BREAST SURGERY
Vascular Variations of the Transverse Upper Gracilis Flap in Consideration for Breast Reconstruction Noe¨l Blythe Natoli, MD and Liza C. Wu, MD Purpose: The transverse upper gracilis (TUG) myocutaneous f lap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability. Methods: A retrospective review of records was performed on patients undergoing a TUG f lap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.). Results: A total of 36 TUG f laps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of f lap harvest. Conclusions: Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for f lap dissection when the microsurgeon encounters such aberrancies. Key Words: transverse upper gracilis myocutaneous flap, TUG flap, autologous breast reconstruction, vascular pedicle variation (Ann Plast Surg 2015;74: 528Y531)
T
he gracilis myocutaneous f lap has frequently been cited for the poor reliability of its skin paddle in regional reconstruction, mainly the perineum. In fact, some reconstructive surgeons have abandoned it completely in favor of other regional f laps such as the myocutaneous rectus abdominus or anterolateral thigh f lap. The reliability of the overlying skin paddle of the gracilis myocutaneous f lap depends on 2 factors, namely, the vascular pedicle and the perforator anatomy. The gracilis f lap is considered a type 2 muscle with dominant pedicle origin from the profundus system and minor perforators originating from the superficial femoral system. The dominant proximal pedicle of the gracilis muscle either branches directly off the profunda femoral vessels or the medial femoral circumflex vessels off the profunda vessels. The pedicle travels on top of the adductor magnus muscle, underneath the adductor longus muscle, to enter the gracilis muscle in the proximal portion generally entering 10 to 12 cm caudal to the pubic tubercle. Venous variations of the venae comitantes of the pedicle with convergence of the vein proximally have also been described by previous investigators
Received April 1, 2013, and accepted for publication, after revision, August 26, 2013. From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA. Conflicts of interest and sources of funding: none declared. Reprints: Noe¨l Blythe Natoli, MD, Long Island Plastic Surgical Group, 999 Franklin Ave, Garden City, NY 11530. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0528 DOI: 10.1097/01.sap.0000435501.19566.75
528
www.annalsplasticsurgery.com
with implication for free tissue transfer permitting harvest of longer pedicles of greater vessel diameter for microanastamosis.1 Well delineated by previous authors are intramuscular communications traveling axially within the substance of the adductor longus between the dominant proximal pedicle derived from the deep femoral system and the secondary minor pedicle off the superficial femoral system.1 The perforators supplying the overlying skin have recently gained more attention as surgeons strive to improve the reliability of the gracilis myocutaneous f lap. Surgical techniques include extending the width of fascial harvest and converting it to an extended myofasciocutaneous f lap.2 This has been substantiated by work from Whetzel and Lechtman,2 investigating the vascular territory of the superficial profundus perforators to the skin paddle by performing ink injections in cadavers of both the proximal minor perforator pedicles as well as the dominant gracilis vascular pedicle and evaluating their contribution to skin paddle staining as a model for skin perfusion. Other investigators have focused on including not only myocutaneous perforators but also septocutaneous perforators to create an extended gracilis perforator f lap.3 An additional aspect of the vascular supply of the gracilis myocutaneous f lap that has not been well delineated in the literature is the variations of the proximal, dominant pedicle. Although these variations may not directly impact the use of the pedicled gracilis myocutaneous f lap, the implications in free tissue transfer can be great. We would like to report the in vivo observation of 6 cases of such vascular anomalies, and moreover, discuss potential clinical implications for breast reconstruction including the introduction of an algorithm for pedicle selection and dissection when encountering such vascular variations.
METHODS AND MATERIALS All transverse upper gracilis (TUG) myocutaneous f laps performed by the senior author (L.C.W.) between July 2006 and November 2011 were reviewed. There were a total of 36 TUG f laps performed in 24 patients for autologous breast reconstruction in the study period. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Upon review of these cases, including evaluation of operative reports and pertinent hospital records, there were 6 such instances of aberrant vascular pedicles including 4 cases of double pedicles and 2 cases of a split proximal pedicle. The relevant surgical details of these 6 cases along with the described methods and techniques for TUG harvest used by the senior author will be discussed later. We encountered major pedicle variability in 6 of 36 or 17% of cases reviewed. In our series, 17% of pedicles were anomalous, with 5.5% displaying a split pedicle and 11% displaying a double main pedicle.
Surgical Technique Preoperatively, the patient is marked in the holding area in the standing position. The superior aspect of the f lap markings is made 2 fingerbreadths below the groin crease; this allows for centralization of the pedicle in the harvested f lap. The lower limits of the f lap, which will determine the vertical height of the f lap, are dictated by patient body habitus and predominantly skin laxity at the medial Annals of Plastic Surgery
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Volume 74, Number 5, May 2015
Annals of Plastic Surgery
& Volume 74, Number 5, May 2015
Vascular Variations of the TUG Flap
thigh. The maximal height achievable with minimal tension on the wound edges is determined by pinch-test and is marked. The anterior border extends to the ventral limit of the mid-anterior thigh and the posterior limit of the f lap is designed at the lateral aspect of the gluteal crease (see Fig. 1 for markings). The patient is positioned supine in the frog-legged position with circumferential preparation of the entire leg from the level of the groin. Flap elevation is generally performed conjointly with the mastectomy. Either contralateral or ipsilateral harvest can be performed and is chosen to maximize medial breast fullness. The margins of the f lap are incised anteriorly and f lap elevation takes place at the level between the superficial and deep fat. The saphenous vein is identified and left intact in the leg. Once the abductor longus muscle and tendon are encountered, the fascia is then incised and the dissection continues in the subfascial plane. The main vascular pedicle of the gracilis is easily identified lying on top of the abductor magnus muscle and is seen entering the gracilis muscle. The pedicle is dissected proximally toward its origin. Dissection proceeds along the gracilis muscle both proximally and distally. The distal extent of the muscle dissection and harvest occurs until the minor pedicle off of the superficial femoral system is identified, clipped, and ligated. The skin paddle elevation continues posteriorly in the suprafascial plane, taking care to ligate all other perforators not coming from the gracilis pedicle.
Case Presentations Case 1 A 52-year-old woman presented after diagnosis of right breast cancer, with a history of left-sided breast cancer, which was reconstructed with a pedicled transverse rectus abdomens myocutaneous flap at another institution. Given the patients’ body habitus and preferences, we decided to proceed with autologous reconstruction from her right inner thigh. A split proximal pedicle to the gracilis was identified (see Fig. 2). Both branches of the pedicle were preserved. The internal mammary vessels were next exposed at the third intercostal space and dissected in preparation for surgical microanastamosis before f lap division. Microanastamosis was performed in standard fashion first by establishing the venous connection with a 2.5-mm coupler and next reestablishing arterial flow of the pedicle proximal to the split with interrupted 8-0 nylon sutures under 3.5 loupe magnification. The breast was next inset and the donor site was closed primarily. The
FIGURE 2. Pedicle demonstrating a split-proximal main pedicle off of the profunda femoral system.
postoperative course of this patient was uneventful and she healed well with an excellent aesthetic result with no evidence of flap necrosis or healing problems.
Case 2 A 37-year-old woman with a paucity of abdominal tissue presented for delayed bilateral breast reconstruction. Flap dissection on the right thigh showed no vascular aberrancy, however, upon flap elevation on the left medial thigh, there were 2 separate pedicles entering the gracilis muscle (see Fig. 3). Both pedicles were dissected proximally to their origins; one seemed to be originating from the profunda system and the other seemed to be originating from the superficial system. Of the double pedicle, the proximal one seemed to be of larger caliber. A decision was made to divide the distal and
FIGURE 1. Standard surgical markings for TUG f lap for breast reconstruction. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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& Volume 74, Number 5, May 2015
seemingly less dominant pedicle. After ligation of the secondary pedicle, the skin paddle was observed for changes in circulation indicating vascular compromise. There was no congestion/pallor observed and pedicle harvest proceeded. The remainder of her encounter including flap inset and postoperative hospital course was uneventful. There was no evidence of partial f lap loss or fat necrosis observed during her hospitalization or in subsequent follow-up after discharge.
Case 3 A 64-year-old woman presented for consultation for breast reconstruction; having been recently diagnosed with recurrent left breast cancer, with a history of left-sided breast conservation therapy. Because of a history of multiple previous abdominal surgeries, it was decided to proceed with left-sided TUG breast reconstruction. Flap elevation was performed in a similar fashion as previously described concomitant with surgical mastectomy. Upon dissection of the vascular pedicle, there was a double main pedicle pattern seen with both pedicles originating from the profunda system (see Fig. 4). These pedicles were adjacent to one another and, like the previous case, were distinct from the minor, more distal pedicle originating off of the superficial femoral system, which was clipped and ligated earlier in the dissection. Although both of these pedicles seemed adequate in caliber for microanastamosis, it was thought that the proximal pedicle was slightly larger and felt to be dominant. Subsequently, the distal pedicle was clipped and ligated and the dissection, microanastamosis, and closure proceeded as described in the previous case. It was noted that the f lap was slightly cool and had diminished capillary refill but was deemed viable. Postoperatively, the f lap remained cool without a cutaneous Doppler signal but with delayed refill. The patient was discharged home on postoperative day 4. The patient presented to the office 2 weeks from the date of surgery with progressive signs of vascular insufficiency, including widespread darkening of the skin paddle, with appreciable but
FIGURE 3. Pedicle demonstrating a double pedicle with 1 contribution from the profunda femoral system and 1 contribution from the superficial femoral system. 530
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FIGURE 4. Pedicle demonstrating a double pedicle with both contributions from the profunda femoral system.
diminished capillary refill. This continued to demarcate, and on postoperative day 16, the patient was ultimately taken back to the operating room for complete removal of the f lap. Approximately 30% of it was viable.
DISCUSSION There has been much clinical interest in the perfusion pattern of the gracilis myocutaneous f lap first described by McCraw et al with its original longitudinal orientation for skin paddle harvest and then reintroduced in a new transverse design by the work of Yousif et al.4 This latter flap design was aimed at improving the skin paddle viability which previously riddled the longitudinal design as reported by McCraw et al,5 Heath et al,6 Copeland et al,7 and in a subsequent literature review by Juricic et al.8 A clear improvement in skin flap perfusion has been realized with increased clinical use of the transverse myocutaneous gracilis flap. The more favorable donor-site scar has paved the way for its application to autologous breast reconstruction. For many notable surgeons, it is their preferred donor site for autologous breast reconstruction; however, at our institution, as is commonplace, it is reserved as a second choice donor site to the abdominal-based flaps. Despite earlier investigations delineating the variability in the vascular pedicle of the gracilis f lap, the clinical implications of this have not been well described with respect to the transverse myocutaneous gracilis flap. A study out of Germany looking at cadaveric dissections described the typical branching pattern of the pedicle proximal to the muscle with an ascending, descending, and 1 or 2 lateral branches.3 This article described deviation from this pattern with a double main pedicle observed in 9 of the 43 gracilis pedicle dissections. Seven of these 9 cases saw a common origin of both main pedicles from the profunda system, whereas the other 2 showed separate origins of the pedicles from the profunda. Of the later 2 cases, both displayed dominance of the more proximal pedicle. This ‘‘dominance’’ was asserted given the greater number of perforating branches as well as increased vessel diameter of the more proximal pedicle with respect to the more distal pedicle. With this article, we describe a high incidence of major pedicle variability in 6 of 36 cases reviewed. We also describe a variation * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 5, May 2015
not previously reported. Peek et al3 in their cadaveric investigations used methylene blue injections in the main pedicle of the gracilis and similarly described vascular pedicle variation in 21% of their dissections. However, most of these (16%) were a split main pedicle off the profunda femoris artery, whereas only 2 (5%) in 43 of their specimens showed independent origin of 2 dominant pedicles to the gracilis, 1 originating from the profunda and 1 from the medial circumf lex femoral artery and vein. In our series, 17% of pedicles were anomalous, with 5.5% displaying a split pedicle and 11% displaying a double main pedicle. We confirmed that in 3 cases of the double pedicle, 1 pedicle came from the medial circumf lex vessels and the other originated from the deep femoral vessels. In the final case of a double pedicle, both pedicles originated from the medial circumf lex vessels. In the split pedicle cases, the origin was the medial circumf lex femoral vessels. This supports the findings of Peek et al3; however, it demonstrates a significantly higher incidence of double main pedicles in our series. These vascular pedicle variations can have significant clinical implications for microsurgical breast reconstruction when the reliability of the fat and overlying skin is necessary to create an adequate breast mound. In the case of the split pedicle with common origin from the profunda femoris artery, there were no untoward clinical implications of the vascular variation. The common trunk of the split pedicle was dissected and used for a single venous and arterial microanastamoses to the internal mammary vessels. In the 2 cases of duplicate vascular pedicles, the fate of the f lap was very different. In both cases, the pedicles were dissected identically by ligating what seemed to be the smaller of the 2 pedicles and the microanastamosis was performed on what seemed to be the more dominant pedicle. In the second case presented, the f lap remained well perfused despite ligation of the duplicate pedicle. However, in the last case reported, ultimately two thirds of the skin paddle was inadequately perfused, resulting in the need for subsequent debridement of the entire flap. Many microsurgeons have enthusiastically embraced the TUG f lap as an alternative to abdominal donor site for breast reconstruction. Because of its anatomical location, it facilitates comfortable f lap harvest alongside of the mastectomy by breast surgeons and does not require a position change during reconstruction. However, it is important not to underestimate the potential for vascular variability in this setting. Because of the high incidence of vascular variations in the gracilis myocutaneous f lap, it is important to develop an algorithm for pedicle dissection in the presence of such anomalies. Due to constraints placed on the vertical height limits of the f lap by the need for primary donor-site closure, and given that there is often a paucity of subcutaneous fat reserves in these patients selected for TUG f lap
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Vascular Variations of the TUG Flap
reconstruction, the implications of even partial f lap loss or small areas of fat necrosis can be devastating for reconstructive outcomes in this population. When a double main pedicle is encountered, the surgeon must first determine if one of the 2 pedicles is dominant; this is judged by size (diameter) of the vessel as well as number of muscular branches off of the pedicle. If one seems clearly dominant by these standards, we would recommend confirming this by placing a temporary vascular clamp (Acland/bulldog) on the nondominant pedicle and observing for any changes in microcirculation of the skin paddle. We recommend proceeding with harvest of the internal mammary vessels at this point to allow adequate time for congestion or ischemic changes to manifest. If there is no alteration in the skin paddle viability, it is probably safe to ligate the nondominant pedicle. Alternatively, if there are changes in viability of the skin paddle or both pedicles seem nearly identical in caliber, we recommend either an endto-side anastamosis of the nondominant/codominant arterial pedicle into the dominant pedicle before anastomosis or anastomosing both pedicles to 2 separate recipient vessels to preserve skin paddle viability. Alternatively, when the technology is available, using indocyanine green angiography can confirm the adequacy of perfusion to the skin paddle after applying an Acland clamp to one of the double main pedicles. Often, more important than the initial images captured after indocyanine green is circulated systemically are the delayed images typically taken 20 minutes after the initial injection. These delayed images are used to rule out a ‘‘blush’’ in the f lap, or high amounts of indocyanine green retained in the flap, which would represent venous congestion. REFERENCES 1. Lasso JM, Rosado J, Luengo EP, et al. Gracilis flap: a variation of the main vascular pedicle. Plast Reconstr Surg. 2004;114:597Y598. 2. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap: vascular anatomy and clinical application. Plast Reconstr Surg. 1997;99:1642Y1652. 3. Peek A, Mu¨ller M, Ackermann G, et al. The free gracilis perforator flap: anatomical study and clinical refinements of a new perforator flap. Plast Reconstr Surg. 2009;123:578Y588. 4. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992;29:482. 5. McCraw JB, Massey FM, Shanklin KD, et al. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg. 1976;58:176. 6. Heath PM, Woods JE, Podratz KC, et al. Gracilis myocutaneous vaginal reconstruction. Mayo Clin Proc. 1984;59:21. 7. Copeland LJ, Hancock KC, Gershenson DM, et al. Gracilis myocutaneous vaginal reconstruction concurrent with total pelvic exenteration. Am J Obstet Gynecol. 1989;160:1095. 8. Juricic M, Vaysse P, Guitard J, et al. Anatomic basis for use of a gracilis muscle flap. Surg Radiol Anat. 1993;15:163.
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Vascular Variations of the Transverse Upper Gracilis Flap in Consideration for Breast Reconstruction Noe¨l Blythe Natoli, MD and Liza C. Wu, MD Purpose: The transverse upper gracilis (TUG) myocutaneous f lap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability. Methods: A retrospective review of records was performed on patients undergoing a TUG f lap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.). Results: A total of 36 TUG f laps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of f lap harvest. Conclusions: Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for f lap dissection when the microsurgeon encounters such aberrancies. Key Words: transverse upper gracilis myocutaneous flap, TUG flap, autologous breast reconstruction, vascular pedicle variation (Ann Plast Surg 2015;74: 528Y531)
T
he gracilis myocutaneous f lap has frequently been cited for the poor reliability of its skin paddle in regional reconstruction, mainly the perineum. In fact, some reconstructive surgeons have abandoned it completely in favor of other regional f laps such as the myocutaneous rectus abdominus or anterolateral thigh f lap. The reliability of the overlying skin paddle of the gracilis myocutaneous f lap depends on 2 factors, namely, the vascular pedicle and the perforator anatomy. The gracilis f lap is considered a type 2 muscle with dominant pedicle origin from the profundus system and minor perforators originating from the superficial femoral system. The dominant proximal pedicle of the gracilis muscle either branches directly off the profunda femoral vessels or the medial femoral circumflex vessels off the profunda vessels. The pedicle travels on top of the adductor magnus muscle, underneath the adductor longus muscle, to enter the gracilis muscle in the proximal portion generally entering 10 to 12 cm caudal to the pubic tubercle. Venous variations of the venae comitantes of the pedicle with convergence of the vein proximally have also been described by previous investigators
Received April 1, 2013, and accepted for publication, after revision, August 26, 2013. From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA. Conflicts of interest and sources of funding: none declared. Reprints: Noe¨l Blythe Natoli, MD, Long Island Plastic Surgical Group, 999 Franklin Ave, Garden City, NY 11530. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0528 DOI: 10.1097/01.sap.0000435501.19566.75
528
www.annalsplasticsurgery.com
with implication for free tissue transfer permitting harvest of longer pedicles of greater vessel diameter for microanastamosis.1 Well delineated by previous authors are intramuscular communications traveling axially within the substance of the adductor longus between the dominant proximal pedicle derived from the deep femoral system and the secondary minor pedicle off the superficial femoral system.1 The perforators supplying the overlying skin have recently gained more attention as surgeons strive to improve the reliability of the gracilis myocutaneous f lap. Surgical techniques include extending the width of fascial harvest and converting it to an extended myofasciocutaneous f lap.2 This has been substantiated by work from Whetzel and Lechtman,2 investigating the vascular territory of the superficial profundus perforators to the skin paddle by performing ink injections in cadavers of both the proximal minor perforator pedicles as well as the dominant gracilis vascular pedicle and evaluating their contribution to skin paddle staining as a model for skin perfusion. Other investigators have focused on including not only myocutaneous perforators but also septocutaneous perforators to create an extended gracilis perforator f lap.3 An additional aspect of the vascular supply of the gracilis myocutaneous f lap that has not been well delineated in the literature is the variations of the proximal, dominant pedicle. Although these variations may not directly impact the use of the pedicled gracilis myocutaneous f lap, the implications in free tissue transfer can be great. We would like to report the in vivo observation of 6 cases of such vascular anomalies, and moreover, discuss potential clinical implications for breast reconstruction including the introduction of an algorithm for pedicle selection and dissection when encountering such vascular variations.
METHODS AND MATERIALS All transverse upper gracilis (TUG) myocutaneous f laps performed by the senior author (L.C.W.) between July 2006 and November 2011 were reviewed. There were a total of 36 TUG f laps performed in 24 patients for autologous breast reconstruction in the study period. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Upon review of these cases, including evaluation of operative reports and pertinent hospital records, there were 6 such instances of aberrant vascular pedicles including 4 cases of double pedicles and 2 cases of a split proximal pedicle. The relevant surgical details of these 6 cases along with the described methods and techniques for TUG harvest used by the senior author will be discussed later. We encountered major pedicle variability in 6 of 36 or 17% of cases reviewed. In our series, 17% of pedicles were anomalous, with 5.5% displaying a split pedicle and 11% displaying a double main pedicle.
Surgical Technique Preoperatively, the patient is marked in the holding area in the standing position. The superior aspect of the f lap markings is made 2 fingerbreadths below the groin crease; this allows for centralization of the pedicle in the harvested f lap. The lower limits of the f lap, which will determine the vertical height of the f lap, are dictated by patient body habitus and predominantly skin laxity at the medial Annals of Plastic Surgery
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
&
Volume 74, Number 5, May 2015
Annals of Plastic Surgery
& Volume 74, Number 5, May 2015
Vascular Variations of the TUG Flap
thigh. The maximal height achievable with minimal tension on the wound edges is determined by pinch-test and is marked. The anterior border extends to the ventral limit of the mid-anterior thigh and the posterior limit of the f lap is designed at the lateral aspect of the gluteal crease (see Fig. 1 for markings). The patient is positioned supine in the frog-legged position with circumferential preparation of the entire leg from the level of the groin. Flap elevation is generally performed conjointly with the mastectomy. Either contralateral or ipsilateral harvest can be performed and is chosen to maximize medial breast fullness. The margins of the f lap are incised anteriorly and f lap elevation takes place at the level between the superficial and deep fat. The saphenous vein is identified and left intact in the leg. Once the abductor longus muscle and tendon are encountered, the fascia is then incised and the dissection continues in the subfascial plane. The main vascular pedicle of the gracilis is easily identified lying on top of the abductor magnus muscle and is seen entering the gracilis muscle. The pedicle is dissected proximally toward its origin. Dissection proceeds along the gracilis muscle both proximally and distally. The distal extent of the muscle dissection and harvest occurs until the minor pedicle off of the superficial femoral system is identified, clipped, and ligated. The skin paddle elevation continues posteriorly in the suprafascial plane, taking care to ligate all other perforators not coming from the gracilis pedicle.
Case Presentations Case 1 A 52-year-old woman presented after diagnosis of right breast cancer, with a history of left-sided breast cancer, which was reconstructed with a pedicled transverse rectus abdomens myocutaneous flap at another institution. Given the patients’ body habitus and preferences, we decided to proceed with autologous reconstruction from her right inner thigh. A split proximal pedicle to the gracilis was identified (see Fig. 2). Both branches of the pedicle were preserved. The internal mammary vessels were next exposed at the third intercostal space and dissected in preparation for surgical microanastamosis before f lap division. Microanastamosis was performed in standard fashion first by establishing the venous connection with a 2.5-mm coupler and next reestablishing arterial flow of the pedicle proximal to the split with interrupted 8-0 nylon sutures under 3.5 loupe magnification. The breast was next inset and the donor site was closed primarily. The
FIGURE 2. Pedicle demonstrating a split-proximal main pedicle off of the profunda femoral system.
postoperative course of this patient was uneventful and she healed well with an excellent aesthetic result with no evidence of flap necrosis or healing problems.
Case 2 A 37-year-old woman with a paucity of abdominal tissue presented for delayed bilateral breast reconstruction. Flap dissection on the right thigh showed no vascular aberrancy, however, upon flap elevation on the left medial thigh, there were 2 separate pedicles entering the gracilis muscle (see Fig. 3). Both pedicles were dissected proximally to their origins; one seemed to be originating from the profunda system and the other seemed to be originating from the superficial system. Of the double pedicle, the proximal one seemed to be of larger caliber. A decision was made to divide the distal and
FIGURE 1. Standard surgical markings for TUG f lap for breast reconstruction. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery
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& Volume 74, Number 5, May 2015
seemingly less dominant pedicle. After ligation of the secondary pedicle, the skin paddle was observed for changes in circulation indicating vascular compromise. There was no congestion/pallor observed and pedicle harvest proceeded. The remainder of her encounter including flap inset and postoperative hospital course was uneventful. There was no evidence of partial f lap loss or fat necrosis observed during her hospitalization or in subsequent follow-up after discharge.
Case 3 A 64-year-old woman presented for consultation for breast reconstruction; having been recently diagnosed with recurrent left breast cancer, with a history of left-sided breast conservation therapy. Because of a history of multiple previous abdominal surgeries, it was decided to proceed with left-sided TUG breast reconstruction. Flap elevation was performed in a similar fashion as previously described concomitant with surgical mastectomy. Upon dissection of the vascular pedicle, there was a double main pedicle pattern seen with both pedicles originating from the profunda system (see Fig. 4). These pedicles were adjacent to one another and, like the previous case, were distinct from the minor, more distal pedicle originating off of the superficial femoral system, which was clipped and ligated earlier in the dissection. Although both of these pedicles seemed adequate in caliber for microanastamosis, it was thought that the proximal pedicle was slightly larger and felt to be dominant. Subsequently, the distal pedicle was clipped and ligated and the dissection, microanastamosis, and closure proceeded as described in the previous case. It was noted that the f lap was slightly cool and had diminished capillary refill but was deemed viable. Postoperatively, the f lap remained cool without a cutaneous Doppler signal but with delayed refill. The patient was discharged home on postoperative day 4. The patient presented to the office 2 weeks from the date of surgery with progressive signs of vascular insufficiency, including widespread darkening of the skin paddle, with appreciable but
FIGURE 3. Pedicle demonstrating a double pedicle with 1 contribution from the profunda femoral system and 1 contribution from the superficial femoral system. 530
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FIGURE 4. Pedicle demonstrating a double pedicle with both contributions from the profunda femoral system.
diminished capillary refill. This continued to demarcate, and on postoperative day 16, the patient was ultimately taken back to the operating room for complete removal of the f lap. Approximately 30% of it was viable.
DISCUSSION There has been much clinical interest in the perfusion pattern of the gracilis myocutaneous f lap first described by McCraw et al with its original longitudinal orientation for skin paddle harvest and then reintroduced in a new transverse design by the work of Yousif et al.4 This latter flap design was aimed at improving the skin paddle viability which previously riddled the longitudinal design as reported by McCraw et al,5 Heath et al,6 Copeland et al,7 and in a subsequent literature review by Juricic et al.8 A clear improvement in skin flap perfusion has been realized with increased clinical use of the transverse myocutaneous gracilis flap. The more favorable donor-site scar has paved the way for its application to autologous breast reconstruction. For many notable surgeons, it is their preferred donor site for autologous breast reconstruction; however, at our institution, as is commonplace, it is reserved as a second choice donor site to the abdominal-based flaps. Despite earlier investigations delineating the variability in the vascular pedicle of the gracilis f lap, the clinical implications of this have not been well described with respect to the transverse myocutaneous gracilis flap. A study out of Germany looking at cadaveric dissections described the typical branching pattern of the pedicle proximal to the muscle with an ascending, descending, and 1 or 2 lateral branches.3 This article described deviation from this pattern with a double main pedicle observed in 9 of the 43 gracilis pedicle dissections. Seven of these 9 cases saw a common origin of both main pedicles from the profunda system, whereas the other 2 showed separate origins of the pedicles from the profunda. Of the later 2 cases, both displayed dominance of the more proximal pedicle. This ‘‘dominance’’ was asserted given the greater number of perforating branches as well as increased vessel diameter of the more proximal pedicle with respect to the more distal pedicle. With this article, we describe a high incidence of major pedicle variability in 6 of 36 cases reviewed. We also describe a variation * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 5, May 2015
not previously reported. Peek et al3 in their cadaveric investigations used methylene blue injections in the main pedicle of the gracilis and similarly described vascular pedicle variation in 21% of their dissections. However, most of these (16%) were a split main pedicle off the profunda femoris artery, whereas only 2 (5%) in 43 of their specimens showed independent origin of 2 dominant pedicles to the gracilis, 1 originating from the profunda and 1 from the medial circumf lex femoral artery and vein. In our series, 17% of pedicles were anomalous, with 5.5% displaying a split pedicle and 11% displaying a double main pedicle. We confirmed that in 3 cases of the double pedicle, 1 pedicle came from the medial circumf lex vessels and the other originated from the deep femoral vessels. In the final case of a double pedicle, both pedicles originated from the medial circumf lex vessels. In the split pedicle cases, the origin was the medial circumf lex femoral vessels. This supports the findings of Peek et al3; however, it demonstrates a significantly higher incidence of double main pedicles in our series. These vascular pedicle variations can have significant clinical implications for microsurgical breast reconstruction when the reliability of the fat and overlying skin is necessary to create an adequate breast mound. In the case of the split pedicle with common origin from the profunda femoris artery, there were no untoward clinical implications of the vascular variation. The common trunk of the split pedicle was dissected and used for a single venous and arterial microanastamoses to the internal mammary vessels. In the 2 cases of duplicate vascular pedicles, the fate of the f lap was very different. In both cases, the pedicles were dissected identically by ligating what seemed to be the smaller of the 2 pedicles and the microanastamosis was performed on what seemed to be the more dominant pedicle. In the second case presented, the f lap remained well perfused despite ligation of the duplicate pedicle. However, in the last case reported, ultimately two thirds of the skin paddle was inadequately perfused, resulting in the need for subsequent debridement of the entire flap. Many microsurgeons have enthusiastically embraced the TUG f lap as an alternative to abdominal donor site for breast reconstruction. Because of its anatomical location, it facilitates comfortable f lap harvest alongside of the mastectomy by breast surgeons and does not require a position change during reconstruction. However, it is important not to underestimate the potential for vascular variability in this setting. Because of the high incidence of vascular variations in the gracilis myocutaneous f lap, it is important to develop an algorithm for pedicle dissection in the presence of such anomalies. Due to constraints placed on the vertical height limits of the f lap by the need for primary donor-site closure, and given that there is often a paucity of subcutaneous fat reserves in these patients selected for TUG f lap
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Vascular Variations of the TUG Flap
reconstruction, the implications of even partial f lap loss or small areas of fat necrosis can be devastating for reconstructive outcomes in this population. When a double main pedicle is encountered, the surgeon must first determine if one of the 2 pedicles is dominant; this is judged by size (diameter) of the vessel as well as number of muscular branches off of the pedicle. If one seems clearly dominant by these standards, we would recommend confirming this by placing a temporary vascular clamp (Acland/bulldog) on the nondominant pedicle and observing for any changes in microcirculation of the skin paddle. We recommend proceeding with harvest of the internal mammary vessels at this point to allow adequate time for congestion or ischemic changes to manifest. If there is no alteration in the skin paddle viability, it is probably safe to ligate the nondominant pedicle. Alternatively, if there are changes in viability of the skin paddle or both pedicles seem nearly identical in caliber, we recommend either an endto-side anastamosis of the nondominant/codominant arterial pedicle into the dominant pedicle before anastomosis or anastomosing both pedicles to 2 separate recipient vessels to preserve skin paddle viability. Alternatively, when the technology is available, using indocyanine green angiography can confirm the adequacy of perfusion to the skin paddle after applying an Acland clamp to one of the double main pedicles. Often, more important than the initial images captured after indocyanine green is circulated systemically are the delayed images typically taken 20 minutes after the initial injection. These delayed images are used to rule out a ‘‘blush’’ in the f lap, or high amounts of indocyanine green retained in the flap, which would represent venous congestion. REFERENCES 1. Lasso JM, Rosado J, Luengo EP, et al. Gracilis flap: a variation of the main vascular pedicle. Plast Reconstr Surg. 2004;114:597Y598. 2. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap: vascular anatomy and clinical application. Plast Reconstr Surg. 1997;99:1642Y1652. 3. Peek A, Mu¨ller M, Ackermann G, et al. The free gracilis perforator flap: anatomical study and clinical refinements of a new perforator flap. Plast Reconstr Surg. 2009;123:578Y588. 4. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992;29:482. 5. McCraw JB, Massey FM, Shanklin KD, et al. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg. 1976;58:176. 6. Heath PM, Woods JE, Podratz KC, et al. Gracilis myocutaneous vaginal reconstruction. Mayo Clin Proc. 1984;59:21. 7. Copeland LJ, Hancock KC, Gershenson DM, et al. Gracilis myocutaneous vaginal reconstruction concurrent with total pelvic exenteration. Am J Obstet Gynecol. 1989;160:1095. 8. Juricic M, Vaysse P, Guitard J, et al. Anatomic basis for use of a gracilis muscle flap. Surg Radiol Anat. 1993;15:163.
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