Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, e1ee6

Bilateral simultaneous breast reconstruction with transverse musculocutaneous gracilis flaps ´de ´ric Bodin*, Thomas Schohn, Caroline Dissaux, Fre Alexandre Baratte, Caroline Fiquet, Catherine Bruant-Rodier Department of Plastic Surgery, Strasbourg Academic Hospital, Strasbourg, France Received 7 August 2014; accepted 22 September 2014

KEYWORDS Transverse musculocutaneous gracilis (TMG) flap; Transverse upper gracilis (TUG) flap; Bilateral breast reconstruction; Prophylactic mastectomy; Microsurgery

Summary Background: A transverse musculocutaneous gracilis flap provides good autologous reconstruction for small- and medium-sized breasts. Although the procedure is well adapted for bilateral breast reconstruction, no publication has specifically addressed simultaneous bilateral cases. Methods: From 2010 to 2014, the authors performed seven simultaneous bilateral breast reconstructions using transverse musculocutaneous gracilis flaps. The results with respect to operative data, immediate complications, second-stage reconstruction, and patient satisfaction after >1 year of follow-up were studied retrospectively. Results: The mean operative time was 7 h and 48 min (range, 6e9 h). Three minor complications occurred: two cases of limited flap necrosis and one case of donor-site wound dehiscence. Surgical revision was not required, and there was no flap failure. A second-stage operation was performed in 71% of the patients to improve the aesthetic results and flap volume. On average, 167 cm3 of fat was injected per breast. After a mean follow-up of 27 months, the satisfaction rate was 86% without significant functional deficits. Conclusions: A transverse musculocutaneous gracilis flap is an effective and safe option for simultaneous bilateral reconstruction. The operating time is shorter than that for other autologous procedures with similar complication rates and high patient satisfaction levels. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Service de Chirurgie plastique et reconstructrice e Ho ˆpital civil e 1, Place de l’ho ˆpital e B.P. N 426 e 67091 Strasbourg Cedex, France. Tel.: þ33 388116197; fax: þ33388115188. E-mail address: [email protected] (F. Bodin). 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.


Introduction Several autologous reconstruction procedures are available to provide natural and sustainable breasts after mastectomy. The deep inferior epigastric perforator (DIEP) flap is the most commonly used procedure.1 However, pedicled latissimus dorsi flaps, gluteal perforator flaps, and transverse musculocutaneous gracilis (TMG) flaps are often preferred, especially when the patient does not have sufficient abdominal skin. The recently developed TMG flap was originally described by Wechselberger and Schoeller in 2004 for breast reconstruction.2 Previous studies have shown a high level of patient satisfaction for small- and medium-sized breast reconstructions with low donor-site morbidity.3 The main consistent vascular pedicle of the gracilis muscle provides the blood supply for the flap.4 The elliptical transversal skin paddle provides sufficient volume for breast reconstruction with concealed scars in the natural folds. The procedure is particularly well adapted for bilateral breast reconstruction that offers a symmetric aesthetic appearance in the upper inner thigh.5 However, no study has yet specifically analyzed the results of simultaneous bilateral cases.

Materials and methods Between November 2010 and January 2014, 36 patients underwent 44 TMG breast reconstructions performed by the same leading surgeon in our surgical department. Of these, seven cases of primary bilateral simultaneous breast reconstructions were identified and analyzed. Approval to conduct this study was obtained from the ethics committee of the academic hospital, and all patients provided written informed consent.

Patients The mean age of the patients was 39.4 years (range, 20e48) with a mean body mass index of 25 kg/cm2 (range, 18.1e31.6). Mastectomies were performed as curative breast cancer therapy (50%) or prophylactically as skinsparing mastectomies (50%). The flaps were transferred in the immediate (50%) or delayed setting (50%). Fifty percent of the patients had previously received radiation therapy or chemotherapy. None of the patients presented significant comorbidities, and none of them were active smokers.

F. Bodin et al. cone shape and partially deepithelialized. The remaining skin was placed on the major breast surface in delayed breast reconstruction, but was reduced to the areola in immediate breast reconstruction with skin-sparing mastectomy. The gracilis muscle was rolled underneath to increase breast projection.

Retrospective evaluation protocol Operative data on operative time, ischemic time, weight of the flap, skin paddle dimension, and vascular pedicle characteristics (diameter and length) were studied. The length of hospital stay and immediate complications were collected and analyzed. After 1 year of follow-up, secondstage operations were recorded, focusing on the lipomodeling process and the volume of fat injected in each breast. Patient satisfaction was measured using a fourpoint Likert scale (very disappointed, disappointed, satisfied, and very satisfied).

Results On average, the operative time was 7 h 48 min (range, 6e9 h) with an ischemic time of 37 min (range, 26e55 min). The flap characteristics are presented in Table 1. No major complications occurred in the immediate postoperative period. No surgical revisions were required, and no flap failures occurred. The mean postoperative hospital stay was 6.4 days, ranging from 6 to 8 days. Three minor complications occurred after surgery (21% of the reconstructed breasts). One patient had a limited 3-cm2 flap necrosis necessitating wound healing for 2 months, and another patient suffered from cytosteatonecrosis. The third complication, a 5-cm wound dehiscence, occurred at the donor site. After a mean follow-up period of 27 months, ranging from 12 to 37 months, five women underwent surgery under general anesthesia for a second-step reconstruction (71%). Monitoring of skin excision, flap modeling, nipple areola complex reconstruction, and lipomodeling were the main procedures used. Bilateral fat volume injection was performed on all patients with a mean volume of 167 cm3 per breast (range, 60e260 cm3). Only one woman described a persistent sensation of tightness on the left thigh during forced abduction. Patient satisfaction regarding the bilateral reconstruction was high, with a satisfaction rate of 86% (Figures 1e4). Four patients were very satisfied (57%), two were satisfied

Surgical procedure The surgical procedure was performed as previously described by Schoeller et al.5 The TMG flaps were harvested from the inner thigh and transferred to the opposite breast using a systematic double-team approach. The pedicle of the flap was end-to-end anastomosed to the internal thoracic vessels in the third intercostal space. A portion below or above the rib cartilage was removed if necessary. Microanastomoses were performed using hand-sewn 9/0 or 8/0 nylon sutures for the artery and a mechanical coupler device for the veins (Synovis Micro Companies Alliance Inc., St Paul, MN, USA). The skin flap was folded onto itself into a

Table 1

Operative parameters.


Value (minemax)

Operation duration Ischemic duration Flap weight Skin paddle length Skin paddle width Artery diameter Coupler size Length of TMG vascular pedicle

468 min (360e540) 37 min (26e55) 356 g (270e487) 22.6 cm (18e30) 9.3 cm (7e10) 2.0 mm (1.5e2) 2.4 mm (1.5e3.5) 5.8 cm (4.5e7)

Bilateral TMG flap


Figure 1 First clinical case. Bilateral prophylactic mastectomy and reconstruction using double TMG flaps. During the second surgical step, 260 cm3 of fat was injected into each breast. Above: prior to surgery. Below: postoperative aesthetic result.

(29%), and the one was disappointed because of an asymmetrical result. She underwent an immediate reconstruction after prophylactic mastectomy on the left side, whereas the right side was treated with radical mastectomy and radiation therapy before delayed reconstruction. A third operative step was proposed to improve the aesthetic outcome.

Discussion Bilateral breast reconstruction after cancer should be examined separately from unilateral procedures because of specific problems. The magnitude of the procedure and the operating duration are substantially higher6e8; however,

Figure 2 Second clinical case. Prophylactic mastectomy on the left side associated with bilateral immediate (left) and delayed (right) breast reconstruction using double TMG flaps. During the second surgical step, 240 cm3 of fat was injected into the left breast, and 180 cm3 was injected into the right breast. Above: prior to surgery. Below: postoperative aesthetic result.

e4 breast symmetry is easier to achieve when the same procedure is employed for both sides.9 Furthermore, the incidence of bilateral breast reconstruction has recently increased because prophylactic mastectomies are widely recommended for BRCA mutation carriers.10 In the current study, 50% of the breast reconstructions were performed immediately after the risk-reducing mastectomy. The TMG flap procedure has proved to be effective for bilateral small- and medium-sized breast reconstructions,2 but, to date, no specific evaluations have been conducted. In the largest TMG flap series, Schoeller et al. performed 26 bilateral breast reconstructions. Unfortunately, the surgical evaluation did not separate unilateral and bilateral cases.5 The same is true for the studies by Fattah et al. (five bilateral cases),11 Vega et al. (six bilateral cases),12 Buntic et al. (12 bilateral cases),13 and Fansa et al. (12 bilateral cases).14 Three of these groups simply reported a mean operative time of 6.7, 6, and 5.4 h for bilateral flaps. Recently, Pu ¨lzl et al. reported their experience with TMG flaps for tertiary breast reconstruction or breast augmentation following capsular contracture. Seventeen cases were bilateral procedures with an operative time of 5 h.15 Locke et al. performed eight double TMG flaps with seven bilateral breast reconstructions. The operative time was not mentioned, but the average length of hospital stay was 8.6 days.16 The follow-up revealed one flap failure (6.3%), four additional procedures with either a DIEP flap or a

F. Bodin et al. silicone implant (25%), and eight second-step lipomodeling procedures (50%). In the current series, we specifically evaluated primary bilateral simultaneous autologous breast reconstruction using TMG flaps. The operative time of 7 h 48 min was somewhat longer than previously published results. No major complications occurred, and there were no surgical revisions or cases of flap loss, indicating the reliability of this procedure. The postoperative hospital stay remained stable at approximately 6.4 days. During the follow-up period, 71% of patients underwent surgery for a secondstage procedure. Bilateral fat volume injections improved aesthetic results by correcting irregularities and increasing breast volume. The patient satisfaction rate was high, at 86%. Alternative procedures to achieve bilateral autogenous breast reconstruction have been shown to require longer operative times than that required for double TMG flaps. According to the literature, the operative time for the simultaneous bilateral DIEP flap procedure ranges from 7 h 18 min to 10 h 54 min (Table 2).17e20 Similarly, bilateral inferior and superior gluteal artery perforator (IGAP and SGAP) flap transfers require 9 he10 h 26 min.18,21e23 Only one publication has reported an operative time of 6 h 36 min with bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flaps.24 Therefore, we concluded that the TMG flap is one of the fastest autologous

Figure 3 First clinical case. Anterior and posterior appearance of the donor site. Above: prior to surgery. Below: postoperative aesthetic result.

Bilateral TMG flap


Figure 4

Table 2

Second clinical case. Aesthetic results of the donor site 6 months following flap harvesting.

Systematic review of the literature on simultaneous autologous bilateral breast reconstruction.


Year Flap

Hamdi et al.17 Guerra et al.18 Drazan et al.19 Chun et al.28 Venkat et al.20 Baldwin et al.24 Paige et al.26 Chun et al.28 Guerra et al.18 Dellacroce et al.21 Levine et al.22 Flores et al.23 Hankins et al.27 Losken et al.29

2004 2004 2008 2010 2012 1994 1998 2010 2004 2005 2009 2012 2008 2010

Number Follow-up of (months) patients

DIEP 49 DIEP 140 DIEP 55 DIEP 58 DIEP 54 pTRAM 28 pTRAM 130 pTRAM 105 SGAP 6 SGAP 20 IGAP 22 SGAP 23 LD 37 LD 83

NA 14.6 (6e76) NA (4e52) 28 32 (6e101) NA 18 (1e64) 74 NA NA 23 (7e42) 12.5 NA 27.6

Operating time Hospital Global Flap Surgical Partial flap (min) stay (days) complication failure revision necrosis rate 570 438 476 NA 654 396 NA NA 570 626 540 570 NA NA

(420e780) (300e720) (396e600)

9 (6e20) 3.9(2e9) 8 (7e11) NA (462e834) 3(2e8) 7.6 NA NA NA 4 (450e660) 4 (4e5) (306e7032) 5.3 (3e24) NA NA

NA 35.60% 27.30% NA 34.0% NA 26.9% NA 33.0% 15.0% 36.3% NA 29.7% NA

1% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1.8%

NA 6.40% 7% NA 7.60% NA NA NA 16.60% 0% 9% 13% NA NA

0% 14.30% 1.80% 19.80% 2% 20% 13.80% 11.80% 16.60% 5% 5% 10.80% 4% 4.80%

DIEP, deep inferior epigastric perforator flap; pTRAM, pedicled transverse rectus abdominal myocutaneous flap; SGAP, superior gluteal artery perforator flap; IGAP, inferior gluteal artery perforator flap; LD, latissimus dorsi flap with or without implant. NA, not available.

procedures for simultaneous breast reconstruction, most likely due to easy flap harvesting, and only one required surgical positioning. The operative time played an important role because Hofer et al. proved that unilateral freeflap breast reconstructions exceeding 8 h resulted in significantly more complications.25 The global complication rate of bilateral autologous breast reconstructions is approximately 30% (Table 2). A systematic review of the literature showed complication rates of 27.3e35.6% for bilateral DIEP flaps, 15e36% for bilateral gluteal flaps, 26.9% for bilateral pedicled TRAM flaps,26 and 29.7% for bilateral latissimus dorsi flaps with implant.27 The revision rate ranged from 6.4% to 16.6% in a free-flap series, and flap necrosis occurred in 2e20% of patients across all techniques (Table 2). Regarding patient satisfaction, the satisfaction level among bilateral TMG patients was almost as high as that in the bilateral DIEP flap series. According to Chun et al., 92.6% of patients were very satisfied.28 In a study conducted by Drazan et al., the satisfaction level was good or excellent in 96.2% of women.19 To inform and help women who consider bilateral autologous breast reconstruction, several benefits relative

to the bilateral TMG flap can be highlighted. The scars are well concealed in natural folds, and functional donor-site deficits are limited.3 Bilateral flap harvesting provides upper inner thigh symmetry with skin lifting. The procedure is feasible even if the body mass index is low and there is no skin or fatty tissue excess. Finally, in cases with insufficient volume, the breast can be easily enlarged with bilateral fat grafting.

Conclusion The TMG flap is an effective and safe option for primary simultaneous bilateral reconstruction. The mean operative duration was 7 h 48 min and was lower than that for most bilateral autologous procedures, most likely because of the quick flap harvesting and unique surgical position. The complication rate was close to that of bilateral perforator flaps without significant functional sequelae at the donor site. After at least 1-year follow-up, 71% of patients had undergone a second-stage operation, with a mean fat grafting volume of 167 cm3 per breast. The high patient

e6 satisfaction level of 86% was almost as high as that in the bilateral DIEP flap series.

Conflict of interest statement The authors declare that they have no conflicts of interest.

Funding None.

Ethical approval The Ethical Committee of the Strasbourg Academic Hospital approved this study.

Acknowledgments The authors wish to thank Professor Thomas Schoeller for his instruction on TMG flaps.

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F. Bodin et al. 12. Vega SJ, Sandeen SN, Bossert RP, Perrone A, Ortiz L, Herrera H. Gracilis myocutaneous free flap in autologous breast reconstruction. Plast Reconstr Surg 2009;124:1400e9. 13. Buntic RF, Horton KM, Brooks D, Althubaiti GA. Transverse upper gracilis flap as an alternative to abdominal tissue breast reconstruction: technique and modifications. Plast Reconstr Surg 2011;128. 607e-13e. 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;122:1326e33. 15. Pu ¨lzl P, Huemer GM, Schoeller T. Transverse musculocutaneous gracilis flap for treatment of capsular contracture in tertiary breast reconstruction. Ann Plast Surg 2013 Jun 19 [Epub ahead of print]. 16. Locke MB, Zhong T, Mureau MAM, Hofer SOP. Tug « O » war: challenges of transverse upper gracilis (TUG) myocutaneous free flap breast reconstruction. J Plast Reconstr Aesthetic Surg 2012;65:1041e50. 17. Hamdi M, Blondeel P, Van Landuyt K, Tondu T, Monstrey S. Bilateral autogenous breast reconstruction using perforator free flaps: a single center’s experience. Plast Reconstr Surg 2004;114:83e9 [discussion 90e92]. 18. Guerra AB, Metzinger SE, Bidros RS, et al. Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps. Ann Plast Surg 2004; 52:246e52. 19. Drazan L, Vesely J, Hyza P, et al. Bilateral breast reconstruction with DIEP flaps: 4 years’ experience. J Plast Reconstr Aesthetic Surg 2008;61:1309e15. 20. Venkat R, Lee JC, Rad AN, Manahan MA, Rosson GD. Bilateral autologous breast reconstruction with deep inferior epigastric artery perforator flaps: review of a single surgeon’s early experience. Microsurgery 2012;32:275e80. 21. DellaCroce FJ, Sullivan SK. Application and refinement of the superior gluteal artery perforator free flap for bilateral simultaneous breast reconstruction. Plast Reconstr Surg 2005; 116:97e103 [discussion 104e105]. 22. Levine JL, Miller Q, Vasile J, et al. Simultaneous bilateral breast reconstruction with in-the-crease inferior gluteal artery perforator flaps. Ann Plast Surg 2009;63:249e54. 23. Flores JI, Magarakis M, Venkat R, Shridharani SM, Rosson GD. Bilateral simultaneous breast reconstruction with SGAP flaps. Microsurgery 2012;32:344e50. 24. Baldwin BJ, Schusterman MA, Miller MJ, Kroll SS, Wang BG. Bilateral breast reconstruction: conventional versus free TRAM. Plast Reconstr Surg 1994;93:1410e6 [discussion 1417]. 25. Hofer SOP, Damen THC, Mureau MAM, Rakhorst HA, Roche NA. A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg 2007;59:137e42. 26. Paige KT, Bostwick J, Bried JT, Jones G. A comparison of morbidity from bilateral, unipedicled and unilateral, unipedicled TRAM flap breast reconstructions. Plast Reconstr Surg 1998;101:1819e27. 27. Hankins CL, Friedman JA. 7-year experience in utilizing the latissimus dorsi myocutaneous flap for bilateral breast reconstruction. Ann Plast Surg 2008;60:134e40. 28. Chun YS, Sinha I, Turko A, et al. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2010;126:1133e41. 29. Losken A, Nicholas CS, Pinell XA, Carlson GW. Outcomes evaluation following bilateral breast reconstruction using latissimus dorsi myocutaneous flaps. Ann Plast Surg 2010;65: 17e22.

Bilateral simultaneous breast reconstruction with transverse musculocutaneous gracilis flaps.

A transverse musculocutaneous gracilis flap provides good autologous reconstruction for small- and medium-sized breasts. Although the procedure is wel...
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