Surgery Spotlight: Transverse Upper Gracilis Mycutaneous Flap: Technical Refinements-Surgery Spotlight: Transverse Upper Gracilis Mycutaneous Flap: Technical Refinements

Surgery Spotlight: Transverse Upper Gracilis Mycutaneous Flap: Technical Refinements

Video Transcription

Autologous free tissue transfer has proved to be an ideal method for breast reconstruction with long-standing aesthetic outcome.  The transverse upper gracilis or transverse myocutaneous gracilis flap is a very useful addition to the palette of breast reconstruction options in recent years, in particular for  women with small to moderate sized breasts with no available lower abdominal tissue.  This video demonstrates the technical refinements which I have introduced to the original description by others and facilitates a routine setup for rapid harvesting of this flap.  The advantages of this flap are multiple, including the possibility of immediate nipple reconstruction for a psychological benefit.  The criticism of this flap has been its short vascular pedicle and the lack of volume that can be achieved.  This video will also give examples of some techniques to circumvent these difficulties. There are certain key points in harvesting this flap safely and efficiently.  These include the markings and positioning of the patient, flap design, preservation of structures, dissection technique, and flap inset.  Preoperative marking is done in standing position. The upper border is marked a finger breadth below the thigh-groin junction and with a  pinch test, the lower border of the flap is decided. An ellipse is drawn and the hatched area will be the region of fat recruitment during dissection.  The ellipse is completed posteriorly, reaching the gluteal crease almost to the ischial tuberosity.  The patient is positioned supine on the operating table. The whole upper leg is prepared and abducted with hip and knee flex during the procedure.  You can see the markings of the muscles here and outline of the flap. An incision is made along the inferior border of the flap. Passing through the fat and  superficial fascia using diathermy, the flap elevation is begun. The fat below the membranous layer of the superficial fascia is recruited to increase the flap  elevation. Where the coloration of the fat changes, that is the scarpa fascia as shown here. The flap is raised towards the medial aspect of the thigh, dissecting below the  lower limb. I leave the great saphenous vein in situ. In my opinion, incorporating this vein does not increase the venous drainage of the flap greatly as suggested by others.  The vena comitantis alone is sufficient and it saves time in dissection as well as it preserves the consequent disruption to a major venous tributary and associated lymphatics  of the lower limb.  That is the vein, the adductor muscle and this is the adductor fascia. Medial to this vein, the dissection is in subfascial plane through the loose areolar tissue where the  septum between adductor longus and gracilis is seen. Opening the septum, medial to the adductor longus, the vascular pedicle is coming into the field now.  that's the nerve running obliquely and the pedicle is lying transverse.  With blunt dissection, the distal end of the gracilis muscle is freed and whilst exerting traction, the muscle is divided without the need for a second incision.  The posterior border of the flap is incised anterior to the midline of the posterior thigh and raised under the deep fascia from posterior to anterior.  For more information visit www.osho.com  Deep to the gracilis muscle, incorporating the investing fascia without trying to identify the musculocutaneous perforators and then lifting away from the adductor musculature.  This is the scapula fascia here, freed from the muscle and now dividing the gracilis muscle from its origin.  The flap is molded into a cone shape by bringing the tips of the ellipse together. It will form a peak at the apex which will be used to create a nipple.  The nipple flaps are inset as folded arms, as appropriate to create adequate nipple projection. The appropriate areas are dehypothelized for flap inset within the skin envelope.  The donor site morbidity is minimal, as you can see in this patient, at 3 months follow-up of the reconstructed right breast.  Because of the short pedicle length, anastomosis to the internal mammary system is more convenient.  By dissecting deeply into the intercostal space, a suitable length of the intercostal perforator, either in the second or third space, can be provided for comfortable anastomosis.  Anastomosis to the thoracodorsal system is also possible, sometimes with the need of a vein graft.  The branch from the thoracodorsal to serratus anterior is another recipient source.  The volume of the flap can be augmented with a breast implant underneath or a double flap placed in an yin-yang orientation,  allowing the pedicle of each flap to reach axilla and sternum, respectively. Finally, this flap can be used as a reliable salvage flap in cases of previous flap failure.

Video Summary

Autologous free tissue transfer, specifically the transverse upper gracilis flap, is highlighted as an effective breast reconstruction method for women lacking lower abdominal tissue. Suitable for small to moderate breast sizes, this video introduces technical refinements for efficient flap harvesting, addressing challenges like short vascular pedicle and limited volume. Key points include preoperative markings, patient positioning, and flap design. The procedure involves careful dissection, preserving major veins and lymphatics to maintain flap integrity and minimize donor site morbidity. Flap volume can be enhanced with implants or dual flaps, providing versatile options for successful breast reconstruction.

Asset Caption

In the video, Dr. Ramakrishnan demonstrates his technical refinements of the transverse upper gracilis flap (TUG) and facilitates a routine setup for rapid harvesting of this flap.

Surgeon Venkat Ramakrishnan, MD

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Keywords

surgery spotlight

Surgical Videos

Venkat Ramakrishnan MD; Memben

transverse upper gracilis flap

breast reconstruction

flap harvesting

donor site morbidity

dual flaps