Simon Mackey

Microvascular Modifications to Optimize the Transverse Upper Gracilis Flap for Breast Reconstruction

Background: The free transverse upper gracilis flap is well described for breast reconstruction and is the authors’ second choice. Medial thigh soft tissue creates a durable, pliable, aesthetic breast; however, it has been criticized for modest volume and short pedicle. This demands frequent use of bilateral flaps for unilateral reconstructions, sacrifice of thoracodorsal vessels, and/or use of vein grafts. The authors have overcome these issues by modifying their microvascular techniques. Methods: The authors describe several maneuvers that they have introduced, including excision and replacement of costal cartilage, using nontraditional internal mammary arterial anastomoses, and using adductor branches for flap-to-flap anastomoses to allow double flap reconstructions. The authors describe their case series of 30 transverse upper gracilis flaps to reconstruct 20 breasts in 18 patients. Results: All flaps have survived. Seventy-five percent of the reconstructions were unilateral, although of these, 67 percent used two flaps to reconstruct one breast. The mean reconstructed breast was 360.9 g. Of 10 breasts reconstructed with double flaps, six used available adductor branches, whereas the others used internal mammary perforators, end-to-side anastomoses, or retrograde arterial flow. To complement this clinical approach, an anatomical study of the branching patterns from the gracilis pedicle has been carried out on 33 cadaveric specimens. Conclusions: The authors’ study has allowed a new classification system to be defined and demonstrates suitable branching patterns to allow flap-to-flap anastomoses in 75 percent of patients; in those 25 percent where this is not possible, alternative strategies for double flaps can be sought and have been used successfully in our clinical series. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.