Surgery Spotlight: Diagonal Upper Gracilis (DUG) Flap-Surgery Spotlight: Diagonal Upper Gracilis (DUG) Flap

Surgery Spotlight: Diagonal Upper Gracilis (DUG) Flap

Video Transcription

Hi, I'm Joseph Dayan. I'm at Memorial Sloan-Kettering and I'll be discussing the Dug flap, which  is a diagonal upper gracilis myocutaneous free flap for breast reconstruction. Basically the whole point of this flap is that it provides a straight line closure along the line of  least tension, meaning that there's a lower chance of wound healing problems. We've done quite a number of these, about three dozen now, and have had really minimal wound healing  complications. Also because you're closing along the line of least tension, you can get a wider flap compared to a tug flap. So if we were going to do a tug flap or a pap flap  on this patient, you have a very narrow flap, usually maybe six centimeters or so. With a Dug flap where the axis is diagonal, you can easily recruit eight centimeters in this  very thin patient, or typically nine, ten, or twelve centimeters in larger patients. So you get a bigger flap and lower complications in terms of wound healing compared to a tug.  However, the downside is that you're going to have a scar that shows in the back of the thigh, and I'll basically show a patient photos of the scar. They either won't mind the scar  or it's a non-starter. It's just another option for a patient. In this particular patient, the indication is really very thin body habitus. There's no abdominal fat. We're using the  axillary nodes for transverse or orthorhidorsal vessels. We can't do a Tdap on that side.  And I do not want to do an ipsilateral latissimus in a patient with lymphedema. So we have a Dug flap, pap flap, tug flap, S-gap flap, although I did not think her donor site was  ideal for an S-gap. And we will probably supplement this with an implant. The markings  are really simple. You just feel for the adductor longus prominens. And just, this is basically  the adductor longus here. This is the longus. Gracilis is here. And then the adductor longus  here. Other notable landmarks of the greater saphenous vein is going to be running along  here. And this usually gives off a posterior branch, this transverse branch, which will  divide. The gracilis pedicle is going to be between the adductor longus and the adductor  muscle and the anterior border of the gracilis muscle. And you'll, of course, see the obturator  nerve over here. And then the artery and vein over here. The markings for the flap are  very simple. You just feel the adductor longus prominens. And just going from the groin crease  basically to the, in the middle of the body of the adductor longus. I'm going to pinch.  And with a pinch test, basically figure out where my posterior border is going to be.  The dimensions of the flap are based on the dimensions of, the horizontal dimensions of the breast over a 3D surface. In her case it's 17 centimeters. I'm going to give myself  a little extra. We'll also give ourselves extra to remove the dog ear. But basically this is the flap. You can also recruit more of this fat if you want by undermining here  or widening the flap. I try not to ask too much from this flap in terms of donor site.  You want to stay away from the greater saphenous vein. We will definitely preserve that vein because the lymphatics are traveling along this area. Most of the lymphatics are in the  anterior side of the greater saphenous vein. And so this is a, this is a, this is a very large flap. It's 8 by 19 centimeters. I usually make my flaps longer these days just to get  out the dog ear. But I'll show you, I'll show you more. So once again, the axis of the tug flap is vertical like this. And this flap is 8 by 19 centimeters. I usually make my  flaps longer these days just to get out the dog ear. But I'll show you, I'll show you  more. Once again, the axis of the tug flap is vertical like this. The axis of a vertical gracilis is along the axis of the gracilis which is like this. The axis of the dug flap  is oblique. So we'll start here. Inject some local. So this is also a nice flap to do because  you'll see, you'll often see the pap flap pedicle. So the incision, I start at the anterior  border. I don't try to bevel anteriorly because I don't want to get into the greater saphenous  vein. So I just go straight down through the superficial fascial system where below, at which point, the greater saphenous vein will encounter. So I'm looking. Here's the superior  fascial system. Going through the superficial fascial system right there. And looking for  the greater saphenous vein. On her pre-op MRI, I do get pre-op imaging although you can argue against it for a gracilis flap. But in this case, she had a very anterior  greater saphenous vein which is good because her lymphatics are far away from us. Scissors.  So this is that posterior branch. Some patients do have a greater saphenous vein that's very  posterior. In this case, this sends some posterior branches but this is not the main saphenous  vein. I go right through the adductor longus fascia. These are posterior branches of the  vein. Scissors. So I'm not looking for the gracilis muscle. I'm not really particularly  interested where it is. I just go right through this adductor longus fascia. So the pedicle  is right here. So the pedicle to the gracilis is right over there. And that's without doing  any dissection. And so we just dissect it down. That's basically it. I was initially  trained to look for the gracilis muscle but I don't look for the gracilis muscle anymore.  I just dissect right on top of the adductor longus. And the gracilis pedicle is right there. There's no way you can possibly injure it because you're going right on to your adductor  longus muscle. So I basically will put a fish hook in here and then do a retrogression.  And then I'll do an obturator dissection. And the gracilis dissection everybody is very familiar with so there's not a lot to say other than basically divide everything that's  going into the muscle because it's a septocutaneous pedicle. Here's the obturator nerve.  Again I'm going to do a little intramuscular dissection. Now when we're getting deep under  the hood we can go over the top of the adductor longus muscle which we're going to do in a  moment. So here we have the pedicle basically almost to its origin but it's really deep  and under the hood. You can just come across the top of the adductor longus. You have to be careful because the ephemeral vessels are on this side of the flap. There you go.  So now what we're going to do is basically take a look at the adductor longus.  Take a look where my pedicle is. Know that my pedicle is below my finger.  And start to just pull this back.  And come around the ephemeral vein here.  One thing about her pedicle is that it's more inferior than typical. Usually it's more proximal.  And as it goes more inferior in the adductor longus, goes anterior, it's in a bit of a tighter space. But now I can see the pedicle from straight up top.  Finally we're in. Usually it's not as big of a chore. Pull this.  Okay so now here's the gracilis pedicle. Here's its origin. And then we have a direct vision  and can dissect all the way proximal to get a much larger caliber. And maximal pedicle  length. Basically just exposing the proximal branches. The main tedious part of this dissection  is separating, good pull there, separating the proximal branches. Because there's usually a web. This just web of crossing branches and all these fibrous bands. But I'm all the  way at the origin of the artery and the vein.  So if pedicle length is an issue, this is a great way to maximize it.  There's a very deep branch and a pretty sizable branch just behind this pedicle. So now we're totally free. So basically here's our vein, here's our artery. We like to separate some  of this out while I'm here.  Curve microscissors. Let's put the vessel loop here and then we'll come in and pick all this fruit off.  Our vessels are pretty much fully dissected. And then The rest of the flap dissection is straightforward. Just a couple points. So here's our gracilis  muscle. Just going sub-fascial. Even if you didn't need the gracilis muscle for bulk and of course it atrophies, I still harvest the whole gracilis. I go all the way up to the  musculotendinous junction around here until it becomes tendon. The reason being is if you don't take it all out, they'll have a bulge in the distal thigh for quite a while.  Everybody knows there's a minor pedicle we have to watch out for here. I'm going to divide it basically at its musculotendinous junction. That's that. Then we'll make our posterior  incision. You'll usually encounter the pap flap pedicle which I'll show you.  It's a good way to start to do pap flaps if you're not comfortable or you're not familiar with the anatomy because you'll come across the pedicle almost every time. You can feather  out into here if you like. Gracilis muscle there. Approximately I'm going to divide the gracilis muscle here. Sub-fascial. Just open up the deep muscle fascia. We've divided the  gracilis approximately and distally. We have our pedicle. This is just to orient you. This is adductor longus, gracilis muscle, adductor magnus, and behind that is semimembranosus.  The pap pedicle is going to be behind, posterior to the gracilis, behind the adductor magnus.  It's going to be coming up along here somewhere. There's going to be a variety of perforators  from the profunza here. Here's a perforator right here. That's not the typical pap pedicle. It's  usually higher. It's variable. You always want to watch where my pedicle is. Here's a perforator  right here. Posterior thigh. Here's the obturator nerve in case we did want to hook it up. Medium  clip please. Patient's paralyzed. We're just coming to the end of this dissection. The nice  thing about the gracilis is the pedicle is always there. It's a pretty fast dissection. That's basically it. That's our dug flap. This is oriented just as it is on the breast.  Ipsilateral 90 degrees. The pedicle goes to the internal mammaries. This can get tucked under or not. This can get flipped up superiorly.  That's our flap and that'll close primarily. The risk of wound healing complications is very low.  We've had one episode of delayed healing in 36 cases. Two episodes of cellulitis. Both treated  non-surgically. A dug flap is not for everybody or even most people, but it does have its role.  There are certain patients I would be wary of doing any thigh flap in and that is somebody who's had has a history of lower extremity swelling. The dug flap anterior incisions are  all posterior to the greater saphenous vein, which around that vein are all the major lymphatic  collectors of the lower extremity. So it's very important to avoid that area and avoid the femoral triangle, which this flap does avoid. However, I think if a patient had any  history of lower extremity swelling or any possibility of having signs of primary lymphedema,  I would avoid a thigh flap altogether. Another option for this patient, I think, is doing  two dug flaps and that was actually an idea after a conversation with Steven Vega about doing two  mini tug flaps or two small dug flaps. I think when you ask too much from this donor site,  you get an ugly, potentially ugly looking donor site. If you're really harvesting too much tissue  and pillaging the medial thigh, it's probably going to end up disappointing. So one of the options is if we wanted a full breast, full autologous reconstruction would be to do two  dug flaps for one breast reconstruction. In this case, because the patient has an implant-based  reconstruction on the other side for sake of symmetry, we're going to use this to replace tissue and then use an implant for volume. Postoperatively, the dug flap, there are no  restrictions, so everybody walks post-op day one. There's no abduction or adduction restrictions in  the thigh. There's a very low wound complication rate in our experience of 36 flaps. We've had  one dehiscence, superficial dehiscence, two episodes of cellulitis, but all treated conservatively. No  major wounds. So nothing exotic here, just getting out the inframammary vessels. I'm going to take out this fourth rib. The printer space is quite narrow. I'm going to end up taking  out, I think, this rib.  Just get into this inner space.  It's always adhering more medially.  I think I'm going to likely remove the third rib, or this rib.  It'll actually be the fourth rib.  Second, third, fourth rib.  Just for a better vessel match and less need for a pedicle length.  I'm just going to go ahead and take this intercostal muscle out.  There we go.  I don't do anything especially exotic. I do much the same thing everybody else does. We have a nice vein, nice artery.  These radiated vessels, everybody knows, are so thin and they're easy to get in trouble very quickly. Just teasing them from the underside of the perichondrium.  And dividing these branches that are going up into the posterior perichondrium. I think we're just about there.  I'm going to send a specimen. This is a right internal mammary lymph node for permanent. In delayed reconstruction, we're just first setting the inframammary folds,  defining the breast footprint, which we kind of determined preoperatively. And there's some considerations.  This patient had lost her implant reconstruction because of an infection. She's got fairly significant radiation change. So this is actually all implant capsule under here.  If the patient didn't have implant reconstruction and it was just a mastectomy without reconstruction, we could actually de-epithelialize this lower half of the mastectomy skin,  which we'd normally discard, to give a little more projection. We can't do that because this was an implant reconstruction. So it's not attached to the base of the chest wall.  In this case, we're not aiming to produce a full-size breast. There are some options. We could do bilateral dug flaps for one breast.  Just after discussion with the patient, the fact that we're doing two free flaps and lymph node transfer, I really just want to focus on  I really want to focus on getting her lymph node, on getting her good lymphatic reconstruction and getting her a base for making a breast.  We'll likely need a breast implant after this for volume. Here's the pectoralis major muscle. It's kind of high-riding. There was an implant in previously.  We're going to be going right for the internal mammary vessels.  Thank you for watching!  Okay, dilators please. This is sort of the most tedious part of the gracilis is just separating the vessels, because there are a lot of little branches.  So, now we're starting micro on the dug flap. This is usually used 10-0, but this vessel is on the larger side, I'm just using 9-0.  And I'll just flip this and do the back wall first. I'll just put in 180-degree sutures.  So I have the two 180 degree sutures in.  And now I'm just going to run it continuous so it interrupts it.  So I just ran this and I'm just tying it down interrupted.  Okay so the back wall's done. I'll check that I haven't back walled.  I'm just focusing on tying down to the to the vessel without evulsing it or tearing it.  Okay I'll take the coupler next please.  So usually take the risuti off the donor vessel just because to get it out of the way and because  it always looks a little crushed by it.  Just make sure this isn't twisted.  So this side of the vein, the caliber is pretty large, so I'm not going to pull any of this  unstretched, kind of lay it in and get an idea of how to evenly distribute this right around the valve.  I've never had a problem with the valve at the anastomosis, and sometimes you're stuck because the pedicle length or the match of the vein or the artery or what have you.  But this valve is obviously going the other direction. This side on the other hand I have to put some stretch.  And this vein is spatulated, that's why it's uneven.  I'm going to close all the way and then open it up until it falls away.  The vein is filling. Just wanted to do a milk test. Let's first make sure the pedicle is okay. The artery and vein length are okay. We spatulated this.  That's why this is at a... just check for any pedicle bleeding. I just want to sew this to the pectoralis major so that when we put in the implant there's no gap.  So basically I'm just... you can see the flap has got a lot of bright red bleeding. The circulation is good. All I'm doing is putting a series of 3-OPDS  sutures from the deepithelialized flap edge to the inferior border of the pec major. This way there'll be a contiguous tissue plane. Actually we can just run  this where we can put an implant in late at a later date. If I do inset this here, Bovey, this will atrophy. But you can fat graft this gracilis muscle.  So I'll incise the epimysium here, incise the epimysium, and then you can spread this. You can spread this out more so it doesn't feel like a sausage inside. And  this is often... I often turn this up like this to fill out the upper pole of the breast. In this case I can just use that as a bridge and use this to fill out the  upper pole. I also want to make sure that the pedicle is covered. Future fat grafting or implant, whatever I do. I'm just going to tuck it under this area. I'm  going to tunnel under where the lymph nodes are. Great. Silk. Let's cut that.  I give the patients Toradol after most of all the dissection is done just so that if they are going to bleed we're going to see where that bleeding is in  drop and not in a pacubae hopefully. And she'll be on standing Toradol post-op. The flap's bleeding well. You can see it's very bright red bleeding. There's no  congestion. So we'll get upper pole fullness with an implant and some fat injection. And at least we have the basis for breast. We put a dart out  here so there's not a cicatricial contracture. We deepithelialized the superior border of the flap skin and sewed it in running fashion to the  inferior pectoralis major muscle border so we can put an implant under that whole plane. And that's basically it. What we've just seen here is a dug flap  for a delayed breast reconstruction. This patient will have a tissue expander placed at a later date and eventually switched out for an implant to match the  other side. She has no restrictions. Tomorrow she'll be walking. Typically she'll go home on post-op day three. The key points here we've I think recovery  I'll inject Xpirel which is a marcaine and a lipid carrier that'll stay in the body for three days so she'll have good analgesia and around the clock toward  all 15 milligrams every six hours scheduled which gives the patient excellent pain control. I think a dug flap is another option. It's in line  with options such as the pap flap, the gap flap, and a deep flap. In patients who are thin basically they have to choose where their scar should go and what's  going to affect the body contour least. The dug flap does contour the thigh so it doesn't create a shark bite in the thigh. It's it's contouring the thigh  along relax tension lines and it's just another it's just another option. Thank you so much.

Video Summary

In the video, Dr. Joseph Dayan from Memorial Sloan-Kettering discusses the Dug flap, a diagonal upper gracilis myocutaneous free flap technique used for breast reconstruction. The main advantage of the Dug flap is its straight-line closure along lines of least tension, reducing the risk of wound healing complications and allowing for a wider flap compared to other options like the TUG or PAP flap. This method is particularly useful for patients with minimal abdominal fat, as it avoids using the abdomen for tissue harvest. However, the Dug flap does leave a visible scar on the back of the thigh, which might be acceptable or a concern for some patients. Dr. Dayan explains the surgical techniques involved, the importance of avoiding major lymphatic collectors and femoral triangle to prevent complications, and potential postoperative outcomes. While the Dug flap isn't suitable for everyone, it provides an additional reconstructive option, particularly for thin patients without abdominal fat. It's another choice alongside other autologous tissue reconstruction methods like GAP and deep flaps, tailored to individual patient needs and preferences.

Asset Caption

This material is presented thanks to a generous licensing grant from Elsevier, and is taken from Plastic Surgery: 6-Volume Set, 3rd Edition edited by Peter C. Neligan, MD. "Three-Stage Folded Forehead Flap" appears in Volume 3: Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery.

Surgeon Joseph Dayan, MD

Disclosure

Dr. Dayan has nothing to disclose. All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Breast

Joseph Dayan MD; Memben

Dug flap

breast reconstruction

myocutaneous free flap

straight-line closure

minimal abdominal fat

surgical techniques

autologous tissue reconstruction

postoperative outcomes