DOUBLE TRANSVERSE MYOCUTANEOUS GRACILIS FREE FLAPS FOR UNILATERAL BREAST RECONSTRUCTION FRANK WERDIN, M.D.,* DANIEL M HAUG, M.D., AMRO AMR, M.D., and THOMAS SCHOELLER, M.D.
Background: In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. Patients and Methods: Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. Results: The average operating time was 6 hours 55 minutes (295 – 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. Conclusion: Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This C 2015 Wiley Periodicals, Inc. Microsurgery method further expands the range of options with autologous tissue in reconstructive breast surgery. V 00:000–000, 2015.
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need for autologous uni- or bilateral breast reconstruction is on the increase. Implant reconstruction or myocutaneous flaps with implants are still commonly mentioned in the literature.1–3 However, in the era of microsurgery, autologous breast reconstruction with free perforator flaps has become the gold standard.4 Autologous tissue provides a long lasting and superior aesthetic reconstructive result. Implant reconstruction is commonly used, but is frequently associated with a great variety of middle and long-term complications.5 In the largest series on patient satisfaction after prophylactic mastectomy and breast reconstruction with implants, patient satisfaction was only 60%2. 1994 Allen and Treece were the first to describe the deep inferior epigastric perforator flap (DIEP flap) for breast reconstruction.6 Since then, it has evolved to the method of choice for autologous breast reconstruction. This also applies to bilateral breast reconstruction where the DIEP flap is also the most common reconstructive method.7–10 Nonetheless, in certain patients there is the need for breast reconstructive methods other than the DIEP flap. Various flaps have been described for the reconstruction of the breast, varying from the thoraco dorsal artery perforator flap (TDAP flap), anterior lateral thigh flap (ALT flap) to the myocutaneous latissimus flap.11,12 Hamdi and Nahabedian recommend the superior gluteal artery perforator flap (sGAP flap) as their reconstructive method of second choice.8,9 The transverse myocutaneous Department of Plastic Surgery, Microsurgery and Reconstructive Breastsurgery, Marienhospital Stuttgart, Germany *Correspondence to: Frank Werdin, M.D., Rosenbergstr. 38, Stuttgart 70176, Germany. E-mail: [email protected] Received 19 August 2014; Revision accepted 29 December 2014; Accepted 13 February 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22397 Ó 2015 Wiley Periodicals, Inc.
gracilis Flap (TMG flap) is favored by many authors as second line treatment for autologous breast reconstruction13–17 as well as for the treatment of patients with Poland’s syndrome.18 The advantages of the TMG flap have been published in various papers and include the easy and quick dissection and the predictable anatomy of the flap.13–16 However, disadvantages include the limited tissue volume that prevents reconstruction of large breasts.13,15,16 We present our results of double TMG free-flap-transfer and define the role for unilateral breast reconstruction. PATIENTS AND METHODS
Between August 2004 and June 2012, 29 patients underwent unilateral breast reconstruction with double TMG flaps. The average age was 56 years and the average BMI of these 29 patients was 23.6 kg/m2. Indications for breast reconstruction were Poland syndrome in two women and breast cancer in 27 women. Three women had complete mastectomies and previous breast reconstruction with DIEP flap or latissimus dorsi myocutanous flap (LDM flap) and with silicone implant. One of the women with DIEP flap reconstruction had recurrence of the breast cancer on the reconstructed side and the other one had an angiosarcoma of the DIEP flap. On both women, the DIEP flap was resected and the breast was reconstructed once again. The woman with LDM flap reconstruction had capsular fibrosis. Twenty-four patients had skinsparing mastectomies (including removal of the nipple-areola). Out of 29 patients, 13 patients were too thin for DIEP flap reconstruction and five patients wished to have breast reconstruction without sacrificing the abdomen. Nine Patients had abdominal scars and a lack of abdominal fat for reconstruction of symmetric breast
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Figure 1. Double TMG reconstruction after skinsparing mastectomy on the left side. (a) microsurgical anastomosis of the medial flap;(b) vertical positioning of the medial flap, additional axillary approach for the second anastomosis with the thoracodorsal vessels;(c) intraoperative vertical positioning of both flaps;(d) postoperative skin islands for monitoring of the flap and nipple reconstruction.
and two patients had previous DIEP flap reconstruction. A single surgeon performed all TMG flaps. Surgical Technique
The preoperative planning and markings of the incision on the inner thigh of the patient were done in a prone position. Surgery was performed in two teams. One team raised the flaps on the thighs, the second team dissected the recipient vessels. The harvesting of the flap was done as previously described in other papers.13,14 As recipient vessels, we used the internal mammary artery (IMA) and its accompanying vein. The serratus branch of the thoracodorsal artery or the thoracoacromial artery with the accompanying veins were the recipient vessels for the second lateral flap. We did not use the distal/retrograde stump of the internal mammary vessels for the second flap due to the long distance to the laterally placed flap in relation to the relatively short TMG pedicle. The arterial anastomoses were performed with microsurgical suture technique under microscope magnification. The venous anastomoses were performed using the coupler system (Synovis Mirco Companies Alliance, Birmingham USA). The primary closure of the donor site defects were done simultaneously by the second team. After harvesting both TMG flaps, the autologous tissue was located in the new position to form the breast. Microsurgery DOI 10.1002/micr
The medial flap was connected to the IMA system (Fig. 1a) and the second flap was anastomosed to the serratus branch of the thoracodorsal artery or the thoracoacromial vessels. There were two different ways of integrating the skin islands. In primary breast reconstruction after skin sparing mastectomy, the skin islands were only used for monitoring (Fig. 1d). They were placed in a vertical position (Figs. 1b and 1c). The skin islands were then removed in a second operation after wound healing or were used for nipple reconstruction. This was done in a short operation under local anesthesia. In some cases where there was a lack of skin due to previous radical mastectomy, the skin islands of both TMG flaps were placed in an oblique, slightly shifted position, as shown in the image 2 (Fig. 2). The monitoring of the flap was done via a Doppler probe or insertion of an intramuscular O2 sensor. All of our patients were immobilized for 2 days and instructed to avoid sitting for 2 weeks. All patients received a standardized antithrombotic therapy in the form of a subcutaneous low-molecular-weight heparin. Operating time and success of the operation were analyzed. Complications were classified into complications of the flap or on the breast and complications of the donor site. Complications included total or partial
TMG-Free-Flaps
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Figure 2. (a) Flap positioning in case of secondary breast reconstruction after radical mastectomy. Horizontal view at the end of the operation. (b) a was the medial TMG flap, marked red was the deepithelialized portion of medial TMG flap that was buried under the original breast skin. b was the lateral TMG flap, marked green was the deepithelialized portion of medial TMG flap that was buried under the original breast.
flap necrosis. Partial flap necrosis was defined as ischemic tissue loss of skin and fat. Fat necrosis was characterized by localized firmness or nodule without skin breakdown. Delayed wound healing described a localized wound dehiscence. Furthermore, skin breakdown referred to skin necrosis of the original breast skin following subcutaneous mastectomy. Other complications were venous or arterial thrombosis, hematoma, infection, or seroma. Seroma was defined as prolonged serous secretions, which required treatment by drainage, punction, or surgery. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in; unsatisfactory, satisfactory, good, and very good.
cedures. There were no infections, local skin breakdown or wound dehiscence. Donor site complications were seen in four patients (14%). There were seroma in three cases of which none required surgical revision. No seroma became infected or required debridement. Wound dehiscence with delayed healing by conservative means was seen in one case. There was no hematoma and no lymphedema on the donor site. The aesthetic result of one patient was classified as unsatisfying. This was the patient with the flap failure and the final implant reconstruction. Three patients were classified into the “satisfactory group” and 13 patients in the “good” group. Results were evaluated as being very good. Examples of the final aesthetic outcome are given in Figures 1d, 3–5.
RESULTS
The average operating time was 6 hours 55 minutes (295–650 minutes). Of all 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (one arterial, six venous). Two venous thrombosis occurred in the anastomosis of the lateral flap due to pressure on the venous drainage. In four cases torsion of the internal mammaria vein led to venous congestion. Operative revision of the microsurgical anastomosis, without the use of a venous graft was successful in all six cases of venous congestion. Accordingly flap failure occurred due to late arterial thrombosis in one (1.7%) case with Poland syndrome on the fourth postoperative day. This flap was removed and replaced with a silicone implant. Complications that were encountered included, partial fat necrosis in two cases, which required surgical removal. One of these cases was treated by an additional pedicled LDM flap for compensation of tissue volume after resection of the necrosis. Hematoma occurred in six cases (in all six cases according to venous thrombosis as mentioned above). All six cases needed flap salvage pro-
DISCUSSION
The aesthetically favorable and long lasting result of free autologous breast reconstruction has led to a wide spread patient acceptance and an increasing demand. Numerous flaps have been described for autologeous reconstruction (LDM-, DIEP-, transverse rectus abdominis muscle flap, i/sGAP-, TMG-, fascia cutaneous infragluteal-, ALT flap).4,7–9,11,13,19–21 The back of the patient or the abdomen are the most commonly used donor sites.4,9,12 The TMG flap is an option for autologous reconstruction. The vascular reliability and safety of the TMG-flap are well known and success rates are reported to vary from 98% to 100%.13,16 In comparison, success rates of alternative flaps for breast reconstruction were 96% to 100% for the DIEP flap,9,22–25 92% to 98% for the s-GAP flap19,26–29 and 96.8% for the i-GAP flap.30 Papp and colleagues report on a success rate of 100% in patients treated with the FCI flap for breast reconstruction.20,31 Due to the reliable anatomical basis and a safe blood supply, partial flap necrosis and fat necrosis have been reported only in 1.2% and 3.9% of TMG flaps.13,32 This Microsurgery DOI 10.1002/micr
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Figure 3. Sixty-five year old patient with radical mastectomy with cancer recurrence after previous DIEP flap reconstruction on the left side. (a) preoperative;(b) 12 month postoperative after double TMG flap and nipple reconstruction.
relatively low necrosis rate is due to the exact preoperative planning and measuring of the flap. In contrast to the DIEP flap, no different perfusion zones are present in the TMG flap.33 Yousif et al. showed in their detailed anatomical study and latex injection of 24 cadaver legs that the blood supply to the skin overlying the gracilis muscle had a pronounced tendency to travel in a transverse direction, supplying the cutaneous territory over the adductor longus and sartorius anteriorly and extending nearby the midline of the dorsal thigh. Preserving this flap design we avoid fat necrosis.33 DIEP flap fat necrosis is reported in 13% to 29%3,24,25,34 of the cases with approximately an additional 2% recording a partial necrosis of the flap.3,24,25 In sGAP flaps fat necrosis rates between 5% to 10% have been reported.19,26,27 Generally, TMG flap donor site morbidity, such as sensory deficit over the posterior thigh in 32% of the patients and flap salvage rate of approximately 10% for wound dehiscence, scar revision or hematoma have been reported.13,16,32 However, due to the location of the scars, patient and surgeon satisfaction is high.13,32 The TMG flap is rather small and recommended for small to medium sized breasts. The size was reported to be 330 grams on average and between 220 and 440 grams.13,16,32 Wong et al. have recently reported an average weight of 469.75 grams for the extended TMG flap (range, 380–605 Microsurgery DOI 10.1002/micr
grams).15 Based on the easy dissection and rapid flap harvesting (varying between 30 and 40 minutes) we decided to use the bilateral flap for reconstruction of unilateral breast to compensate the lack of tissue volume in TMG flaps. In these cases, the extended TMG Flap would not have sufficed. With this method, we were able to double the transplanted tissue volume. Other options to extend volume would have been, a single TMG flap in combination either with lipofilling or with an implant as described by Trignano et al.17 To achieve an amount of 300 grams tissue by lipofilling requires on the one hand, several additional operations and on the other hand, we require a large depot of fat for liposuction which was not available in these slim patients. The combination with an implant could be a salvage procedure in case of flap failure. The primary goal remains the autologous breast reconstruction. To extend flap design on back of the thigh the PAP pedicle could be an option in flap harvesting. However, due to aesthetic reasons and possible postoperative pain syndrome we do not like to extend the flap design over the midline of the dorsal thigh. The size of the flap is of upmost importance for flap selection. The sGAP flap is a large flap, even in slim patients an average size of 451 grams has been recorded (190–894 grams).26 The iGAP flap provides a similar amount of tissue, with an average flap weight of 407 grams (137–806 grams).30
TMG-Free-Flaps
Figure 4. Sixty-two years old patient with capsular fibrosis after implant reconstruction and radiation of the right breast. (a) preoperative; (b) 12 months postoperative after double TMG flap and nipple reconstruction as well as abdominal scar correction.
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A major disadvantage is perhaps the necessity to anastomose two pedicles. Initially, this may sound like a microsurgical challenge connected with an increased rate of complications, but other surgeons have also shown that double flaps for breast reconstruction, such as double ALTs or double hemi DIEP, can be successfully carried out.9,21,23,25 With the improvement of microsurgical instruments in the last years, increasing microsurgical experience, well trained operational staff and the experience of surgeons, we did not register an increase in our complication rates. Furthermore, the risk factors for flap failure in microsurgical breast reconstruction are well known.35 This helps to preoperatively evaluate patients and increases awareness, leading to increased monitoring, such as the O2 monitoring device.35 The success rate of 98% in this study demonstrates a similar success rate as a one-sided reconstruction with the TMG flap or alternative methods described in the literature.13,16 Although twice the numbers of microsurgical vascular anastomoses were needed in unilateral breast reconstruction with two flaps, the thrombosis rate was comparable to other single flap microsurgical procedures.9,22,25,27,35 The average operating time was approximately 7 hours. Retrospectively, we noted an initially relatively long operating time, with a notable decrease, as with all learning curves. DIEP flap operating times vary from 4 hours 36 minutes to 6 hours 28 minutes,22,24,36 and for the iGAP flap from 5 hours to 5 hours 18 minutes.30,37 The sGap flap operating times are reported to be between 5 hours 23 minutes and 7 hours 12 minutes.26–29 However, operating times are also largely dependent on the surgeons experience and technical items (e.g., preparation
Figure 5. Forty-five year old patient with capsular fibrosis after implant reconstruction and radiation of the left breast. (a) preoperative, frontal view; (b) preoperative dorsal view; (c) 12 months postoperative after double TMG flap and nipple reconstruction, frontal view; (d) 12 months postoperative after double TMG flap and nipple reconstruction, dorsal view.
Microsurgery DOI 10.1002/micr
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of two or more perforators for enlargement of flaps). It is also important to consider that the patients in this retrospective analysis only had a single operation. The lasting results seem to compensate the rather long operating times. Theoretically, donor site morbidity should be doubled in our patients compared with unilaterally use of the TMG flap. However, we can only report on three seromas and one wound dehiscence. This is comparable to the unilateral TMG or other flaps.13,38,39 Donor site morbidity of the sGAP flap is low with an flap salvage rate of 6%. Though, seroma after sGAPharvest is also commonly reported and occurs in up to 35% of the patients.26–29 Donor site problems of the FCI flap included 21% seroma rates, which resolved conservatively and a high percentage of sensory changes with associated sitting problems.20,31 These, however, resolved over time. The iGAP flap shares a similar donor site and in 2004 Guerra et al. reported that they discontinued the iGAP flap, because of temporary dysesthesias (about 12 weeks) and for fear of causing chronic pain syndromes.26 In fact, the in-the-crease iGAP flap decreased the incidence of temporary sitting problem (3.2%),30 nonetheless, it seems current practice of these experienced surgeons to perform sGAP flaps in slightly [mt]50%.8,9,40,41 Finally, it should be mentioned that the senior author has a long experience with the TMG flap in breast reconstruction and can look back on a large series.13,18,32 This great experience also explains the low complication and high success rates, comparable to that of other flaps used for breast reconstruction. As with all new surgical techniques, we also experienced a learning curve. In the end, the abdomen remains our donor site of first choice. With increasing experience, the abdomen is available in patients who were initially not considered suitable for a DIEP- or TRAM flap. Obesity is not a contraindication,42 abdominal scars rarely43,44 and even previous liposuction on the abdomen is not a strict contraindication.45 In patients with previously dissected deep inferior epigastric vessels, anastomosis can be performed with the individual perforators.46 However, the abdomen cannot be used if the patient is to thin. In many published series of DIEP flaps, the average BMI was between 26 and 27.4,34,42 Our patients presented with an average BMI of 23.6 kg/m2 and in many cases the abdomen was to thin to serve as a donor site. Furthermore, the combination of a slim patient with abdominal scarring may prevent the harvest of an adequate sized DIEP. CONCLUSION
We successfully reconstructed aesthetically pleasing breasts with double TMG flaps in patients with larger breast Microsurgery DOI 10.1002/micr
size. In our opinion, the constant anatomy, easy flap dissection and the additional benefit of a bilateral thigh-lift compensates the necessity of the enlarged microsurgical procedure. The presented method, further expands the range of options for breast reconstruction with autologous tissue.
REFERENCES 1. Isern AE, Tengrup I, Loman N, Olsson H, Ringberg A. Aesthetic outcome, patient satisfaction, and health-related quality of life in women at high risk undergoing prophylactic mastectomy and immediate breast reconstruction. J Plast Reconstr Aesthet Surg 2008;34: 1148–1154. 2. Bresser PJ, Seynaeve CV, Gool AR, Brekelmans CT, MeijersHeijboer H, van Geel AN, Menke-Pluijmers MB, Duivenvoorden HJ, Klijn JG, Tibben A. Satisfaction with prophylactic mastectomy and breast reconstruction in genetically predisposed women. Plast Reconstr Surg 2006;117:1675–1682. 3. Kroll SS. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000;106:576–583. 4. Healy C, Allen RJ Sr. The evolution of perforator flap breast reconstruction: Twenty years after the first DIEP flap. J Reconstr Microsurg. 2014;30:121–125. 5. Handel N, Jensen JA, Black Q, Waisman JR, Silverstein MJ. The fate of breast implants: A critical analysis of complications and outcomes. Plast Reconstr Surg 1995;96:1521–1533. 6. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–38. 7. Tran NV, Buchel EW, Convery PA. Microvascular complications of DIEP flaps. Plast Reconstr Surg. 2007;119:1397–1405. 8. Nahabedian MY. Discussion: Bilateral autogenous breast reconstruction using perforator free flaps: A single center‘s experience. Plast Reconstr Surg 2004;114:90–92. 9. 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;114:83–89. 10. Manahan MA, Prucz RB, Shridharani SM, Baltodano PA, Rosson GD. Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps. Microsurgery. 2014;34:595–601. 11. Krochmal DJ, Rebecca AM, Casey WJ, Smith AA 3rd. Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction. Can J Plast Surg 2011;19:27–30. 12. Hamdi M. Oncoplastic and reconstructive surgery of the breast. Breast 2013;22(Suppl 2):100–105. 13. 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. 14. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse myocutaneous gracilis flap: Technical refinements. J Plast Reconstr Aesthet Surg 2010;63:305–313. 15. Wong C, Mojallal A, Bailey SH, Trussler A, Saint-Cyr M. The extended transverse musculocutaneous gracilis flap: Vascular anatomy and clinical implications. Ann Plast Surg 2011;67:170–177. 16. 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. 17. Trignano E, Fallico N, Dessy LA, Armenti AF, Scuderi N, Rubino C, Ramakrishnan V. Transverse upper gracilis flap with implant in postmastectomy breast reconstruction: A case report. Microsurgery 2014;34:149–152.; 18. Wechselberger G, Hladik M, Reichl H, Ensat F, Edelbauer M, Haug D, Schoeller T. The transverse musculocutaneous gracilis flap for chest wall reconstruction in male patients with Poland’s syndrome. Microsurgery 2013;33:282–286.)
TMG-Free-Flaps 19. Blondeel PN. The sensate free superior gluteal artery perforator (SGAP) flap: A valuable alternative in autologous breast reconstruction. Br J Plast Surg 1999;52:185–193. 20. Papp C, Windhofer C, Gruber S. Breast reconstruction with the fasciocutaneous infragluteal free flap (FCI). Ann Plast Surg 2007;58: 131–136. 21. Rosenberg JJ, Chandawarkar R, Ross MI, Chevray PM. Bilateral anterolateral thigh flaps for large-volume breast reconstruction. Microsurgery 2004;24:281–284. 22. De GC. Breast reconstruction by DIEP free flap: About 100 cases. Ann Chir Plast Esthet 2005;50:56–61. 23. Drazan L, Vesely J, Hyza P, Castagnetti F, Stupka I, Justan I, Novak P, Monni N. Bilateral breast reconstruction with DIEP flaps: 4 years’ experience. J Plast Reconstr Aesthet Surg 2008;61:1309– 1315. 24. Gill PS, Hunt JP, Guerra AB, Dellacroce FJ, Sullivan SK, Boraski J, Metzinger SE, Dupin CL, Allen RJ. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004;113:1153–1160. 25. Guerra AB, Metzinger SE, Bidros RS, Rizzuto RP, Gill PS, Nguyen AH, Dupin CL, Allen RJ. Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: An experience with 280 flaps. Ann Plast Surg 2004;52:246–252. 26. Guerra AB, Metzinger SE, Bidros Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery perforator (GAP) flaps: A critical analysis of 142 cases. Ann Plast Surg 2004;52:118–125. 27. Baumeister S, Werdin F, Peek A. The sGAP flap: Rare exception or second choice in autologous breast reconstruction? J Reconstr Microsurg 2010;26:251–258. 28. Werdin F, Peek A, Martin NC, Baumeister S. Superior gluteal artery perforator flap in bilateral breast reconstruction. Ann Plast Surg 2010;64:17–21. 29. Werdin F, Peek A, Schuster H, Baumeister S. Experience with the s-GAP flap for autologous breast reconstruction. Handchir Mikrochir Plast Chir 2008;40:255–261. 30. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006;118:333–339. 31. Papp C, Windhofer C, Michlits W. Autologous breast augmentation with the deepithelialized fasciocutaneous infragluteal free flap: A 10-year experience. Ann Plast Surg 2011;66:5872592 32. 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.
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33. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg 1992; 29:482–490. 34. Garvey PB, Buchel EW, Pockaj BA, Casey WJ, III, Gray RJ, Hernandez JL, Samson TD. DIEP and pedicled TRAM flaps: A comparison of outcomes. Plast Reconstr Surg 2006;117:1711–1719. 35. Masoomi H, Clark EG, Paydar KZ, Evans GR, Nguyen A, Kobayashi MR, Wirth GA. Predictive risk factors of free flap thrombosis in breast reconstruction surgery. Microsurgery 2014;34:589–594. 36. Blondeel PN. One hundred free DIEP flap breast reconstructions: A personal experience. Br J Plast Surg 1999;52:104–111. 37. Patenotre P, Duquennoy-Martinot V, Capon N, Dumortier R, Pellerin P. Breast reconstruction using gluteal inferior free flaps. 34 cases in 30 patients. Ann Chir Plast Esthet 2001;46:103–111.115: 447–457. 38. Schirmer S, Warnecke IC, Frerichs O, Cervelli A, Fansa H. Alternative autologous breast reconstruction using the free microvascular gracilis muscle flap with horizontal skin island. Handchir Mikrochir Plast Chir. 2008;40:262–266. 39. Saint-Cyr M, Wong C, Oni G, Maia M, Trussler A, Mojallal A, Rohrich RJ. Modifications to extend the transverse upper gracilis flap in breast reconstruction: Clinical series and results. Plast Reconstr Surg 2012;129:24e–36e. 40. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction using perforator flaps. J Surg Oncol 2006;94:441–454. 41. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg 2006;59:614–621. 42. Garvey PB, Buchel EW, Pockaj BA, Liu J, Robb GL, Beahm EK. The deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients. Plast Reconstr Surg 2005;115:447–457. 43. Schoeller T, Huemer GM, Kolehmainen M, Otto-Schoeller A, Wechselberger G. Management of subcostal scars during DIEP-flap raising. Br J Plast Surg 2004;57:511–514. 44. Hamdi M, Larsen M, Craggs B, Vanmierlo B, Zeltzer A. Harvesting free abdominal perforator flaps in the presence of previous upper abdominal scars. J Plast Reconstr Aesthet Surg 2014;67:219–225. 45. De FB, Van LK, Hamdi M, Blondeel P, Roche N, Voet D, Monstrey S. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006; 59:1031–1036. 46. Koshima I, Tsutsui T, Takahashi Y, Nanba Y. Free gluteal artery perforator flap with a short, small perforator. Ann Plast Surg 2003; 51:200–204.
Microsurgery DOI 10.1002/micr
Background: In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. Patients and Methods: Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. Results: The average operating time was 6 hours 55 minutes (295 – 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. Conclusion: Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This C 2015 Wiley Periodicals, Inc. Microsurgery method further expands the range of options with autologous tissue in reconstructive breast surgery. V 00:000–000, 2015.
The
need for autologous uni- or bilateral breast reconstruction is on the increase. Implant reconstruction or myocutaneous flaps with implants are still commonly mentioned in the literature.1–3 However, in the era of microsurgery, autologous breast reconstruction with free perforator flaps has become the gold standard.4 Autologous tissue provides a long lasting and superior aesthetic reconstructive result. Implant reconstruction is commonly used, but is frequently associated with a great variety of middle and long-term complications.5 In the largest series on patient satisfaction after prophylactic mastectomy and breast reconstruction with implants, patient satisfaction was only 60%2. 1994 Allen and Treece were the first to describe the deep inferior epigastric perforator flap (DIEP flap) for breast reconstruction.6 Since then, it has evolved to the method of choice for autologous breast reconstruction. This also applies to bilateral breast reconstruction where the DIEP flap is also the most common reconstructive method.7–10 Nonetheless, in certain patients there is the need for breast reconstructive methods other than the DIEP flap. Various flaps have been described for the reconstruction of the breast, varying from the thoraco dorsal artery perforator flap (TDAP flap), anterior lateral thigh flap (ALT flap) to the myocutaneous latissimus flap.11,12 Hamdi and Nahabedian recommend the superior gluteal artery perforator flap (sGAP flap) as their reconstructive method of second choice.8,9 The transverse myocutaneous Department of Plastic Surgery, Microsurgery and Reconstructive Breastsurgery, Marienhospital Stuttgart, Germany *Correspondence to: Frank Werdin, M.D., Rosenbergstr. 38, Stuttgart 70176, Germany. E-mail: [email protected] Received 19 August 2014; Revision accepted 29 December 2014; Accepted 13 February 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22397 Ó 2015 Wiley Periodicals, Inc.
gracilis Flap (TMG flap) is favored by many authors as second line treatment for autologous breast reconstruction13–17 as well as for the treatment of patients with Poland’s syndrome.18 The advantages of the TMG flap have been published in various papers and include the easy and quick dissection and the predictable anatomy of the flap.13–16 However, disadvantages include the limited tissue volume that prevents reconstruction of large breasts.13,15,16 We present our results of double TMG free-flap-transfer and define the role for unilateral breast reconstruction. PATIENTS AND METHODS
Between August 2004 and June 2012, 29 patients underwent unilateral breast reconstruction with double TMG flaps. The average age was 56 years and the average BMI of these 29 patients was 23.6 kg/m2. Indications for breast reconstruction were Poland syndrome in two women and breast cancer in 27 women. Three women had complete mastectomies and previous breast reconstruction with DIEP flap or latissimus dorsi myocutanous flap (LDM flap) and with silicone implant. One of the women with DIEP flap reconstruction had recurrence of the breast cancer on the reconstructed side and the other one had an angiosarcoma of the DIEP flap. On both women, the DIEP flap was resected and the breast was reconstructed once again. The woman with LDM flap reconstruction had capsular fibrosis. Twenty-four patients had skinsparing mastectomies (including removal of the nipple-areola). Out of 29 patients, 13 patients were too thin for DIEP flap reconstruction and five patients wished to have breast reconstruction without sacrificing the abdomen. Nine Patients had abdominal scars and a lack of abdominal fat for reconstruction of symmetric breast
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Figure 1. Double TMG reconstruction after skinsparing mastectomy on the left side. (a) microsurgical anastomosis of the medial flap;(b) vertical positioning of the medial flap, additional axillary approach for the second anastomosis with the thoracodorsal vessels;(c) intraoperative vertical positioning of both flaps;(d) postoperative skin islands for monitoring of the flap and nipple reconstruction.
and two patients had previous DIEP flap reconstruction. A single surgeon performed all TMG flaps. Surgical Technique
The preoperative planning and markings of the incision on the inner thigh of the patient were done in a prone position. Surgery was performed in two teams. One team raised the flaps on the thighs, the second team dissected the recipient vessels. The harvesting of the flap was done as previously described in other papers.13,14 As recipient vessels, we used the internal mammary artery (IMA) and its accompanying vein. The serratus branch of the thoracodorsal artery or the thoracoacromial artery with the accompanying veins were the recipient vessels for the second lateral flap. We did not use the distal/retrograde stump of the internal mammary vessels for the second flap due to the long distance to the laterally placed flap in relation to the relatively short TMG pedicle. The arterial anastomoses were performed with microsurgical suture technique under microscope magnification. The venous anastomoses were performed using the coupler system (Synovis Mirco Companies Alliance, Birmingham USA). The primary closure of the donor site defects were done simultaneously by the second team. After harvesting both TMG flaps, the autologous tissue was located in the new position to form the breast. Microsurgery DOI 10.1002/micr
The medial flap was connected to the IMA system (Fig. 1a) and the second flap was anastomosed to the serratus branch of the thoracodorsal artery or the thoracoacromial vessels. There were two different ways of integrating the skin islands. In primary breast reconstruction after skin sparing mastectomy, the skin islands were only used for monitoring (Fig. 1d). They were placed in a vertical position (Figs. 1b and 1c). The skin islands were then removed in a second operation after wound healing or were used for nipple reconstruction. This was done in a short operation under local anesthesia. In some cases where there was a lack of skin due to previous radical mastectomy, the skin islands of both TMG flaps were placed in an oblique, slightly shifted position, as shown in the image 2 (Fig. 2). The monitoring of the flap was done via a Doppler probe or insertion of an intramuscular O2 sensor. All of our patients were immobilized for 2 days and instructed to avoid sitting for 2 weeks. All patients received a standardized antithrombotic therapy in the form of a subcutaneous low-molecular-weight heparin. Operating time and success of the operation were analyzed. Complications were classified into complications of the flap or on the breast and complications of the donor site. Complications included total or partial
TMG-Free-Flaps
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Figure 2. (a) Flap positioning in case of secondary breast reconstruction after radical mastectomy. Horizontal view at the end of the operation. (b) a was the medial TMG flap, marked red was the deepithelialized portion of medial TMG flap that was buried under the original breast skin. b was the lateral TMG flap, marked green was the deepithelialized portion of medial TMG flap that was buried under the original breast.
flap necrosis. Partial flap necrosis was defined as ischemic tissue loss of skin and fat. Fat necrosis was characterized by localized firmness or nodule without skin breakdown. Delayed wound healing described a localized wound dehiscence. Furthermore, skin breakdown referred to skin necrosis of the original breast skin following subcutaneous mastectomy. Other complications were venous or arterial thrombosis, hematoma, infection, or seroma. Seroma was defined as prolonged serous secretions, which required treatment by drainage, punction, or surgery. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in; unsatisfactory, satisfactory, good, and very good.
cedures. There were no infections, local skin breakdown or wound dehiscence. Donor site complications were seen in four patients (14%). There were seroma in three cases of which none required surgical revision. No seroma became infected or required debridement. Wound dehiscence with delayed healing by conservative means was seen in one case. There was no hematoma and no lymphedema on the donor site. The aesthetic result of one patient was classified as unsatisfying. This was the patient with the flap failure and the final implant reconstruction. Three patients were classified into the “satisfactory group” and 13 patients in the “good” group. Results were evaluated as being very good. Examples of the final aesthetic outcome are given in Figures 1d, 3–5.
RESULTS
The average operating time was 6 hours 55 minutes (295–650 minutes). Of all 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (one arterial, six venous). Two venous thrombosis occurred in the anastomosis of the lateral flap due to pressure on the venous drainage. In four cases torsion of the internal mammaria vein led to venous congestion. Operative revision of the microsurgical anastomosis, without the use of a venous graft was successful in all six cases of venous congestion. Accordingly flap failure occurred due to late arterial thrombosis in one (1.7%) case with Poland syndrome on the fourth postoperative day. This flap was removed and replaced with a silicone implant. Complications that were encountered included, partial fat necrosis in two cases, which required surgical removal. One of these cases was treated by an additional pedicled LDM flap for compensation of tissue volume after resection of the necrosis. Hematoma occurred in six cases (in all six cases according to venous thrombosis as mentioned above). All six cases needed flap salvage pro-
DISCUSSION
The aesthetically favorable and long lasting result of free autologous breast reconstruction has led to a wide spread patient acceptance and an increasing demand. Numerous flaps have been described for autologeous reconstruction (LDM-, DIEP-, transverse rectus abdominis muscle flap, i/sGAP-, TMG-, fascia cutaneous infragluteal-, ALT flap).4,7–9,11,13,19–21 The back of the patient or the abdomen are the most commonly used donor sites.4,9,12 The TMG flap is an option for autologous reconstruction. The vascular reliability and safety of the TMG-flap are well known and success rates are reported to vary from 98% to 100%.13,16 In comparison, success rates of alternative flaps for breast reconstruction were 96% to 100% for the DIEP flap,9,22–25 92% to 98% for the s-GAP flap19,26–29 and 96.8% for the i-GAP flap.30 Papp and colleagues report on a success rate of 100% in patients treated with the FCI flap for breast reconstruction.20,31 Due to the reliable anatomical basis and a safe blood supply, partial flap necrosis and fat necrosis have been reported only in 1.2% and 3.9% of TMG flaps.13,32 This Microsurgery DOI 10.1002/micr
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Figure 3. Sixty-five year old patient with radical mastectomy with cancer recurrence after previous DIEP flap reconstruction on the left side. (a) preoperative;(b) 12 month postoperative after double TMG flap and nipple reconstruction.
relatively low necrosis rate is due to the exact preoperative planning and measuring of the flap. In contrast to the DIEP flap, no different perfusion zones are present in the TMG flap.33 Yousif et al. showed in their detailed anatomical study and latex injection of 24 cadaver legs that the blood supply to the skin overlying the gracilis muscle had a pronounced tendency to travel in a transverse direction, supplying the cutaneous territory over the adductor longus and sartorius anteriorly and extending nearby the midline of the dorsal thigh. Preserving this flap design we avoid fat necrosis.33 DIEP flap fat necrosis is reported in 13% to 29%3,24,25,34 of the cases with approximately an additional 2% recording a partial necrosis of the flap.3,24,25 In sGAP flaps fat necrosis rates between 5% to 10% have been reported.19,26,27 Generally, TMG flap donor site morbidity, such as sensory deficit over the posterior thigh in 32% of the patients and flap salvage rate of approximately 10% for wound dehiscence, scar revision or hematoma have been reported.13,16,32 However, due to the location of the scars, patient and surgeon satisfaction is high.13,32 The TMG flap is rather small and recommended for small to medium sized breasts. The size was reported to be 330 grams on average and between 220 and 440 grams.13,16,32 Wong et al. have recently reported an average weight of 469.75 grams for the extended TMG flap (range, 380–605 Microsurgery DOI 10.1002/micr
grams).15 Based on the easy dissection and rapid flap harvesting (varying between 30 and 40 minutes) we decided to use the bilateral flap for reconstruction of unilateral breast to compensate the lack of tissue volume in TMG flaps. In these cases, the extended TMG Flap would not have sufficed. With this method, we were able to double the transplanted tissue volume. Other options to extend volume would have been, a single TMG flap in combination either with lipofilling or with an implant as described by Trignano et al.17 To achieve an amount of 300 grams tissue by lipofilling requires on the one hand, several additional operations and on the other hand, we require a large depot of fat for liposuction which was not available in these slim patients. The combination with an implant could be a salvage procedure in case of flap failure. The primary goal remains the autologous breast reconstruction. To extend flap design on back of the thigh the PAP pedicle could be an option in flap harvesting. However, due to aesthetic reasons and possible postoperative pain syndrome we do not like to extend the flap design over the midline of the dorsal thigh. The size of the flap is of upmost importance for flap selection. The sGAP flap is a large flap, even in slim patients an average size of 451 grams has been recorded (190–894 grams).26 The iGAP flap provides a similar amount of tissue, with an average flap weight of 407 grams (137–806 grams).30
TMG-Free-Flaps
Figure 4. Sixty-two years old patient with capsular fibrosis after implant reconstruction and radiation of the right breast. (a) preoperative; (b) 12 months postoperative after double TMG flap and nipple reconstruction as well as abdominal scar correction.
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A major disadvantage is perhaps the necessity to anastomose two pedicles. Initially, this may sound like a microsurgical challenge connected with an increased rate of complications, but other surgeons have also shown that double flaps for breast reconstruction, such as double ALTs or double hemi DIEP, can be successfully carried out.9,21,23,25 With the improvement of microsurgical instruments in the last years, increasing microsurgical experience, well trained operational staff and the experience of surgeons, we did not register an increase in our complication rates. Furthermore, the risk factors for flap failure in microsurgical breast reconstruction are well known.35 This helps to preoperatively evaluate patients and increases awareness, leading to increased monitoring, such as the O2 monitoring device.35 The success rate of 98% in this study demonstrates a similar success rate as a one-sided reconstruction with the TMG flap or alternative methods described in the literature.13,16 Although twice the numbers of microsurgical vascular anastomoses were needed in unilateral breast reconstruction with two flaps, the thrombosis rate was comparable to other single flap microsurgical procedures.9,22,25,27,35 The average operating time was approximately 7 hours. Retrospectively, we noted an initially relatively long operating time, with a notable decrease, as with all learning curves. DIEP flap operating times vary from 4 hours 36 minutes to 6 hours 28 minutes,22,24,36 and for the iGAP flap from 5 hours to 5 hours 18 minutes.30,37 The sGap flap operating times are reported to be between 5 hours 23 minutes and 7 hours 12 minutes.26–29 However, operating times are also largely dependent on the surgeons experience and technical items (e.g., preparation
Figure 5. Forty-five year old patient with capsular fibrosis after implant reconstruction and radiation of the left breast. (a) preoperative, frontal view; (b) preoperative dorsal view; (c) 12 months postoperative after double TMG flap and nipple reconstruction, frontal view; (d) 12 months postoperative after double TMG flap and nipple reconstruction, dorsal view.
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of two or more perforators for enlargement of flaps). It is also important to consider that the patients in this retrospective analysis only had a single operation. The lasting results seem to compensate the rather long operating times. Theoretically, donor site morbidity should be doubled in our patients compared with unilaterally use of the TMG flap. However, we can only report on three seromas and one wound dehiscence. This is comparable to the unilateral TMG or other flaps.13,38,39 Donor site morbidity of the sGAP flap is low with an flap salvage rate of 6%. Though, seroma after sGAPharvest is also commonly reported and occurs in up to 35% of the patients.26–29 Donor site problems of the FCI flap included 21% seroma rates, which resolved conservatively and a high percentage of sensory changes with associated sitting problems.20,31 These, however, resolved over time. The iGAP flap shares a similar donor site and in 2004 Guerra et al. reported that they discontinued the iGAP flap, because of temporary dysesthesias (about 12 weeks) and for fear of causing chronic pain syndromes.26 In fact, the in-the-crease iGAP flap decreased the incidence of temporary sitting problem (3.2%),30 nonetheless, it seems current practice of these experienced surgeons to perform sGAP flaps in slightly [mt]50%.8,9,40,41 Finally, it should be mentioned that the senior author has a long experience with the TMG flap in breast reconstruction and can look back on a large series.13,18,32 This great experience also explains the low complication and high success rates, comparable to that of other flaps used for breast reconstruction. As with all new surgical techniques, we also experienced a learning curve. In the end, the abdomen remains our donor site of first choice. With increasing experience, the abdomen is available in patients who were initially not considered suitable for a DIEP- or TRAM flap. Obesity is not a contraindication,42 abdominal scars rarely43,44 and even previous liposuction on the abdomen is not a strict contraindication.45 In patients with previously dissected deep inferior epigastric vessels, anastomosis can be performed with the individual perforators.46 However, the abdomen cannot be used if the patient is to thin. In many published series of DIEP flaps, the average BMI was between 26 and 27.4,34,42 Our patients presented with an average BMI of 23.6 kg/m2 and in many cases the abdomen was to thin to serve as a donor site. Furthermore, the combination of a slim patient with abdominal scarring may prevent the harvest of an adequate sized DIEP. CONCLUSION
We successfully reconstructed aesthetically pleasing breasts with double TMG flaps in patients with larger breast Microsurgery DOI 10.1002/micr
size. In our opinion, the constant anatomy, easy flap dissection and the additional benefit of a bilateral thigh-lift compensates the necessity of the enlarged microsurgical procedure. The presented method, further expands the range of options for breast reconstruction with autologous tissue.
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TMG-Free-Flaps 19. Blondeel PN. The sensate free superior gluteal artery perforator (SGAP) flap: A valuable alternative in autologous breast reconstruction. Br J Plast Surg 1999;52:185–193. 20. Papp C, Windhofer C, Gruber S. Breast reconstruction with the fasciocutaneous infragluteal free flap (FCI). Ann Plast Surg 2007;58: 131–136. 21. Rosenberg JJ, Chandawarkar R, Ross MI, Chevray PM. Bilateral anterolateral thigh flaps for large-volume breast reconstruction. Microsurgery 2004;24:281–284. 22. De GC. Breast reconstruction by DIEP free flap: About 100 cases. Ann Chir Plast Esthet 2005;50:56–61. 23. Drazan L, Vesely J, Hyza P, Castagnetti F, Stupka I, Justan I, Novak P, Monni N. Bilateral breast reconstruction with DIEP flaps: 4 years’ experience. J Plast Reconstr Aesthet Surg 2008;61:1309– 1315. 24. Gill PS, Hunt JP, Guerra AB, Dellacroce FJ, Sullivan SK, Boraski J, Metzinger SE, Dupin CL, Allen RJ. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004;113:1153–1160. 25. Guerra AB, Metzinger SE, Bidros RS, Rizzuto RP, Gill PS, Nguyen AH, Dupin CL, Allen RJ. Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: An experience with 280 flaps. Ann Plast Surg 2004;52:246–252. 26. Guerra AB, Metzinger SE, Bidros Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery perforator (GAP) flaps: A critical analysis of 142 cases. Ann Plast Surg 2004;52:118–125. 27. Baumeister S, Werdin F, Peek A. The sGAP flap: Rare exception or second choice in autologous breast reconstruction? J Reconstr Microsurg 2010;26:251–258. 28. Werdin F, Peek A, Martin NC, Baumeister S. Superior gluteal artery perforator flap in bilateral breast reconstruction. Ann Plast Surg 2010;64:17–21. 29. Werdin F, Peek A, Schuster H, Baumeister S. Experience with the s-GAP flap for autologous breast reconstruction. Handchir Mikrochir Plast Chir 2008;40:255–261. 30. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006;118:333–339. 31. Papp C, Windhofer C, Michlits W. Autologous breast augmentation with the deepithelialized fasciocutaneous infragluteal free flap: A 10-year experience. Ann Plast Surg 2011;66:5872592 32. 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.
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33. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg 1992; 29:482–490. 34. Garvey PB, Buchel EW, Pockaj BA, Casey WJ, III, Gray RJ, Hernandez JL, Samson TD. DIEP and pedicled TRAM flaps: A comparison of outcomes. Plast Reconstr Surg 2006;117:1711–1719. 35. Masoomi H, Clark EG, Paydar KZ, Evans GR, Nguyen A, Kobayashi MR, Wirth GA. Predictive risk factors of free flap thrombosis in breast reconstruction surgery. Microsurgery 2014;34:589–594. 36. Blondeel PN. One hundred free DIEP flap breast reconstructions: A personal experience. Br J Plast Surg 1999;52:104–111. 37. Patenotre P, Duquennoy-Martinot V, Capon N, Dumortier R, Pellerin P. Breast reconstruction using gluteal inferior free flaps. 34 cases in 30 patients. Ann Chir Plast Esthet 2001;46:103–111.115: 447–457. 38. Schirmer S, Warnecke IC, Frerichs O, Cervelli A, Fansa H. Alternative autologous breast reconstruction using the free microvascular gracilis muscle flap with horizontal skin island. Handchir Mikrochir Plast Chir. 2008;40:262–266. 39. Saint-Cyr M, Wong C, Oni G, Maia M, Trussler A, Mojallal A, Rohrich RJ. Modifications to extend the transverse upper gracilis flap in breast reconstruction: Clinical series and results. Plast Reconstr Surg 2012;129:24e–36e. 40. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction using perforator flaps. J Surg Oncol 2006;94:441–454. 41. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg 2006;59:614–621. 42. Garvey PB, Buchel EW, Pockaj BA, Liu J, Robb GL, Beahm EK. The deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients. Plast Reconstr Surg 2005;115:447–457. 43. Schoeller T, Huemer GM, Kolehmainen M, Otto-Schoeller A, Wechselberger G. Management of subcostal scars during DIEP-flap raising. Br J Plast Surg 2004;57:511–514. 44. Hamdi M, Larsen M, Craggs B, Vanmierlo B, Zeltzer A. Harvesting free abdominal perforator flaps in the presence of previous upper abdominal scars. J Plast Reconstr Aesthet Surg 2014;67:219–225. 45. De FB, Van LK, Hamdi M, Blondeel P, Roche N, Voet D, Monstrey S. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006; 59:1031–1036. 46. Koshima I, Tsutsui T, Takahashi Y, Nanba Y. Free gluteal artery perforator flap with a short, small perforator. Ann Plast Surg 2003; 51:200–204.
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