BREAST Donor-Site Morbidity following Harvest of the Transverse Myocutaneous Gracilis Flap for Breast Reconstruction Barbara Craggs, M.D. Bert Vanmierlo, M.D. Assaf Zeltzer, M.D. Ronald Buyl, Ph.D. Patrick Haentjens, M.D., Ph.D. Moustapha Hamdi, M.D., Ph.D. Brussels, Belgium

Background: The transverse myocutaneous gracilis flap provides adequate autologous tissue for breast reconstruction from the high thigh region, but flap harvest may affect the patient’s activities of daily living, sexuality, and quality of life. The authors evaluated the reconstruction outcome, postoperative donorsite complications, and quality-of-life outcomes. Methods: All patients who underwent transverse myocutaneous gracilis breast reconstruction performed by the senior author (M.H.) since 2007 were included in the study. Patient files were reviewed, and a questionnaire was used to assess patient satisfaction. Results: Forty-nine transverse myocutaneous gracilis flaps were performed in 36 patients for breast reconstruction. Total flap necrosis occurred in two flaps (4 percent). Additional fat grafting was required in 61 percent of flaps, and donorsite complications occurred in 59 percent of patients. Wound dehiscence and infection were the most commonly encountered donor-site complications. However, by harvesting less skin and gracilis muscle, there was a statistically significant (p < 0.001) lower complication rate in the last 16 patients. Twenty-two patients with at least 6 months of follow-up were included in the questionnaire study. Eighteen returned questionnaires. Most patients were happy to very happy with their result and could go about their activities of daily living. There was no statistically significant correlation between the independent variables (e.g., age, body mass index, and radiotherapy) and the dependent variables (e.g., breast satisfaction, sexuality, and donor-site morbidity). There was a statistically significant difference regarding donor-site satisfaction when comparing patients with and without donor-site complications (p = 0.01). Conclusions: Although fat grafting was often required, patients were happy with the result of their transverse myocutaneous gracilis breast reconstruction. Donor-site complications correspondence inversely to patient satisfaction. (Plast. R ­ econstr. Surg. 134: 682e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A

utologous microvascular breast reconstruction can be performed using several donor sites.1–8 The choice of donor site depends on the availability of tissue, the desired size and volume of the reconstructed breast, the surgeon’s experience, and the patient’s preference. However, the impact of donor-site From the Departments of Plastic and Reconstructive Surgery and Medical Statistics, Brussels University Hospital; and the Department of Biomedical Statistics and Information Technology, Free University of Brussels (Vrije Universiteit Brussel VUB). Received for publication August 25, 2013; accepted April 17, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000612

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morbidity on this decision should not be underrated. It can affect the quality of life, sexuality, and general life circumstances of the patient. Currently, the deep inferior epigastric artery perforator (DIEP) flap is the criterion standard for free autologous breast reconstruction.9–12 Contraindications for using the abdominal donor site include previous abdominal surgery in which the inferior epigastric vessels were divided or damaged (including abdominoplasty or a prior abdominal based flap), or a patient with insufficient pannus. Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Volume 134, Number 5 • Donor-Site Morbidity after Flap Harvest The transverse myocutaneous gracilis flap was first described by Yousif et al. in 1992.4 The advantage of the transverse myocutaneous gracilis flap for breast reconstruction is that it can provide adequate autologous tissue with a hidden scar.5–7 Because of its small volume compared with abdominally based flaps, the transverse myocutaneous gracilis flap has been proposed as a viable option in the treatment of small to moderate breasted women when excision of breast tumors would result in poor cosmetic outcomes. Its uses include partial and complete breast reconstruction8 as a second-line choice for larger breasted women, or as a salvage flap in cases of previous flap failure.5 Donor-site morbidity is considered minimal, with a concealed scar and minimal contour irregularities of the thigh, even in the setting of unilateral harvest.5,7,13,14 Several patient series have been published in the literature.5,13–15 Previously, questionnaires were used to evaluate postoperative patient evaluation of breast reconstruction results, donor-site morbidity, and sexuality by Fansa et al.14 in 2008 and Pülzl et al.13 in 2011. Immediate small breast reconstruction is often limited by lack of potential donor-site tissue, a thinner skin envelope, and limited implant choice. Contralateral symmetrization surgery can offset this problem of asymmetry in the thin and small-breasted patient but is often an unavailable option, too expensive, or declined by the patient.3 When considering our own experience with the transverse myocutaneous gracilis flap for breast reconstruction, we noticed relatively large numbers of patients with donor-site problems that might affect their quality of life. This led us to compare our results with the results presented in the literature, where patients’ postoperative satisfaction was assessed using a questionnaire.13,14 The transverse myocutaneous gracilis flap provides adequate autologous tissue for breast reconstruction from the high thigh region. However, scar location, sacrifice of the gracilis muscle, and harvesting tissue close to the genital area may affect the patient in her activities of daily living, sexuality, and quality of life. The purpose of this study was to report postoperative complications at the donor site and postoperative satisfaction with the scar, and to explore the impact of donor-site morbidity on patient satisfaction and quality-oflife parameters.

PATIENTS AND METHODS The study was approved by the Brussels University Hospital Institutional Review Board (study

protocol reference 2012/236). All patients who underwent transverse myocutaneous gracilis flap breast reconstruction between 2007 and 2012 performed by the senior author (M.H.) were included in this study. The indications for transverse myocutaneous gracilis flap were any contraindication for a DIEP flap, such as multiple scars, previous abdominoplasty, patients who were extremely lean, or as a second-line choice as a salvage flap in cases of previous DIEP flap failure. Surgical Technique of Thigh Closure The surgical technique was similar to that described by previous authors.5–8,13,14 Breast reconstruction is performed by means of a two-team approach, with the patient lying supine with legs bent in frog-leg position. While the first team prepares the recipient site at the internal mammary artery in the third or fourth intercostal space, the second team harvests the flap by dissecting the skin paddle that is marked preoperatively. Effort is made to place the incision as high as possible in the groin fold to hide the scar postoperatively. Attention is paid to deviate away from the vulva medially (Fig. 1, left). The anterior margin exceeds the upper border of the adductor longus muscle by only 2 cm (Fig. 1, right, above and center). The posterior margin is the midline of the inferior gluteal fold. The distal margin is marked transversely over the gracilis muscle; estimation of flap width is tested by the pinch test. However, the flap design was modified after the first 20 patients to decrease wound dehiscence. The flap width never exceeded 8 cm (range, 5 to 8 cm). In addition, the upper incision line was moved one fingerbreadth down away from the thigh crease. The harvested gracilis muscle was also limited to midmuscle length without extensive distal undermining. After flap harvesting, the thigh is closed as a thigh lift. Suspension sutures were used to hook the superficial fascia of the thigh to the periosteum of the pubis, using nonabsorbable sutures. Additional 2-0 Vicryl (Ethicon, Inc., Somerville, N.J.) stitches are used, followed by 3-0 Vicryl at the level of the deep dermis. Finally, a running cuticular 3-0 Monocryl (Ethicon) suture is used. Further separate sutures may be added at the area where there is high-tension closure (Fig. 1, right, below). One suction drain is left at the donor area. Drains are removed when drain output is less than 20 ml/day. Patients are allowed to get out of bed the first day after surgery and ambulate. However, we ask the patients to avoid sitting the first week after surgery.

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Plastic and Reconstructive Surgery • November 2014

Fig. 1. Transverse myocutaneous gracilis flap harvesting and donor-site closure. (Left) Preoperative design. (Right, above) Pedicle dissection. (Right, center) The flap was harvested. (Right, below) The donor site was closed as a thigh lift with separate stitches on the high-tension part.

Study Design Patients’ files were reviewed for postoperative complications, outcomes, and secondary operations. In addition, patients were contacted and asked to complete a 38-point postal questionnaire. Twenty-two patients with a minimum of 6 months’ follow-up were included in the questionnaire study. None of the patients had wound healing problems at the time of completing the questionnaire. Response was maximized by telephone and postal reminders. The postal questionnaire was designed to assess patient satisfaction with breast

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reconstruction and donor-site, overall satisfaction, and sexuality after breast reconstruction. Questionnaires were developed from the BREAST-Q instrument, and the questionnaires used by Pülzl et al. and Fansa et al.13,14 The BREAST-Q survey asks six questions on sexuality. Three of these questions were used in our questionnaire; the fourth question was used from the questionnaire by Pülzl et al. because the BREAST-Q survey does not cover the possible impact of donor-site problems on sexual activity. The BREAST-Q question “Confident sexually about how your breast(s)

Volume 134, Number 5 • Donor-Site Morbidity after Flap Harvest Table 1.  Patient Characteristics and Results Characteristic

Value (%)

No. of patients Age, yr BMI, kg/m2 No. of TMG flaps  Total  Unilateral  Bilateral Flap weight, g Mean hospital stay, days Flap-related complications  Total flap loss  Fat necrosis Donor-site complications  Wound healing  Seroma/hematoma  Fistula Further surgery  Fat grafting (1 session)  Fat grafting (≥2 sessions)  Implant  None

36 48 ± 11 22 ± 2 49 23 13 224 ± 67 5.7 ± 2 2/49 (4) 1/49 (2) 33/49 (67) 3/49 (6) 2/49 (4) 30/49 (61) 12/49 (25) 1/49 (2) 6/49 (12)

BMI, body mass index; TMG, transverse myocutaneous gracilis.

look when unclothed?” was of less importance for our study on donor site. Breast Q questions “Comfortable/at ease during sexual activity?” and “Confident sexually?” were not included to make the total questionnaire length (38 questions) acceptable. All patients with a minimum of 6 months’ follow-up were eligible for the questionnaire study. Ten questions evaluated satisfaction with breast reconstruction on a four-point scale (i.e., very unhappy, unhappy, happy, and very happy). When evaluating the donor site, several questions were asked regarding donor-site morbidity: on the scar, on thigh circumference, wound problems, changes in mobility, and changes in the genital area. Patients’ sexuality was assessed using five questions. Results were analyzed in collaboration with the Department of Statistics of the Free University of Brussels and the Brussels University Hospital. Descriptive statistical analysis looking at means, standard deviations, and ranges was performed. Comparisons of means were performed using independent t tests. A Fisher’s exact test was performed on the number of wound dehiscences before and after modification of surgical technique (SPSS for Windows, Version 18.0; SPSS, Inc., Chicago, Ill.).

RESULTS Clinical Experience A total of 49 transverse myocutaneous gracilis flaps in 36 patients were performed for breast

reconstruction. There were 23 unilateral and 13 bilateral transverse myocutaneous gracilis flaps (Table 1). All flap operations were performed by the senior author (M.H.). The mean age of patients undergoing reconstruction was 48 ±e11 years. Most patients (Fig. 2) were lean, with a mean body mass index of 22 ± 2 kg/m2. None of the patients were active smokers, and none had a history of diabetes mellitus. Mean mastectomy breast weight was 232 ± 116 g and mean flap weight was 224 ± 67 g. Mean length of hospital stay after breast reconstruction was 5.7 ± 2 days. Two transverse myocutaneous gracilis flaps failed (4 percent): one flap was lost because of venous thrombosis in the internal mammary vein 9 days postoperatively after the patient left the hospital because of external compression, and the second transverse myocutaneous gracilis flap was performed after a failed DIEP flap despite microvascular revision. Further investigation showed a hypercoagulability disorder in the second patient.16 One flap was salvaged after arterial thrombosis on the fifth postoperative day but resulted in a progressive atrophy requiring lipofilling 3 months postoperatively. Fat necrosis occurred in one patient, which required surgical excision and fat grafting as a second-stage procedure. Fifty-nine percent of patients (21 of 36) experienced donor-site problems (Figs. 3 and 4). However, with modifications to the flap design, donor-site complications were reduced significantly (Table 2). With a mean follow-up time after reconstruction of 29 ±918 months (range, 6 to 64 months), two patients required additional donorsite surgery. Questionnaire Study With a minimum 6-month follow-up, 22 patients were included in the questionnaire study. Eighteen of 22 questionnaires were returned. Assessment of Patient Satisfaction with Transverse Myocutaneous Gracilis Flap Breast Reconstruction The sum of a four-point scale (very unhappy, unhappy, happy, and very happy) for satisfaction with breast reconstruction, based on 10 questions, gave a mean score for breast reconstruction of 29.6 ± 7 of 40 (74 percent) (Table 3). Assessment of Donor-Site Morbidity The sum of a four-point scale for assessment of donor-site morbidity on 18 questions gave a mean score for scar-related issues of 58 ± 6 of 72 (81 percent) (Table 4). The majority of the patients (94

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Plastic and Reconstructive Surgery • November 2014

Fig. 2. A 36-year-old patient who presented for a delayed-immediate reconstruction using autologous tissue. She had a right mastectomy with expander reconstruction followed by postoperative radiotherapy. Because of the lack of abdominal tissue, a free transverse myocutaneous gracilis flap was planned for breast reconstruction. (Above, left and center) Preoperative views. (Above, right, and center, left) Postoperative views at 1 year after surgery. (Center, center; center, right; and below) Transverse myocutaneous gracilis donor site, preoperatively, at 3 months after reconstruction, and at 1 year postoperatively. The scar migrated two fingerbreadths caudally and became more visible.

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Volume 134, Number 5 • Donor-Site Morbidity after Flap Harvest

Fig. 3. An immediate postoperative complication after harvesting a unilateral transverse myocutaneous gracilis flap in a patient with a high body mass index. Wound dehiscence complicated by an infection required oral antibiotic therapy and local dressing for 3 weeks to achieve wound healing.

percent) were moderately to very happy with the position of the scar, despite the scar being visible in 78 percent of cases. More importantly, 17 of 18 patients had no difficulties finding appropriate underwear. All patients could go about their activities of daily living (14 patients experienced no problem at all, and four patients experienced only minor difficulties). None of the patients reported

moderate or serious difficulties in sitting for a long time. Sensitivity around the scar was reduced in 74 percent of patients. The reduction in sensitivity was found disturbing by four of these 13 patients. Assessment of Patients’ Sexuality Three of 18 patients chose not to answer the questions regarding sexuality (two were not sexually active) (Table 5). The mean score for sexuality was 15 ± 3 of 20 (76 percent). One patient had less sex because of genital changes, and three other patients experienced occasional troubles. Statistical Analyses There is no statistically significant correlation between the independent variables (i.e., age, body mass index, radiotherapy, and laterality) and dependent variables (success of breast reconstruction, sexuality, or donor-site morbidity and complications). There is a statistically significant difference (p = 0.01) regarding donor-site satisfaction when comparing patients with and without Table 2.   Postoperative Complications at the Donor Site before and after Introduction of the Modifications to Flap Design/Harvest Standard Modified Design/ Technique (%) Harvest of Flap (%)

Fig. 4. Donor site after harvesting bilateral transverse myocutaneous gracilis for breast reconstruction in a patient with a low body mass index. Scar displacement and traction on the labia majora occurred bilaterally (3-year follow-up).

No. of flaps Donor-site complications  Wound dehiscence/ infection  Seroma/hematoma  Fistula

29

20

28 (86) 2 (6.8) 2 (6.8)

9 (45)* 1 (5) 0 (0)

*p < 0.001.

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Plastic and Reconstructive Surgery • November 2014 Table 3.   Assessment of Patient Satisfaction with Transverse Myocutaneous Gracilis Flap Breast Reconstruction No. of Patient (n = 18) Answers per Scale

With your breasts in mind, how satisfied or dissatisfied have you been with:  1. How you look in the mirror clothed?  2. The softness of your reconstructed breast(s)?  3. The size of your reconstructed breast(s)?  4. How equal in size your breasts are to each other?  5. How comfortably your bras fit?  6. How naturally your reconstructed breast(s) sits/hangs?  7. How your reconstructed breast(s) feels to touch?  8. H  ow much your reconstructed breast(s) feels like a natural part of your body?  9. H  ow your reconstructed breast(s) look now compared to before you had any breast surgery? 10. How you look in the mirror unclothed?

donor-site complications (70 percent and 79 percent were satisfied, respectively). Modification of the surgical technique (i.e., harvesting less skin and gracilis muscle) caused a statistically significant (p < 0.001) lower complication rate in the last 16 patients using the Fisher’s exact test (Table 2). Our results are compared with the literature in Table 6.

DISCUSSION Previous studies have delivered substantial evidence that the transverse myocutaneous gracilis flap is a valid option in breast reconstruction, especially for the reconstruction of small to medium-size breasts and in patients who cannot have an abdominally based breast reconstruction because of a lack of abdominal pannus or previous surgery. However, the upper thigh provides a limited amount of soft tissue in our patients; therefore, fat grafting was required in 61 percent of our patients. Fat grafting helped to improve flap contour and breast shape and was performed in one session, together with nipple reconstruction and contralateral breast remodeling when indicated. This is more than the postoperative fat grafting that is required in other microvascular free flap breast reconstructions (26.7 percent with an average of 1.12 operative sessions in the study by Weichman et al. of 374 reconstructed breasts17). Autologous fat grafting has become a common technique for revision breast surgery18 but appears more likely after transverse upper gracilis breast reconstruction. All successful (66.7 percent) transverse upper gracilis flaps in the study by Locke et al. showed deficient flap volume or breast contour requiring augmentation by lipofilling.15 The close relationship to the genital and perineal area, and traction on the wound during movement, might explain the high number of patients

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Very Dissatisfied

Somewhat Dissatisfied

Somewhat Satisfied

Very Satisfied

1 1 1 2 1 0 4

0 1 2 6 1 3 5

7 9 11 6 11 10 8

10 7 4 4 5 5 1

1

2

10

5

1 3

6 4

3 7

8 4

who experienced problems during the healing of the donor site. Problems caused by inflammation, infection, and suture fistulae were present in up to 59 percent of our patients. However, all wounds healed eventually with conservative treatment (local wound care, and antibiotics in some cases). Surgical débridement and primary closure were required in only two patients, after which the wound healed without further complications. Flap width also plays a role. Harvesting a large skin flap can result in a higher risk of wound dehiscence, which may be complicated by secondary infection. Flap width up to 12 cm was described by Arnez et al.6 Others7,8,13,14 recommended a pinch test to evaluate the possible harvested amount; however, this is not always accurate in obese patients, and overzealous skin harvesting may ensue. Schoeller et al.19 recommended using a pinch test but with patients in standing position. Our efforts to reduce postoperative donor-site complications included designing a transverse myocutaneous gracilis flap with less flap width (range, 5 to 8 cm) and also pushing down the upper incision line 2 cm to obtain wound closure with less tension. Moreover, the gracilis muscle was transected at a higher level in the thigh without total muscle harvesting, as suggested by previous authors.5–9 The more limited skin undermining and the dead space compared with the standard technique resulted in less wound dehiscence and secondary infection (Table 2). Consequently, the weight of the harvested flap was less; however, fat grafting compensated for the reduced flap volume. As fat grafting is required for most patients undergoing transverse myocutaneous gracilis flap breast reconstruction, we prefer to harvest a smaller flap with the advantages of reducing postoperative complications at the donor site.

Volume 134, Number 5 • Donor-Site Morbidity after Flap Harvest Table 4.   Number of Patient Answers per Scale on 18 Questions Regarding the Donor Site No. of Patient (n = 18) Answers per Scale* Questions   1. Are you satisfied with the position of the scar?   2. Is the scar visible?   3. Is the scar optically disturbing to you?   4. Is the scar visible in front?   5. Is the scar visible in profile?   6. Do you have limitations in finding the right underwear caused by the scar?   7. Are your thighs asymmetrical?   8. Do you find any asymmetry disturbing?   9. Do you find your thighs attractive when clothed? 10. D  id you have problems with healing?† 11. Is the scar painful? 12. D  o you have limitations in movement caused by the scar? 13. A  re there any things you can’t do because of the scar? 14. D  o you have problems with sitting for a long time? 15. D  oes the scar impair your everyday life? 16. A  re there certain sports you can’t do because of the scar? 17. H  ave you recognized swelling of the leg after the operation? 18. H  ave you recognized changes in the genital area?

0

1

2

3

4

0 0

0 4

1 7

6 5

11 2

0

6

10

2

0

0

6

9

1

2

0

13

2

3

0

0

17

1

0

0

0

5

5

7

1

3

6

6

3

0

1

2

3

5

7

0 0

8 10

3 7

2 1

5 0

0

9

7

2

0

0

9

5

3

1

0

15

3

0

0

0

14

4

0

0

0

13

3

1

1

1

11

4

1

1

1

13

0

1

3

*0, no answer; 1, not; 2, a little; 3, moderate; and 4, very. †Wound healing problems (e.g., inflammation, infection, suture fistulae), hematoma/seroma requiring drainage.

Although theoretically the donor site is inconspicuous because it is hidden in the inguinal area, like a medial thigh lift, the scar tends to be visible in a large percentage of patients.13,14,20 The patient group reported by Pülzl et al.13 had difficulty finding underwear that could conceal the scar in 39 percent compared with 6 percent in our patient group. Despite this, mean satisfaction was high in both studies (83 percent). The scar was painful in a minority of patients (11 percent), although more than half suffered persistent hypesthesia, which was found disturbing in one-third of these patients.

Hypesthesia of the lower abdomen, however, is also present in patients after DIEP flap breast reconstruction.21 Although care is taken during the preoperative design of the transverse myocutaneous gracilis flap to avoid traction on the genital area, 11 percent of patients suffered traction on the labia majora during physical activity. This was comparable to the result in the study by Pülzl et al.13 Donor-site–related problems had an effect on sexuality in four patients: one patient had less sex, and the other three experienced issues from time to time, because of a tense feeling on the scar when spreading the legs. This did not impact significantly on their activities of daily living, which remained unchanged in all patients. One patient had to adapt her sporting activities because of traction on the scar. In particular, sports requiring stretching of the legs can pose problems.13 Adductor weakness itself did not influence sporting activities, considering that the gracilis muscle is a weak adductor.14 This finding was confirmed by Deutinger et al.20 in 1995, who studied the adduction strength of the hip joint in 36 patients after gracilis harvest using dynamometric measurements. The patients did not notice the 11 percent loss in adduction strength. The sitting position, even for a long time, does not pose a problem. We were interested to discover which of the independent variables (i.e., age, body mass index, previous radiotherapy, and unilaterality or bilaterality of surgery) affected patient satisfaction related to breast reconstruction, sexuality, scar, and quality-of-life indicators, such as activities of daily living and sporting activities. The mean age of patients undergoing reconstruction was comparable to that in other studies (48 ± 11 years). There was no effect of age on outcome and no difference between premenopausal (n = 9) and postmenopausal (n = 9) patients. The effect of body mass index could not be investigated because all patients were relatively lean (mean body mass index, 21 ± 2 kg/m2). Radiotherapy and laterality also did not influence outcome. Furthermore, we investigated the relationship between the three main groups of outcome variables (success of breast reconstruction, sexuality, and donor-site morbidity and complications). Better breast reconstruction results were not associated with more sexuality. Worse donor-site morbidity did not affect sexuality negatively in a statistically significant way, although it may be troublesome, as illustrated by four of the 18 patients.

CONCLUSIONS The retrospective analysis of our transverse myocutaneous gracilis patient population showed

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Plastic and Reconstructive Surgery • November 2014 Table 5.   Assessment of Patients’ Sexuality No. of Patient Answers (n = 18) per Scale* Questions Regarding Sexuality

Not Applicable

Never

Now and Again

Sometimes

3 3 3

1 3 1

0 1 3

2 7 2

6 2 6

6 2 3

3

10

4

0

1

0

 1. Sexually attractive in your clothes?  2. Sexually attractive when unclothed?  3. Satisfied with your sex life?  4. Have you lost interest or enjoyment in sex caused by the donor site?

Often Always

*Not applicable, 0; never, 1; now and again, 2; sometimes, 3; often, 4; and always, 5.

Table 6.  Patient Characteristics in Three Studies Evaluating Donor-Site Morbidity after Harvesting Transverse Myocutaneous Gracilis Flap for Breast Reconstruction Fansa et al., 200814

Pülzl et al. 201113

Hamdi et al., 2014

No. of patients No. of flaps Follow-up, mo  Average  Range Questionnaire response rate, % Problems sitting, % Satisfaction with scar, % Persistent hypesthesia, %

20 32

22 25

22 22

6 4–11 80 Not specified Not specified 25

58

Painful scar, % Problem finding underwear, % Stretching of labia majora, %

Not specified Not specified 0

29 6–64 82 14 83 74 (23% found it disturbing) 11 6 11

results similar to those of previous studies performed: most patients were happy with the results of their breast reconstruction. Although it was not the aim of our study, we did find that fat grafting was required in 61 percent of our patients for volume and contour correction, which is probably more than required in other microvascular free flap breast reconstructions. Our patients found no difficulties in concealing the scar with their underwear and could go about their activities of daily living. However, a more in-depth analysis of donor-site morbidity and specifically its effect on patient happiness with scar-related outcomes shows a relatively high percentage of patients with donor-site morbidity, which relates inversely to patient happiness. In other words, the impact of donor-site morbidity should not be underestimated. Potential complications and influence on quality of life should be clearly discussed with the patients preoperatively. Surgical modifications to flap harvesting technique will benefit the patient because of fewer postoperative complications of the donor site. Moustapha Hamdi, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Brussels University Hospital Laarbeeklaan 101 1090 Brussels, Belgium [email protected]

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100 22 83 56 (40% found it disturbing) 17 39 11

REFERENCES 1. Healy C, Ramakrishnan V. Autologous microvascular breast reconstruction. Arch Plast Surg. 2013;40:3–10. 2. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: Patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002;110:466–475; discussion 476. 3. Kitcat M, Molina A, Meldon C, Darhouse N, Clibbon J, Malata CM. A simple algorithm for immediate postmastectomy reconstruction of the small breast: A single surgeon’s 10-year experience. Eplasty 2012;12:e55. 4. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992;29:482–490. 5. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse myocutaneous gracilis flap: Technical refinements. J Plast Reconstr Aesthet Surg. 2010;63:305–313. 6. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57:20–26. 7. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: A valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg. 2004;114:69–73. 8. McCulley SJ, Macmillan RD, Rasheed T. Transverse upper gracilis (TUG) flap for volume replacement in breast conserving surgery for medial breast tumours in small to medium sized breasts. J Plast Reconstr Aesthet Surg. 2011;64:1056–1060. 9. Damen TH, Morritt AN, Zhong T, Ahmad J, Hofer SO. Improving outcomes in microsurgical breast reconstruction: Lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon. J Plast Reconstr Aesthet Surg. 2013;66:1032–1038. 10. Nahabedian MY, Tsangaris T, Momen B. Breast recon struction with the DIEP flap or the muscle-sparing (MS-2)

Volume 134, Number 5 • Donor-Site Morbidity after Flap Harvest free TRAM flap: Is there a difference? Plast Reconstr Surg. 2005;115:436–444; discussion 445–446. 11. Arnez ZM, Khan U, Pogorelec D, Planinsek F. Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg. 1999;52: 351–354. 12. Gurunluoglu R, Gurunluoglu A, Williams SA, Tebockhorst S. Current trends in breast reconstruction: Survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013;70:103–110. 13. Pülzl P, Schoeller T, Kleewein K, Wechselberger G. Donorsite morbidity of the transverse musculocutaneous gracilis flap in autologous breast reconstruction: Short-term and long-term results. Plast Reconstr Surg. 2011;128: 233e–242e. 14. Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. The transverse myocutaneous gracilis muscle flap: A fast and reliable method for breast reconstruction. Plast Reconstr Surg. 2008;122:1326–1333. 15. Locke MB, Zhong T, Mureau MA, Hofer SO. Tug ‘O’ war: Challenges of transverse upper gracilis (TUG) myocutaneous

free flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2012;65:1041–1050. 16. Hamdi M, Andrades P, Thiessen F, et al. Is a second free flap still an option in a failed free flap breast reconstruction? Plast Reconstr Surg. 2010;126:375–384. 17. Weichman KE, Broer PN, Tanna N, et al. The role of autologous fat grafting in secondary microsurgical breast reconstruction. Ann Plast Surg. 2013;71:24–30. 18. Losken A, Pinell XA, Sikoro K, Yezhelyev MV, Anderson E, Carlson GW. Autologous fat grafting in secondary breast reconstruction. Ann Plast Surg. 2011;66:518–522. 19. 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. 20. Deutinger M, Kuzbari R, Paternostro-Sluga T, et al. Donorsite morbidity of the gracilis flap. Plast Reconstr Surg. 1995;95:1240–1244. 21. Tindholdt TT, Tønseth KA. Donor site sensitivity after breast reconstruction with deep inferior epigastric artery perforator flap. Ann Plast Surg. 2009;63:143–147.

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Donor-site morbidity following harvest of the transverse myocutaneous gracilis flap for breast reconstruction.

The transverse myocutaneous gracilis flap provides adequate autologous tissue for breast reconstruction from the high thigh region, but flap harvest m...
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