps. The skin
paddle measures 27 × 7 cm on average, and the vascular pedicle is 7–3 cm
in length. This flap represents another excellent alternative to the
abdominal donor site.
10. Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator
location on preoperative imaging for the profunda artery perforator
flap. Microsurgery. 2012;32:507–511. CT angiography was performed on
40 patients scheduled for PAP flap breast reconstruction. Preoperative
imaging was found to correlate with observed perforators in all PAP flaps.
Flap survival was 100% in 35 cases.
an alternative to the abdomen and ideally suited for
small to moderate sized breasts with lipodystrophy in
the posterior thigh territory. The weight of this flap
ranges from 250 to 700 g. The advantages of this flap
over gluteal flaps and medial thigh flaps are that lymph-
edema risk is minimal, pedicle length is increased, and
gluteal contour is not affected.
The following three chapters describe the indications,
technical aspects, and outcomes associated with all of
these alternative flaps for breast reconstruction. All are
capable of providing excellent outcomes in properly
selected patients.
References
1. Ahmadzadeh R, Bergeron L, Tang M, et al. The superior and
inferior gluteal artery perforator flaps. Plast Reconstr Surg.
2007;120:1551–1556. This study describes the anatomic basis for these
flaps based on perforator length and caliber. The flaps can be used as
pedicle or free tissue transfer for a variety of indications.
2. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal
artery perforator flap for breast reconstruction. Plast Reconstr Surg.
2006;118:333–339. The authors describe using the inferior gluteal artery
in 59 patients. The flap results in a well concealed scar, can be extended as
needed, not associated with sciatic nerve injury, and is an excellent
alternative to the abdominal donor site.
3. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction
with gluteal artery perforator flaps: a critical analysis of 142 flaps.
Ann Plast Surg. 2004;52:118–125. The authors describe the evolution of
gluteal flaps for breast reconstruction. They report on their 9-year
experience with this flap and describe important refinements, advantages,
disadvantages, and lessons learned.
4. Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction with
gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg.

SECTION II • Reconstructive Breast Surgery
21.2 
Gluteal free flaps for breast reconstruction
Matthew D. Goodwin, Jaime Flores, and Bernard W. Chang
SYNOPSIS
■ Free flap breast reconstruction has advanced in the last 15 years,
especially in the development of perforator flap reconstruction, and
numerous donor sites have been identified based on reliable and
identifiable perforating blood vessels.
■ The mainstay of donor sites remains the abdomen; however, not all
patients are candidates for deep inferior epigastric artery perforator
(DIEP) flap or superficial inferior epigastric artery (SIEA)
reconstructions due to lack of tissue or previous surgery.
■ The gluteal region remains a good secondary source of tissue for
breast reconstruction in most patients, including thin patients. These
flaps usually provide excellent projection and volume for breast
reconstruction. The blood supply is very well defined with fairly reliable
perforators being always present.
■ The difficulty remains in the dissection of these perforators to their
source at the superior gluteal artery or inferior gluteal artery as well as
limitations in pedicle length and vessel mismatch with recipient
vessels.
■ Numerous branches also exist prior to gluteal flap source vessels,
which are typically a better size match distal to these branches for the
internal mammary vessels.
Introduction
Free flap breast reconstruction has advanced significantly
in the last 15 years, especially in the development of
perforator flap reconstruction. Numerous donor sites
have been identified based on reliable and identifiable
perforating blood vessels. The mainstay of donor sites
remains the abdomen; however, not all patients are can-
didates for DIEP flap or SIEA reconstructions due to lack
of tissue or previous surgery. The gluteal region remains
a good secondary source of tissue for breast reconstruc-
tion in most patients who are not candidates for
reconstruction from the abdomen (i.e., paucity of tissue,
previous abdominal surgery including failed transverse
rectus abdominis myocutaneous (TRAM) or DIEP flap
reconstruction, or incisions or scarring that have affected
the blood supply to the abdomen) or have failed implant
reconstruction. These flaps usually provide excellent
projection and volume for breast reconstruction. Suffi-
cient gluteal tissue is usually present, even in very thin
patients, depending on how much tissue is required for
reconstruction. The blood supply is very well defined
with fairly reliable perforators being present. Gluteal
tissue may be harvested based on the superior gluteal
artery (SGAP) or the inferior gluteal artery (IGAP). The
difficulty remains in the dissection of these perforators to
their source at the SGAP or IGAP as well as the limita-
tions in pedicle length and vessel mismatch with recipi-
ent vessels. Numerous branches also exist prior to gluteal
flap source vessels which are typically a better size match
for the internal mammary vessels. This chapter reviews
the anatomy, surgical planning, and execution of the
dissection of gluteal flaps.
Gluteal tissue for autogenous breast reconstruction
was first introduced by Fujino et al. (1975)1 for patients
with congenital aplasia of the breast. Shaw,2 Codner,
and Nahai3 popularized the gluteal myocutaneous
flaps (both superior and inferior gluteal flaps), noting
the disadvantage of a short pedicle necessitating vein
grafts. Koshima et al. (1993)4 described the SGAP flap
for pedicled reconstruction of sacral pressure sores.
Allen and Tucker5 in 1995 first reported the technique
of SGAP flap breast reconstruction. Since then, gluteal
flaps have become an increasingly utilized method of
breast reconstruction in microsurgery even for bilateral
  Access video content for this chapter online at expertconsult.com

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SECTION II
CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
choice if DIEP flap reconstruction is available. The DIEP
flap is usually more popular for donor site cosmetic
reasons. Advantages of the gluteal flap include no risk
of hernia; good projection; sufficient tissue in thin
patients; and a donor site that is relatively well hidden.
This practice’s preference is usually the SGAP flap over
the IGAP flap, mainly because of the better scar donor
site location, which may be more easily hidden under
clothing.
Contraindications
Relative contraindications typically include patients of
poor general medical health, for whom prolonged
surgery and general anesthetic would expose them to
excess risk. Patients who are likely to require radiation
are usually delayed until after radiation treatment to
avoid radiation damage to the flap, which may cause
atrophy and scarring of the tissues and aesthetic changes
in breast shape. Obesity and tobacco use are usually not
exclusionary criteria in this practice; however, the
patient is counseled that risk of flap failure, either com-
plete or partial, is greater. The authors have found a
significantly increased rate of flap failure in patients
with a body mass index greater than 30; therefore SGAP
reconstruction is not recommend for this population.
The increased risk in this population is related to logis-
tics of flap positioning during microsurgical anastomosis
(i.e., increased flap thickness and a relatively short
pedicle). The only absolute contraindication is if there
is inadequate tissue or previous surgery or trauma to
either the donor or recipient sites that would make the
operation too difficult or impossible to perform.
Disadvantages of the gluteal flap include longer
operative times (6–8 h minimum) than the DIEP flap;
potential for vessel mismatch; shorter pedicle length;
thinner donor site veins; more technical skills required
for flap dissection and anastomoses; and a lower success
rate than with the DIEP flap. The main disadvantage of
the IGAP flap is dissection adjacent to the sciatic nerve,
which can result in transient sciatica due to swelling
around the sciatic nerve.
Patient selection
In the authors’ practice, lower abdominal perforators
(DIEP and SIEA) and the SGAP are our most commonly
used flaps for autogenous breast reconstruction. All
patients are examined carefully for sufficient donor site
tissue in these locations and for the possibility of implant
reconstruction. Concomitant variables are assessed
including skin tightness, radiation changes, and any
other relevant medical issues. Patient education is
reconstruction.6 Yet, many breast microsurgeons still do
not perform the procedure due to lack of experience
with the technique and the availability of more familiar
alternatives (e.g., TRAM, DIEP, latissimus dorsi).
While technically demanding, the anatomy of the
superior gluteal donor site consistently has adequate
tissue and vessels for microsurgical transfer on a consis-
tent basis.
Plastic surgeons with good microsurgical experience
should be able to safely and consistently perform
this procedure. Beyond the abdominal tissue donor site,
options for breast reconstruction from other autogenous
donor sites (e.g., latissimus dorsi, anterolateral thigh)
often require an implant to obtain enough volume
for symmetry. Other donor sites are also available but
often have less donor tissue present or less consistent
anatomy and smaller vessels (e.g., profunda artery
perforator, transverse upper gracilis). Gluteal flap breast
reconstruction should be considered a part of any
complete breast reconstructive surgeon’s microsurgical
armamentarium.
Indications and contraindications
■ Usually secondary choice to DIEP flap
reconstruction
■ Most patients are eligible candidates
■ Avoid in obese patients due to shorter pedicle
length and bulk of flap
■ May be indicated for immediate or delayed
reconstruction
■ Consider expanding skin for delayed reconstruction
if skin too tight or radiated
■ Bilateral reconstruction can be performed at once or
each side in two separate operations
• Avoid internal mammary recipient vessels in
patients with cardiac history or strong family
history of cardiac disease.
Indications
Candidates for gluteal flap breast reconstruction may
include patients electing autogenous breast reconstruc-
tion but who do not desire implant reconstruction, or if
the abdominal donor site is unavailable due to previous
surgery, failed abdominal free flap, or those who are too
thin. Implant reconstruction is also less desirable in
patients who have undergone previous chest wall radia-
tion, failed previous reconstruction, or due to patient
preference. In the authors’ practice, gluteal flap recon-
struction may be offered to all patients electing autog-
enous reconstruction; however, it is usually a secondary

377
Operative approach
video, brochure, etc.). It is important to fully inform the
patient so that they may know what to expect; this is
especially important with regard to possible flap failure
or the inability to do reconstruction intraoperatively.
Secondary options, if they exist, should be planned
ahead of time and may be possible with the initial
surgery if the gluteal flap is not feasible at surgery (i.e.,
inadequate recipient vessels). Each stage of the recon-
struction with timing should be explained as well as the
in-hospital stay. Patients need to be advised ahead of
time to avoid positions in the postoperative period that
may cause kinking of the vascular pedicle.
Preoperative computed tomography
angiography for perforator mapping
Although preoperative perforator imaging is not uti-
lized in the authors’ practice, it can be a useful modality
for mapping out perforators prior to surgery if it is
available. The authors have found the perforators to be
uniformly present for gluteal flap reconstruction, and
they are located with a hand-held Doppler. In addition,
this avoids added radiation exposure to the patient and
lowers costs involved with the reconstruction.
Operative approach
Overview
The operation begins with the patient in the supine
position for preparation of the recipient mastectomy
defect and the internal mammary vessels. The internal
mammary vessels are usually exposed at the level of the
3rd medial rib cartilage but may be utilized at the 4th
or 5th cartilage. If a large internal mammary space is
available, dissection may be performed in the interspace
without cartilage removal, but this is not usually done.
If a large internal mammary perforator is present, this
can also be used. If previous internal mammary vessel
dissection has been performed, the vessels may still be
used one level up, or the distal portion of the internal
mammary vessels may possibly be used. In cases where
internal mammary vessels are not available due to
radiation or previous surgery, a vein loop may be created
to the thoracodorsal vessels with a saphenous vein
graft, which may be used for the gluteal flap.
The patient is then placed in the prone position for
unilateral or bilateral flap harvest. After flap harvest, the
flap vessels are prepared with microscopic visualization
on a side-table, while the donor site is being closed. The
patient is then placed back in the supine position for
arterial and venous anastomosis, followed by contour-
ing and insetting of the flap.
important as is assessing the patient’s understanding of
the processes involved in all types of reconstruction.
Ultimately, the patients are given all options that are
reasonable, with their potential risks and complications,
and the patient may choose the method of reconstruc-
tion that they feel comfortable with. Special consider-
ation is given to bilateral reconstruction if SGAP or
IGAP breast reconstruction is chosen. If only one expe-
rienced microsurgeon is available, bilateral reconstruc-
tion is usually staged several months apart due to the
complexity and length of the procedure. If two micro-
surgeons are available, bilateral gluteal flap reconstruc-
tion may be possible with only a moderate increase in
operating room time, since simultaneous flap harvest
may be performed.
Preoperative history and considerations
A thorough preoperative history and physical exam is
necessary prior to surgery due to the length of surgery
and to help avoid complications. In patients who are
newly diagnosed, the type of tumor is important, as
well as the potential for locoregional or distant spread.
These factors may directly impact the outcome if radia-
tion therapy is needed, or if there is a high likelihood
of local recurrence. Some patients may have already
undergone preoperative adjuvant chemotherapy or
previous radiation therapy. In patients who are having
delayed reconstruction, prior radiation to the chest wall
or tight, thin skin may necessitate pre-flap tissue expan-
sion. Other risk factors need to be assessed including
smoking history, age, diabetes, and other general health
issues such as cardiac or pulmonary problems. Past
medical history and physical exam are performed with
attention paid to the donor and recipient sites for evi-
dence of previous surgery or trauma that may compli-
cate the surgery.
The patient is examined with regard to the donor site,
as well as the contralateral breast to assess for symmetry.
Ptotic or large contralateral breasts may require a mas-
topexy or reduction for balancing during second stage
surgery. In rare cases, the patient may have a smaller
breast on the contralateral side that they wish to have
augmented. This needs to be discussed carefully with
the surgical oncologist and the patient before being
pursued. The gluteal region is assessed for adequate
tissue by palpation. The tissue that is utilized for the
SGAP is over the greater sciatic foramen, which can be
palpated and is oriented in an oblique fashion (see
Surgical technique section, below). Inferior gluteal
tissue may be utilized and can be harvested “in-the-
crease” or above.
Patient education is very important and should be
employed with numerous modalities (e.g., consultation,

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CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
following the wrong vessel. Numerous perforating
branches from the superior gluteal artery and venae
comitantes supply the superior buttock tissue and skin,
although usually one or two are dominant. The pedicle
length is typically between 6 and 8 cm. Several cadaveric
anatomic studies of the vascular anatomy for the SGAP
flap have found perforator diameter to range from 0.9 to
1.5 mm.7,8
The inferior gluteal artery and vein emanates from
the anterior division of the internal iliac artery and vein
and also exits the pelvis through the greater sciatic
foramen above the piriformis. The artery travels adja-
cent to the sciatic nerve beneath the gluteus muscle.
Dissection is not always necessary to this level. The
perforator tends to travel more obliquely, and therefore
a slightly longer pedicle may be obtained (7–10 cm).
Surgical technique
Recipient site markings
The outline of the breast for immediate reconstruction
should be marked in the standing upright position with
special reference to the medial, lateral, and inframam-
mary crease (Fig. 21.2.1). These landmarks are especially
important if these areas are disrupted by the surgical
oncologist and need to be anchored at flap inset. If
previous reconstruction or a mastectomy has been per-
formed and a delayed reconstruction is planned, appro-
priate borders are marked, based on judgement, using
the contralateral breast if available, as a guide. Previous
scars are marked to make safe skin flaps. The 3rd costal
cartilage is palpated and marked.
Donor site markings
The SGAP flap design should be centered over the main
perforators of the superior gluteal artery (Fig. 21.2.2).
These can be found by palpating the greater sciatic
foramen and are confirmed by a hand-held Doppler,
with the patient prepped or in the preoperative area
with the patient prone (Figs. 21.2.3–21.2.5). The flap
markings should then be adjusted with these Dopplered
points as the central portion of the flap. The dominant
perforators usually lie a few centimeters below the upper
edge of the greater sciatic foramen. The axis of the flap is
slightly oblique or may be more horizontally oriented.
The medial extension of the flap design is usually located
several centimeters below the upper portion of the mid-
gluteal crease and may be curved down to avoid a dog-
ear. The width of the flap is usually between 8 and 12 cm
and may be closed with slight undermining.
IGAP flap design begins with the lower border of
the flap in the gluteal crease, and the upper edge of the
flap may be outlined after Doppler confirmation of
Basic science/anatomy
Perforator flap reconstruction relies on blood supply to
the skin and fat emanating from the perforating vessels,
which travel between underlying muscle fibers, in some
cases, as intermuscular vessels. These vessels are dis-
sected out as a pedicle through the muscle fibers down
to their origin and terminate in the overlying skin and
fat. This pedicle is divided and re-anastomosed to
recipient vessels at the site of reconstruction as a free
tissue transfer.
The primary recipient vessel choice for SGAP recon-
struction is the internal mammary artery and vein. In the
authors’ experience, the internal mammary vessels are
almost always available, even after failed DIEP recon-
struction, since the thoracodorsal vessels are the preferred
recipient vessels for DIEP flaps. Alternatively, if the
internal mammary vessels have already been used, dis-
section may be performed one rib space further cephalad.
The second rib cartilage is easily palpated for reference,
and the third cartilage is usually removed medially
through a split in the pectoral muscle. Occasionally, the
4th or 5th rib cartilage may be used. The internal
mammary vessels are located fairly medially. Each
respective internal mammary artery (IMA) originates
from the first part of the subclavian artery and descends
behind the costal cartilages 1–1.5 cm lateral to the sternum
with numerous branches to the intercostals and perfora-
tors to the overlying breast tissue and skin. It ultimately
splits to supply the musculophrenic and superior epigas-
tric arteries at the level of the 6th costal cartilage. At the
level of the 3rd costal cartilage the IMA diameter is
approximately 2–3 mm in diameter and is usually
accompanied by 1–2 venae comitantes which drain into
the respective brachiocephalic veins. Internal mammary
vein diameter typically ranges from 2.5–3.5 mm.
Alternative recipient vessels include the thoracodor-
sal vessels but are less ideal given the short flap pedicle
length of the SGAP. Cephalic vein turndown from the
shoulder may be used as a venous backup or for addi-
tional venous drainage if necessary and is identified
between the clavicular and sternal head of the pectoralis
major muscle. It can be dissected distal into the upper
arm through several small counter incisions.
The superior gluteal artery and vein emanate from the
pelvis through the greater sciatic foramen above the piri-
formis muscle, just under the subgluteal fat pad. Several
large branches exist at this level traveling along the
periosteum and into the overlying muscle. The main
vessels and several small branches typically lie against
the periosteum, making dissection difficult. Some sur-
geons have referred to this region as “Medusa’s Head”
due to the number of branches and to the risk of

379
Operative approach
Fig. 21.2.1  (A,B) The outline of the breast for immediate
reconstruction should be marked in the standing upright
position with special reference to the medial, lateral, and
inframammary crease. The preferred location for exposure
of the internal mammary artery and vein is the 3rd
interspace.
A
B
Fig. 21.2.2  The superior gluteal artery perforator flap design should be centered
over the main perforators of the superior gluteal artery.
Fig. 21.2.3  The main perforators of the superior gluteal artery can be found by
palpating the greater sciatic foramen and are confirmed by a hand-held Doppler
with the patient prepped or in the preoperative area with the patient prone.

380
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CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
Fig. 21.2.5  The main perforators of the superior gluteal artery can be found by
palpating the greater sciatic foramen and are confirmed by a hand-held Doppler
with the patient prepped or in the preoperative area with the patient prone.
Fig. 21.2.6  Note the quality and caliber of the internal mammary vessels.
electrocautery and a Freer elevator. Great care must be
maintained when under the cartilage because the vessels
and the parietal pleural are located immediately poste-
rior. The cartilage is removed by use of a rib-cutter and
rongeur up to the edge of the sternum.
The posterior perichondrium is opened laterally with
a 15-blade, and a Freer elevator is passed beneath the
perichondrium above the internal mammary vessels.
The perichondrium is opened longitudinally with scis-
sors and the vessels exposed. Intercostal muscle is
divided along the entire interspace between the 2nd and
4th costal cartilages. There will often be some remaining
fascia overlying the vessels that can be carefully removed
by use of a Freer elevator and Metzenbaum scissors. The
vessels themselves are then separated along their extent
to facilitate mobility upon ligation prior to anastomosis.
Note the quality and caliber of the vessels (Figs. 21.2.6).
The recipient site is temporarily closed with staples and
a bio-occlusive dressing is placed.
perforators above the lower flap margin. The width of
the flap is usually between 8 and 12 cm.
Recipient site preparation
The patient is prepped and draped in the supine posi-
tion. This may have been done prior to mastectomy by
the oncologic breast surgeon. If a previous reconstruc-
tion has been performed, remaining tissue or implant
material is removed. A capsulectomy is performed if
capsular tissue is present. The recipient bed is assessed
for areas where the breast borders may have been vio-
lated by the resection. These can be re-established with
interrupted 3-0 Vicryl sutures. The 3rd costal cartilage
is then located by palpation in the upper medial quad-
rant. Dissection by electrocautery is used to split the
pectoralis muscle along fibers and expose the costal
cartilage. The perichondrium is dissected off by use of
Fig. 21.2.4  The main perforators of the superior gluteal artery can be found by
palpating the greater sciatic foramen and are confirmed by a hand-held Doppler
with the patient prepped or in the preoperative area with the patient prone.

381
Operative approach
Occasionally, IMA perforators can be found that are
adequate for recipient vessel anastomosis. This neces-
sitates their having been left following the mastectomy
and their having sufficient caliber. This technique,
however, can spare the patient significant morbidity
from harvest of the rib cartilage and spares the vessels
for potential future procedures such as coronary artery
bypass.
Donor flap dissection
The patient is then repositioned in the prone position.
The patient is re-prepped and draped. Through the use
of a hand-held Doppler probe, several arterial perfora-
tors may be identified. These usually lie a few centime-
ters inferior to the marked site of the center of the
greater sciatic foramen. If necessary, the flap marking
is adjusted so that these perforators lie at the central
portion of the flap. The skin is incised, and dissection
proceeds with electrocautery (power 30–40 W) beveling
away from the flap for improved contour. Dissection
continues directly down to the underlying muscle.
Flap elevation is performed from the lateral and medial
aspect of the flap to identify perforators. Upon encoun-
tering the muscle at the lateral edge of the buttock,
electrocautery is decreased to begin the careful search
for perforators. The iliotibial band of the fascia lata is
most lateral. The gluteal fat is lifted off this fascia
until the insertion of the gluteus maximus is encoun-
tered. This is noted when muscle fibers change from a
cephalad-caudal direction to an oblique-downward
lateral direction. At this point, the fascia is incised
and dissection proceeds directly on the muscle in the
subfascial plane taking care to identify and protect
potential perforators (Fig. 21.2.7 & 21.2.8). Usually
1–3 potential perforators are discovered. The authors
Fig. 21.2.7  The fascia is incised, and intraoperative depiction of the dissection
proceeding along the surface of the gluteus maximus muscle
Fig. 21.2.8  The fascia is incised, and schematic illustration depicting the subfacial
dissection to isolate the perforator
typically utilize one perforator that has adequate
caliber; however, very occasionally two perforators are
utilized, especially if they are close together and are
lined up in the same muscle split.
Dissection continues through the muscle adjacent to
the perforator, with the use of a long hemostatic forcep/
clamp (Figs. 21.2.9 & 21.2.10). Vessel clips are used
liberally to divide the numerous muscular branches.
Fig. 21.2.9  Schematic illustration demonstrating the intramuscular dissection of
the superior gluteal artery perforator.

382
SECTION II
CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
dissection is necessary here to avoid deep bleeding.
Once the pedicle is free from the periosteum and
branches are divided, the artery and vein are cleaned
and sometimes separated (Video 21.2.1
). For IGAP
flap dissection, the perforator is dissected in a muscle
split in the gluteus maximus and is followed until
adequate arterial vessel diameter is found, which is
often prior to the greater sciatic foramen. There are less
branches encountered in this dissection, and periosteal
branches are less often visualized (Video 21.2.2
).
Preparing for pedicle division, it is our practice to
give the patient 5000 units of intravenous heparin. At
5 min after giving heparin, the artery and vein are
divided with vessel clips and ischemia time is noted.
The remaining portion of the flap is dissected off with
electrocautery. The flap is then removed from the field
and placed onto a side-table for microdissection and
separation of the artery and vein within the pedicle with
the use of the sterile draped microscope (Fig. 21.2.13).
Self-retaining retractors are placed and frequently
adjusted to enable sufficient visualization of the deep
dissection. For SGAP flaps, the pedicle dissection will
usually lead to fascial edges of either the gluteus medius,
minimus, or piriformis muscles. These must also be
released for several centimeters to allow for adequate
visualization (Fig. 21.2.11). As the dissection proceeds
deeper beneath these fascial planes, numerous large and
small periosteal branches are encountered (Medusa’s
Head). Care must be taken to examine each branch to
avoid damaging the pedicle. It is important not to ter-
minate dissection too early to preserve pedicle length
and to have adequate arterial diameter for a good size
match to the IMA. Pedicle length typically ranges
between 6 and 8 cm (Fig. 21.2.12). At the deepest extent
of the dissection, the pedicle lies along the periosteum
of the pelvis as it passes through the greater sciatic
foramen. As it does so, numerous small branches exist
and go under, in, and over the periosteum. Careful
Fig. 21.2.10  Intraoperative image demonstrating the intramuscular dissection of
the gluteal artery perforator.
Fig. 21.2.11  The pedicle dissection will usually lead to fascial edges of either the
gluteus medius, minimus, or piriformis muscles. These must also be released for
several centimeters to allow for adequate visualization.
Fig. 21.2.12  Pedicle length typically range at 6–8 cm.
Fig. 21.2.13  The flap is then removed from the field and placed onto a side-table
for microdissection and separation of the artery and vein within the pedicle with the
use of the sterile draped microscope.

383
Operative approach
The venous anastomosis is next performed with a
venous coupler device (Synovis Micro Companies Alli-
ance, Birmingham, AL; Fig. 21.2.14). A vessel sizer is
utilized to choose the appropriate coupler size. The
authors usually use coupler sizes ranging from 2.0 to
3.5 mm. A vessel clip is placed on the distal end of the
recipient vein usually located just above the 4th rib. A
single Acland clamp is placed on the proximal side. The
vein is divided just proximal to the clip with microscis-
sors. The recipient side vein end is then cleaned and
freshened. The flap side vein is placed in a single Acland
clamp. The two venous ends are placed within the
coupler holes and secured to the prongs. When ready,
the coupler device is activated for anastomosis.
The Acland clamps are removed in the following
order: distal vein, proximal vein, distal artery, proximal
artery. End of ischemia time is noted. The anastomoses
are assessed for patency and for leaks. Occasionally,
additional sutures are needed to stop arterial leaks.
Mild oozing is monitored for several minutes; this will
usually stop. Continued oozing from the venous side
The artery is cleaned first, and a microclamp is applied
to the vein. Sterile saline is then infused antegrade in
order to dilate the venous system. This facilitates pre-
paring the venous end, which normally is very thin,
friable, and floppy. Furthermore, the inside of the vein
must be assessed for nearby valves that could create an
obstruction. If a valve is noted near the end of the vein,
another site proximal to the valve should be selected
and prepared.
The donor site is irrigated and assessed for hemosta-
sis. The muscle is closed with interrupted 2-0 Vicryl
sutures. A single fluted 15 French drain is placed coming
out at the superior lateral end of the wound. The deep
fat and Scarpa’s fascia are closed with interrupted 2-0
Vicryl sutures. Extra sutures are often placed in the
central portion because this is the area of greatest
tension. The skin is closed with interrupted 3-0 Vicryl
inverted dermal sutures, a running 4-0 Monocryl sub-
cuticular suture, and DermaBond.
Anastomosis and flap inset
Along with operating room staff, the team member that
closed the donor site re-preps the patient. The patient is
returned to the supine position. The recipient site expo-
sure is obtained with large retractors and sutures to
retract the skin.
Once the flap preparation on the side-table is com-
plete, it is brought into the surgical field. It is placed in
a surgical towel and secured with towel clips in a
manner that facilitates appropriate placement and
exposure of the anastomosis. Given the thickness of
gluteal flaps, which can impede direct vision of the
anastomosis, the authors often elevate the back of the
patient to ease visualization. This is where optimized
pedicle and recipient vessel length is valuable.
The microscope is placed over the field in a position
appropriate for both the microsurgeon and assistant.
The pedicle and recipient sites are reassessed, further
prepared, and approximated for anastomosis.
The arterial anastomosis proceeds first. The recipient
artery is clipped distally. This is usually just above the
4th rib. A double Acland clamp is placed on the proxi-
mal side. The artery is divided just proximal to the clip
with microscissors. The artery is then assessed for
patency and adequate blood pressure by quickly and
carefully releasing and then replacing the Acland
clamp. The recipient arterial end is then cleaned and
freshened. The flap side artery is then placed in the
other side of the double Acland clamp, approximating
the two arterial sides. Using an 8-0 nylon microsuture
in an interrupted fashion, the arterial ends are
anastomosed.
Fig. 21.2.14  The mastectomy skin flaps are trimmed and the gluteal flap skin
de-epithelialized as necessary for appropriate inset.

384
SECTION II
CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
per os (NPO) for the first postoperative night. They
receive intravenous fluid, antibiotics, and pain control
by patient-controlled analgesic (PCA). Postoperative
deep venous thrombosis (DVT) prophylaxis should be
used routinely with sequential compression devices.
Adjuvant DVT prophylaxis (e.g., subcutaneous heparin,
enoxaparin, etc.) should be considered, especially in
overweight or obese patients.
On postoperative day 1, the patient is transferred to
the surgical floor if the flap is assessed as successful.
They are begun on a clear diet and advanced as toler-
ated. Activity may also include transferring to a reclin-
ing chair.
On postoperative day 2, the patient’s Foley catheter
is removed and she may begin ambulating. Pain control
is changed to oral pills. Occupational therapy and drain
care teaching is employed to prepare the patient for
discharge.
On postoperative day 3, if the patient is tolerating
food, oral pain control, ambulation, and voiding spon-
taneously, she may be discharged from the hospital with
instructions to follow-up in the clinic 1 week later.
Prescriptions for pain control and antibiotics are pro-
vided. Furthermore, the patient is instructed to limit
activity but may shower. Home nursing care to assist
with drain care is often prescribed.
The 1st week follow-up appointment usually consists
of drain removal from the breast pocket. The patients
return for further follow-up appointments as necessary
for removal of the donor site drain and revision plan-
ning. As stated above, percutaneous aspiration of
seromas is often required.
Long-term care
The intervals between each step are usually 3 months;
therefore the entire process can take 6 months to 1 year,
or longer if complications occur. Upon completion, the
patient should return for yearly follow-up for cancer
surveillance. Gluteal flaps will grow and shrink with
weight fluctuations and develop progressive ptosis,
similar to the contralateral breast. Unlike implant recon-
struction, further surgery is usually unnecessary.
Bilateral gluteal flap reconstruction
When the surgical team includes two microsurgeons,
simultaneous bilateral SGAP or IGAP reconstruction
can be performed safely and with reasonable operative
times.9,10 Each side can be operated on simultaneously
for most of the procedure except for when using the
microscope for anastomosis. Ideally, each side has its
own separate team including assistant, surgical scrub
technician, and surgical instruments.
will usually require removal and revision of the coupler
device.
Once the anastomoses are deemed patent and intact,
the path of the pedicle is assessed for potential sites of
compression or kinking. The authors will often divide
some extra muscle on the edges to prevent compression
on the pedicle or create a groove in the muscle with
cautery. This is also a good point to ensure recipient site
hemostasis.
The retractors are then removed and the flap inset.
Take care to avoid over-rotation and stretching of the
pedicle. Occasionally, it is useful to place several deep
absorbable sutures securing the Scarpa’s layer of the flap
to the chest wall in order to prevent sliding of the flap that
may damage the pedicle. Most often, however, the skin
envelope with dermal sutures are used to secure
the flap.
A fluted 15 French drain is placed exiting through the
skin in the axilla. The drain position should be away
from the pedicle.
The mastectomy skin flaps are trimmed and the
gluteal flap skin de-epithelialized as necessary for
appropriate inset (see Fig. 21.2.15). Care must be taken
to avoid an overly tight skin envelope that can compress
the flap. A hand-held Doppler probe is used to re-identify
the cutaneous arterial perforators. These are marked
and the gluteal flap skin paddle designed around
them for postoperative monitoring. Alternately, Vioptix,
transcutaneous oxygen monitoring for flap monitoring,
which may also be connected to WiFi for mobile phone
or computer access, can be used.
The skin is closed with interrupted 3-0 Vicryl deep
dermal sutures, a running 4-0 Monocryl subcuticular
suture, and DermaBond.
The patient is undraped, cleansed, and anesthesia
terminated. This marks the end of the operation.
Postoperative care
Immediate
Patients are relieved of general anesthesia and extubated
in the operating room upon completion of the opera-
tion. They may be transferred to the recovery room or
directly to the observation/ICU. The patient typically
will spend the first postoperative night in this
observation/ICU. The level of care required in this
unit must permit hourly patient and flap monitoring.
Nursing staff should be aware of signs of flap compro-
mise including color changes, flap temperature, capil-
lary refill times, loss of Doppler pulse, and expanding
hematoma. Patients remain on bedrest and nothing

385
Complications and side effects
■ Microsurgical technique
■ Patient anatomy
■ Patient risk factors
■ Postoperative care.
For published series of greater than 10 SGAP recon-
structions, flap failure rates range from 0% to 7.7%.10–13
In the authors’ unpublished data of 106 flaps on 90
patients over 7 years, the flap success rate has increased
yearly as experience has increased from 88.7% to 96.5%,
with an overall success rate of 92.5%.14
Even with these listed factors, surgical technique is
usually a component of every flap failure, especially
complete flap loss. Meticulous microsurgical technique
can avoid anastomotic obstruction. Details of technique
are, however, beyond the scope of this chapter. Venous
occlusion is also responsible for the vast majority of
flap failures.15 The pedicle can be compromised from
kinking, stretching, a tight skin closure, or an expanding
hematoma or seroma. Attention to detail cannot be
overstressed.
Occasionally, patient anatomy prohibits gluteal flap
reconstruction. Patients having had radiation may have
scarred or thrombosed IMA vessels. Very rarely, patients
simply have vessels that are too small for free flap
reconstruction.
Patient risk factors including smoking, atherosclerosis,
obesity, hypertension, and hypercholesterolemia often
negatively impact outcome. These can contribute to
partial flap loss. Various blood clotting disorders can also
lead to clotted venous pedicles or excessive bleeding.
Postoperative care is important in preserving the
integrity of the flap and its perfusion. Excessive motion
or inappropriate patient positioning can compromise
the flap pedicle. Furthermore, frequent flap monitoring
by those knowledgeable on the signs of flap compromise
can potentially lead to a failing flap being saved.
Other complications include bleeding, hematoma,
seroma, infection, wound breakdown, scarring, pain,
and pneumothorax.
How to prevent and manage complications
Bleeding and hematoma are prevented by meticulous
hemostasis. An enlarging hematoma can potentially
lead to a venous clot when compressing on the pedicle.
Expanding flap pocket, change in color of flap or mas-
tectomy skin, tachycardia, and anemia are all signs that
should raise suspicion. There should be a low threshold
for returning to the operating room for evacuation when
present in the immediate postoperative period.
Seroma is a long-term sequela that most often pre-
sents at the donor site (>80% SGAP patients). Drains are
left in the reconstruction site and donor site until daily
Revisions
Complete gluteal flap reconstruction usually requires
three or four procedures on separate visits. These include:
■ The initial free flap, as described above.
■ Gluteal flap reshaping usually is performed at least
3 months following the initial free flap. This usually
involves trimming or removing the remaining skin
paddle and softening the edges of the flap to
improve breast shape. Occasionally, some
liposuction is utilized for shaping and softening
areas of fat necrosis. The authors are increasingly
utilizing fat grafting for flap enlargement or contour
deformities. Often, this is combined with a
contralateral breast reduction, mastopexy, or
augmentation as necessary to improve symmetry.
■ The donor site scar is often revised at this point,
with trimming of dog-ears and liposuction of
irregularities to improve upper buttock contour. The
contralateral buttock is also sometimes treated with
liposuction for symmetry.
■ Reconstruction of the nipple areolar complex (NAC)
can sometimes be performed in the second stage
when adequate symmetry between breasts is present.
If a procedure for symmetry is required, however,
NAC reconstruction should be delayed until a third
stage. There are numerous techniques in the
literature adequate for NAC reconstruction. The final
procedure performed, after all shaping and
symmetry procedures are healed, is tattooing of the
NAC.
Sensate SGAP flap
Including nervous repair in the SGAP reconstruction
has been described for creating a sensate breast recon-
struction.12 Typically 1–2 nerve perforators are repaired
to the T4 thoracic nerve branch.
Complications and side effects
The most serious complications in SGAP reconstruction
are those similar to all surgeries requiring general anes-
thesia: myocardial infarction, DVT, pulmonary embo-
lism, possibly even death. SGAP surgery, especially
when combined with mastectomy, is prolonged, usually
more than 6 h, which raises these risks. Patient selection
based on medical history, physical examination, and
preoperative testing is paramount for avoiding these
disasters.
Flap failure is the most serious complication specific
for free flap reconstruction.
Flap failure, partial or complete, can be the result of
a multitude of factors. These include:

386
SECTION II
CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
relieve atelectasis. Long-term pain from scarring or
pinched nerves is rare but possible and should be treated
appropriately.
It is uncommon for patients to develop a symptom-
atic pneumothorax from the rib cartilage resection.
Careful dissection and rib removal should avoid dam-
aging the parietal pleura. If a pneumothorax is sus-
pected, diagnosis can be confirmed with radiographs.
A small pneumothorax can often be treated with a
small suction tube and immediately closed. More sig-
nificant lung collapse should be treated with thoracos-
tomy tube suction.
Patient examples
Various patient examples are shown for SGAP and
IGAP procedures, in Figs. 21.1.15–21.2.22.
Conclusion
As autogenous tissue has become increasingly utilized
for breast reconstruction, surgical techniques have
evolved, setting new standards and raising patient
expectations. Traditional donor sites for breast recon-
struction may not be available, yet the same outcome is
still expected. SGAP or IGAP reconstruction is a valuable
option for patients that are not candidates for reconstruc-
tion using their abdominal tissue. While it is a challeng-
ing procedure, it has relatively consistent anatomy and
provides excellent results, thus making it an important
part of the breast reconstructive surgeon’s repertoire.
drainage drops to less than 30 cc/day consistently. This
is usually 1 week at the reconstruction site and 2–3
weeks at the donor site. Despite this, seromas often form
at the donor site requiring percutaneous aspiration
during follow-up visits. Seromas should not be left to
expand without treatment to avoid potential wound
breakdown.
Wound infections at either surgical site are rare. Pre-
and intraoperative antibiotics should be given routinely
in this surgery. The authors also give a short course of
postoperative antibiotics. Erythema, swelling, or puru-
lent drainage are signs of infection that should be
aggressively treated with antibiotics and/or surgical
drainage as necessary.
Wound breakdown typically results from the afore-
mentioned complications. It should be treated with
standard local wound care.
As with any surgery, scars are a sequela of every
incision. Therefore, the surgeon must balance the need
for surgical exposure with the development of scarring.
Patients should be educated preoperatively regarding
these scars in order to have realistic expectations of the
final cosmetic result. Scar revision and treatment of
deeper fibrotic scars and fat necrosis are usually per-
formed in the revision stages.
The most acutely painful site in this surgery is typi-
cally where the rib cartilage is removed. A PCA usually
provides adequate pain control. The authors prefer
avoiding the use of non-steroidal anti-inflammatory
drugs (e.g., ketorolac) in the immediate postoperative
period, from fear of bleeding complications. Patients
will often have some degree of splinting; therefore, an
incentive spirometer should be utilized routinely to
Fig. 21.2.15  (A–D) History of radiation therapy to left chest after mastectomy. Bilateral superior gluteal artery perforator reconstruction.
A
B
Text continued on p. 391

387
Conclusion
C
D
Fig. 21.2.15, cont’d
A
B
Fig. 21.2.16  (A–D) Bilateral prophylactic mastectomy for BRCA1. Bilateral superior gluteal artery perforator reconstruction. Skin paddle shown for monitoring the flap and
final result.
C
D

388
SECTION II
CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
Fig. 21.2.17  (A–D) Delayed right and immediate left superior gluteal
artery perforator..
A
B
C
D
Fig. 21.2.18  (A–D) Immediate bilateral SGAP.
A
B

389
Conclusion
Fig. 21.2.19  (A–C) Left delayed superior gluteal artery perforator with history of
radiation therapy and failed deep inferior epigastric artery perforator to internal mammary
vessels. Saphenous vein loop to thoracodorsal vessels.
A
B
C
C
D
Fig. 21.2.18, cont’d

390
SECTION II
CHAPTER 21.2 • Gluteal free flaps for breast reconstruction
Fig. 21.2.20  (A) preoperative image; (B) postoperative image following bilateral
SGAPs; (C) postoperative image of the gluteal donor site.
A
B
C
A
B
Fig. 21.2.21  (A) preoperative image; (B) postoperative image following bilateral
SGAP flaps; (C) postoperative image of the gluteal donor site.
C

391
Conclusion
Fig. 21.2.22  (A,B) Bilateral nipple-sparing mastectomy and immediate inferior gluteal artery perforator..
A
B
2. Shaw WW. Superior gluteal free flap breast reconstruction. Clin
Plast Surg. 1998;25:267–274. Illustrates some of the early work done on
the anatomy of this region and how the SGAP evolved.
3. Codner MA, Nahai F. The gluteal free flap breast reconstruction:
making it work. Clin Plast Surg. 1994;21:289–296. Helpful tips for
performing this difficult surgery.
5. Allen RJ, Tucker C. Superior gluteal artery perforator free flap for
breast reconstruction. Plast Reconstr Surg. 1995;95:1207–1212. Good
overall review of anatomy and technique for SGAP reconstruction.
6. Flores JI, Magarakis M, Venkat R, et al. Bilateral simultaneous
breast reconstruction with SGAP flaps. Microsurgery. 2012;32:344–
350. Another example of how bilateral SGAPS can be accomplished by
two skilled microsurgeons.
7. Mu LH, Yan YP, Luan J, et al. Anatomy study of superior and inferior
gluteal artery perforator flap. Zhonghua Zheng Xing Wai Ke Za Zhi.
2005;21:278–280. Helps to understand the vessel anatomy in this region.
8. Kankaya Y, Ulusoy MG, Oruç M, et al. Perforating arteries of the
gluteal region. Ann Plast Surg. 2006;56:409–412. Helps to understand
the perforator anatomy of the SAP and IGAP flap.
10. Della Croce FJ, Sullivan SK. Application of the superior gluteal
artery perforator free flap for bilateral simultaneous breast
reconstruction. Plast Reconstr Surg. 2005;116:87–104. Not for the
average microsurgeon but shows how bilateral gluteal flaps may be
performed by two microsurgeons.
11. Munhoz AM, Ishida LH, Montag E, et al. Perforator flap breast
reconstruction using internal mammary perforator branches as a
recipient site: an anatomical and clinical analysis. Plast Reconstr
Surg. 2004;114:62–68. An alternative for recipient vessels for the SGAP
flap.
15. Nahabedian MY, Momen B, Manson PN. Factors associated with
anastomotic failure after microvascular reconstruction of the breast.
Plast Reconstr Surg. 2004;114:74–82. Helps to understand the pitfalls of
micro-anastomotic failure.
Access the complete reference list online at

391.e1
References
References
1. Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasia of the
breast and pectoral region by microvascular transfer of a free flap
from the buttock. Plast Reconstr Surg. 1975;56:178–181.
2. Shaw WW. Superior gluteal free flap breast reconstruction. Clin
Plast Surg. 1998;25:267–274. Illustrates some of the early work done on
the anatomy of this region and how the SGAP evolved.
3. Codner MA, Nahai F. The gluteal free flap breast reconstruction:
making it work. Clin Plast Surg. 1994;21:289–296. Helpful tips for
performing this difficult surgery.
4. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based
flap for repair of sacral pressure sores. Plast Reconstr Surg.
1993;91:678–683.
5. Allen RJ, Tucker C. Superior gluteal artery perforator free flap for
breast reconstruction. Plast Reconstr Surg. 1995;95:1207–1212. Good
overall review of anatomy and technique for SGAP reconstruction.
6. Flores JI, Magarakis M, Venkat R, et al. Bilateral simultaneous
breast reconstruction with SGAP flaps. Microsurgery. 2012;32:344–
350. Another example of how bilateral SGAPS can be accomplished by
two skilled microsurgeons.
7. Mu LH, Yan YP, Luan J, et al. Anatomy study of superior and
inferior gluteal artery perforator flap. Zhonghua Zheng Xing Wai Ke
Za Zhi. 2005;21:278–280. Helps to understand the vessel anatomy in this
region.
8. Kankaya Y, Ulusoy MG, Oruç M, et al. Perforating arteries of the
gluteal region. Ann Plast Surg. 2006;56:409–412. Helps to understand
the perforator anatomy of the SAP and IGAP flap.
9. Guerra AB, Soueid N, Metzinger SE, et al. Simultaneous bilateral
breast reconstruction with superior gluteal artery perforator (SGAP)
flaps. Ann Plast Surg. 2004;53:305–310.
10. Della Croce FJ, Sullivan SK. Application of the superior gluteal
artery perforator free flap for bilateral simultaneous breast
reconstruction. Plast Reconstr Surg. 2005;116:87–104. Not for the
average microsurgeon but shows how bilateral gluteal flaps may be
performed by two microsurgeons.
11. Munhoz AM, Ishida LH, Montag E, et al. Perforator flap breast
reconstruction using internal mammary perforator branches as a
recipient site: an anatomical and clinical analysis. Plast Reconstr
Surg. 2004;114:62–68. An alternative for recipient vessels for the SGAP
flap.
12. Blondeel PN. The sensate free superior gluteal artery perforator
(SGAP) flap: a valuable alternative in autologous breast
reconstruction. Br J Plast Surg. 1999;52:185–193.
13. Feller AM, Richter-Heine I, Rudolf KD. The superior gluteal artery
perforator flap (S-GAP flap). HandchirMikrochir Plast Chir.
2002;34:257–261.
14. Huang K, Chang B. Consecutive superior gluteal artery perforator
(SGAP) flaps in a community hospital: a single surgeon’s experience.
Presented at the World Society of Reconstructive Microsurgery
meeting, Athens, Greece, June 2007.
15. Nahabedian MY, Momen B, Manson PN. Factors associated with
anastomotic failure after microvascular reconstruction of the breast.
Plast Reconstr Surg. 2004;114:74–82. Helps to understand the pitfalls of
micro-anastomotic failure.

SECTION II • Reconstructive Breast Surgery
21.3 
Medial thigh flaps for breast reconstruction
Venkat V. Ramakrishnan and Nakul Gamanlal Patel
SYNOPSIS
■ Autologous free tissue transfer has proved to be an ideal method for
breast reconstruction with long-standing aesthetic outcome.
■ Many women undergo procedures on their abdomen or would want to
avoid surgery that uses the abdomen as a donor site.
■ Alternative autologous options include the transverse upper gracilis
(TUG) flap.
■ Understanding of the anatomy helps with the potential donor site
morbidity.
■ The TUG flap is not only useful for women with small- to moderate-
sized breasts with no available lower abdominal tissue but also
occasionally for larger breasts.
■ The criticism of this flap has been its short vascular pedicle, limited
volume that can be achieved, and the donor site morbidity.
Access the Historical Perspective section and
Fig. 21.3.1 online at

Introduction
The transverse upper gracilis (TUG) flap, also known
as the transverse myocutaneous gracilis (TMG) flap,
with the variations in flap design, is a useful donor site
when abdominal flaps are not an option.
Careful patient selection is essential for optimal breast
and donor site outcomes. This flap can be harvested
in the supine position, thereby allowing a two-team
approach. It provides soft and easily moldable tissue
with an early recovery.
Operative considerations focus on minimizing donor
site morbidity, ensuring adequate tissue harvest, and
contouring of the flap.
More posterior shift of the skin paddle, caudal exten-
sion of sub-Scarpa fat, recruitment of posterior thigh fat,
preservation of the saphenous vein with the accompa-
nying lymphatics, and limiting the muscle harvest
reduce morbidity and allow adequate tissue harvest.
Pleasing breast shape can be achieved by molding the
flap in three ways, to match the breast morphology. The
use of intercostal perforators as the recipients, adjunc-
tive procedures such as primary lipofilling of the pecto-
ralis or the gracilis muscle, additional flaps, and use of
implants increase the applications of the flap. The main
criticisms of the TUG flaps are limited volume, short
pedicle, and donor site issues.
The variations in skin paddle design including the
extended TUG and the diagonal upper gracilis (DUG)
flaps are useful variations of this flap.
Basic science/disease process
The gracilis muscle is a type II musculocutaneous flap
in the Mathes and Nahai classification.12 The myocuta-
neous gracilis flap can be designed with several skin
paddle types, and there are numerous acronyms. These
include transverse upper gracilis (TUG), transverse
myocutaneous gracilis (TMG), diagonal upper gracilis
(DUG), vertical upper gracilis (VUG), and bilateral
stacked vertical upper gracilis (BUG).13–16 This chapter
will focus on the TUG flap (Fig. 21.3.2).
Anatomical studies have demonstrated that the
angiosomes of the upper gracilis muscle lie at 90° to the
muscle, hence a transverse skin paddle has been more
reliable.6,17
  Access video content for this chapter online at expertconsult.com

392.e1
Historical perspective
Historical perspective
The gracilis muscle flap was first described by Pickrell
for rectal sphincter reconstruction in 1952.1 Two decades
later, Orticochea first used the gracilis myocutaneous
flap to reconstruct an ankle defect.2 In 1976, Harii and
colleagues reported the first free gracilis myocutaneous
flap where they presented canine models, cadaver dis-
sections, and clinical applications for reconstruction of
the head and neck and lower extremity.3
Orticochea was the first to describe the gracilis mus-
culocutaneous flap without the delay maneuver.2 He
recognized that the skin survival was based on the
vascular supply of the underlying muscle.
McCraw and colleagues developed the theory and
conceptualized the musculocutaneous perforators. The
skin paddle over the muscle remained unreliable with
a longitudinal skin paddle. They described partial flap
necrosis in 27% of their patients and major flap necrosis
in 9%.4 In a larger review of 192 gracilis musculocutane-
ous flaps, the results of flap necrosis with a longitudinal
skin paddle remained high.5
The TUG myocutaneous flap was first used in breast
reconstruction in 1992 by Yousif and colleagues.6 They
mapped the musculocutaneous perforators and devised
the transverse skin paddle within the upper third of the
muscle, which had a significantly more reliable skin
paddle (Fig. 21.3.1).
Hallock reported modifications of the TUG flap by
identifying the perforators off the medial circumflex
femoral artery. He used this flap predominantly for
lower leg reconstruction for trauma patients.7,8 The free
TUG flap was used for breast reconstruction by Arnez
in seven patients, in which he had five successful recon-
structions.9 In 2004, Schoeller and Wechselberger
described 12 TUG flaps for breast reconstruction that
were all successful. It is this work that has led to the
popularity for the TUG flap for breast reconstruction.10
Peek et  al. delineated the anatomy of the blood
supply to the gracilis muscle and surrounding skin
and described variations of the TUG perforator flap
for breast reconstruction. They found an average of
5 perforators per thigh in a study of 43 cadaver
dissections.11
Fig. 21.3.1  Timeline for the transverse upper gracilis flap.

393
Patient selection
Patient selection
If the abdomen cannot be used as a donor site due to
multiple scars or patient preference, autologous recon-
struction using the medial thigh can be considered as a
second choice.
The typical patient for TUG flap reconstruction is a
slim patient with a small to moderate-sized breast in
which the abdomen cannot be used (Fig. 21.3.4). The
indications of the TUG flap have increased, and many
more patients can be considered for a TUG flap; however,
additional measures are required with the larger recon-
structions, and these are discussed later in the chapter
(Figs. 21.3.5–21.3.9).
Fig. 21.3.2  The anatomy of the transverse upper
gracilis flap with key landmarks. AB, adductor
brevis; AL, adductor longus; AM, adductor magnus;
G, gracilis; LSV, long saphenous vein. (© Nakul
Patel and Venkat Ramakrishnan.)
Tip
• Delayed reconstructions often require more skin, which can
be a challenge in comparison to immediate reconstruction
following skin-sparing mastectomy (Fig. 21.3.3)
Fig. 21.3.3  Patient with bilateral transverse upper gracilis flap reconstructions
– right skin-sparing mastectomy with immediate reconstruction and left delayed
reconstruction. (© Nakul Patel and Venkat Ramakrishnan.)
Diagnosis/patient presentation
The common use of the TUG flap is immediate
breast reconstruction with a skin-sparing mastectomy
approach. The TUG flap with immediate nipple recon-
struction lends itself well to this procedure. A smaller
proportion of patients presents in a delayed manner
with either no reconstruction or complications of their
implant-based reconstruction. Lastly, the TUG flap has
also been useful in partial breast defect reconstruction
or when used in conjunction with implants and another
free flap.
In our practice, the TUG flap has replaced the use of
latissimus dorsi (LD) musculocutaneous flap for breast
reconstruction. The TUG flap provides a skin island
comparable to the LD flap. The LD is the largest muscle
of the back and carries a reliable skin paddle. The flap
can be raised with ease and mitigates the need for
microsurgery. All these factors have led to its popularity
and widespread use. There has been associated func-
tional impairment and weakness seen in those that have
this muscle harvested.18 In addition, the volume of
muscle from the LD decreases with time as it atrophies.
These problems are largely addressed with the use of
the TUG flap. It provides a similar vascular envelope
with another choice of concealed scar.

394
SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
Fig. 21.3.4  Typical patient suitable for transverse upper gracilis flap breast
reconstruction with small breasts and no abdominal donor site. (© Nakul Patel and
Venkat Ramakrishnan.)
Fig. 21.3.5  No breast volume – pre- and postoperative photographs of a patient with virtually no breast tissue reconstructed with bilateral transverse upper gracilis flaps.
(© Nakul Patel and Venkat Ramakrishnan.)
Treatment/surgical technique
The patient is marked in the standing position with the
donor leg slightly forward. The upper border of the flap
is marked a finger-breadth below the thigh–groin junc-
tion, and with a pinch test the lower border of the flap
is decided. Typically, the width of the crescent is 7 cm
although in those with an excessive laxity up to 12 cm
can be taken.19 The crescent is completed posteriorly
reaching the gluteal crease almost to the ischial tuberos-
ity. Fat is recruited beyond the skin island, predomi-
nantly from the inferior border medially and posteriorly
(Fig. 21.3.10). The original description was to take a
cutaneous skin paddle centered over gracilis, but in the
authors’ experience skewing the flap design more pos-
teriorly helps with fat recruitment, concealing the scar
in the medial thigh and infragluteal crease and reduces
the possibility of injury to the lymphatic tissues.20
Tips
• It is useful to mark the midaxial line of the thigh anteriorly
and posteriorly.
• Posteriorly avoid fat recruitment lateral to the midaxial line
to avoid damage to the posterior cutaneous nerve of the
thigh.
• The upper border of the flap is marked one finger-breadth
below the groin–thigh crease both to allow re-suspension of
the donor site without distortion of the labia majora and to
leave the scar away from the gusset of underwear, which
could cause discomfort (see Fig. 21.3.10).
Patient positioning
The patient is positioned supine on the operating table.
The whole thigh is prepared and abducted with the
hip and knee flexed during the procedure with the

395
Treatment/surgical technique
Fig. 21.3.6  Small breast volume – pre- and postoperative photographs of a patient with right breast reconstruction with a transverse upper gracilis flap. (© Nakul Patel and
Venkat Ramakrishnan.)
Fig. 21.3.7  Moderate breast volume – pre- and postoperative photographs of a patient with bilateral transverse upper gracilis flaps with implants. (© Nakul Patel and
Venkat Ramakrishnan.)

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SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
Fig. 21.3.8  Large breast volume – pre- and postoperative photographs of a patient with right breast reconstruction using stacked transverse upper gracilis flaps. (© Nakul
Patel and Venkat Ramakrishnan.)
Fig. 21.3.9  Partial breast defects – pre- and postoperative photographs of a patient with partial right breast reconstruction using a transverse upper gracilis flap. (© Nakul
Patel and Venkat Ramakrishnan.)

397
Treatment/surgical technique
muscles will help with orientation during flap harvest.
An incision is made along the inferior border of the flap.
The fat below the membranous layer of the superficial
fascia is recruited to increase the flap volume (Fig.
21.3.12).
Fig. 21.3.10  Preoperative markings of a
transverse upper gracilis flap with a skewed flap
design to recruit fat from the inferior border
medially and posteriorly. (© Nakul Patel and
Venkat Ramakrishnan.)
Fig. 21.3.11  Patient is positioned supine with the legs draped freely. (© Nakul
Patel and Venkat Ramakrishnan.)
Tip
• The leg is free-draped such that this can be moved during
the procedure to aid harvest and closure of the flap (see
Fig. 21.3.11).
operating surgeon standing on the contralateral side to
flap harvest (Fig. 21.3.11).
Flap harvest
There are certain key points in harvesting this flap safely
and efficiently, these including the marking and posi-
tioning of the patient, flap design, preservation of
structures, dissection technique, and flap inset.
Step 1: caudal incision with fat recruitment
The medial-most bulk of tissue in the upper thigh is
composed of adductor longus (anterior two-thirds) and
gracilis muscles (posterior one-third). Marking these
Tip
• Even a small increase in volume of fat recruited can have a
significant impact overall (i.e., 50 g of extra fat recruitment
in a 250 g flap accounts for a 20% increase in the new
breast reconstruction).
Step 2: anterior flap elevation (see Videos
21.3.1 and 21.3.2 )
The anterior flap is raised just above the Scarpa fascia
up to the level of the long saphenous vein, leaving it in
situ. The venae comitantes drain the flap predictably
without requiring the long saphenous system. Exclu-
sion of the long saphenous vein makes the dissection
quicker and preserves the lymphatics along the vein
(Fig. 21.3.13).
Once the dissection is past the long saphenous vein, the
dissection can continue medially in a deeper subfascial
plane, through the loose areolar tissue, up to the septum
between adductor longus and gracilis. It is within this
Tip
• Avoid transgressing the femoral triangle and lymphatic
content, which could theoretically lead to increased risk of
seroma, lymphocele, wound breakdown, infection, and
potentially lymphedema.

398
SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
septum that both the vascular and nerve pedicles to
gracilis can be found. The key to identification of the
medical circumflex femoral vessels is lateral retraction
of adductor longus.
Fig. 21.3.12  Step 1 – caudal incision with fat recruitment. (© Nakul Patel and
Venkat Ramakrishnan.)
A
B
Tip
• The anterior branch of the obturator nerve lies obliquely
compared to the vascular pedicle, which is orientated
transversely. This is a useful way of identifying the gracilis
pedicle (see Fig. 21.3.17).
Step 3: division of distal gracilis
Using blunt dissection, the distal end of the gracilis
muscle is freed, and whilst exerting traction, the muscle
is divided without the need of a second incision. It is
important to ensure adequate hemostasis of the muscle
edge as there can be bleeding from the secondary ped-
icles to the gracilis muscle (Fig. 21.3.14).
Tip
• The transection of gracilis is through the middle third of the
muscle belly with direct vision. Recruitment of the distal half
of gracilis does not add much volume to the flap but might
lead to bleeding from the secondary pedicles, which may
be difficult to visualize and access (see Fig. 21.3.14).
Step 4: elevation of posterior flap
The posterior border of the flap is incised, anterior to
the midline of the posterior thigh, with further recruit-
ment of fat in the sub-Scarpa plane, from posterior to
anterior. It is critical to ensure that sufficient volume has
been harvested as this provides the bulk of the flap
volume (Fig. 21.3.15).
Tip
• Avoiding dissection past the midline of the posterior thigh
will prevent injury to the posterior cutaneous nerve of the
thigh and secondary painful neuromas and paraesthesia.

399
Treatment/surgical technique
Step 5: division of proximal gracilis
As the posterior flap is being raised, ensure that the
dissection plane is deep to the gracilis muscle incorpo-
rating the investing fascia without trying to identify the
musculocutaneous perforators and then lifting away
from the adductor musculature. Divide the proximal
gracilis from its origin (Fig. 21.3.16).
Step 6: pedicle dissection
and flap detachment
Dissect the medial circumflex femoral vessels to the
profunda femoris and divide them at the origin to
ensure a long pedicle and large caliber vessels.
Although some descriptions of the flap describe
identification of musculocutaneous perforators entering
the skin paddle, this is not necessary. Instead, by ensur-
ing that the investing fascia of the gracilis muscle is left
intact, the flap is more reliable, speed of flap harvest
improved, and some difficult dissection is avoided (Fig.
21.3.17).
Fig. 21.3.13  Step 2 – anterior flap elevation. (© Nakul Patel and Venkat
Ramakrishnan.)
A
B
Tip
• There are often large muscle branches to the adductors,
which are worth dissecting out should a double TUG be
required.
Step 7: flap molding and inset
The flap is usually molded into a cone shape by bring-
ing the tips of the ellipse together. It will form a peak at
the apex, which will be used to make a nipple (Fig.
21.3.18). The appropriate areas are de-epithelialized for
flap inset within the skin envelope.
Flap molding and shaping is determined intraopera-
tively depending on the thickness of the flap and fat
distribution within it. In addition, comparison is made
to the contralateral breast shape, size, footplate, and
glandular tissue distribution. The degree of coning is
determined by the width of the breast, such that a
half cone or unconed TUG flap could be utilized
(Fig. 21.3.19).

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SECTION II
CHAPTER 21.3 • Medial thigh flaps for breast reconstruction
Secondary choices include the thoracodorsal system,
serratus anterior branches, or the thoracoacromial
vessels, which may require interposition vein graft.
Postoperative care
Patients are nursed in a supine position with the head
slightly up and knees slightly flexed. Flap observations
are undertaken every 15 minutes in recovery and every
hour on the ward overnight, with urgent surgical team
review if there are any concerns. Patients are able to
drink clear fluids the first postoperative night with
additional intravenous fluid to maintain urine outputs
of greater than 0.5 mL/kg/hr. Forced-air warming
blankets (Bair Hugger, 3M) are used to maintain the
patient’s temperature between 36.5°C and 37.5°C. It
normally stays on overnight postoperatively.
Analgesic requirements include regular paracetamol
and non-steroidal anti-inflammatories supplemented
with OxyContin as required. Postoperative nausea
and vomiting are combated with regular cyclizine and
breakthrough ondansetron. Patients are also given
The closure is started posteriorly by flexing the hip
and feeding in the standing cone deformity. The leg can
then be straightened for the remaining closure. Use a 2-0
vicryl suture for the fascia and an absorbable 3-0 barbed
suture closed over a suction drain (Fig. 21.3.20).
Step 8: microsurgery
Because of the relatively short pedicle length and size
of medial circumflex femoral vessels, anastomosis to the
internal mammary perforators is more convenient. By
dissecting deep into the intercostal space, a suitable
length of the intercostal perforator in the second, third,
or occasionally fourth interspace can be used for com-
fortable anastomoses. The internal mammary vessels
at the fourth interspace tend to be of good size match
(Fig. 21.3.21).
Fig. 21.3.14  Step 3 – division of distal gracilis. (© Nakul Patel and Venkat
Ramakrishnan.)
A
B
Tips
• Use of the intercostal perforators compliments the short
pedicle length of the gracilis flap.
• Opportunistic use of the lower perforators allows for more
aesthetic lateralization of the breast mound.