Paper #8711 - Confex



The Extended Indications for the TMG-Flap in Breast Reconstruction

Thomas Schoeller, MD, MSc and Gottfied Wechselberger, MD, MSc

Introduction: The goal of the presentation was to look for new possible donor sties beside the widely known pathways that would result in a more concealed scar than the TRAM-flap or latissimus dorsi flap. The key for that challenging aim was the Transverse myocutaneous gracilis (TMG)-flap. The TMG-flap was first described by Yousif NJ and further popularized for breast reconstruction by the two authors and simultaneously by Arnez Z. 1-6 With the gaining experience the indications for a TMG-flap breast reconstruction extended continuously. At the beginning we thought that only the small to moderate sized breast should be reconstructed with a TMG-flap (Fig.1). But using two flaps for one breast allows also to reconstruct even larger breasts with an aesthetical pleasing donor site even in slim patients. The incision lines and the donor-site morbidity is similar to a classic medial thigh lift. Due to the very low donor site morbidity the flap is suitable to correct various breast deformities such as contour and volume deficiencies after breast conserving therapy and poland’s syndrome.

Material and Method: From 01/2002 to 05/2005 the flap was used 79 times in four patients for augmentation, in 29 patients after unilateral skin sparing mastectomy, in 9 patients after bilateral skin sparing mastectomy, in 8 patients a bilateral TMG-flap plasty was used for one breast. The TMG-flap was used in three patients for a secondary reconstruction (once bilateral, once unilateral with two flaps and one unilateral with one flap) and two times for correction of a contour deformity after breast conserving therapy. In three patients with polands' syndrome the flap was used to replace the missing pectoral muscle and to add volume to the hypoplastic breast. The volume of the TMG-flap was measured in all cases by water displacement intraoperativly and ranged from 260 cc to 550 cc per flap.

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Fig. 1 unilateral TMG-flap reconstruction

Results: We have lost two flaps (2,5%) from 79 which were replaced by a prosthesis. In no single case we have encountered a perfusion problem with the skin island or a tip necrosis. In four cases a scar revision was done to improve the donor site. Six patients had small areas of ischaemic skin necrosis related to very thin preparation of the mastectomy skin envelope without altering the final good aesthetic results. There was no functional donor-site morbidity caused by harvesting the gracilis flap and a very inconspicuous donor site scar was always encountered. In the long term (more than 2 years) follow up patients (n=12) no visable volume reduction due to anticipated muscle atrophy was noticed.

Summary: The TMG-flap is a most valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy and in selected patients for secondary reconstruction. It has become the first choice option in our hands for skin sparing reconstructions of small to moderate breasts even before tissue sources from the lower abdomen or the gluteal region. The flap seems also ideal to correct a poland’s chest deformity. The advantages are the following: The TMG-flap is easy to harvest because no perforators have to be prepared. A simultaneous two team approach is possible in performing the skinsparing mastectomy during flap harvest as well as closing the donor site while revascularizing the flap. The donorsite results in a most inconspicuous scar. The anatomy is highly constant (in our clinical experience of 187 gracilis flaps no pedicle variation or abnormality was encountered) and the skin peddle in the transverse fashion is reliable opposed to the often failing longitudinal “classical” myocutaneous gracilis skin peddle, because the angiosome of the gracilis skin perforators in the cranial third is distributed transversely like in zebras while the middle and distal third perforators are missing. In cases bilateral reconstruction often the TMG-flap provides more tissue bulk than a hemi TRAM-flap (Fig.2&3).

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Fig.2 bilateral breast reconstruction after skin sparing mastectomy

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Fig. 3 Secondary bilateral TMG-flap reconstruction

We are convinced that this method will win recognition in the following years for it's simple technique compared to the demanding perforator surgery and the most pleasing donor site, which even allow aesthetic indications (Fig. 4). We strongly encourage all microsurgeons to use the TMG-flap as a powerful alternative in breast reconstruction.

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Fig.4 bilateral autologous breast augmentation with TMG-flap

References:

1. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992 Dec;29(6):482-90.

2. Furnas HJ. Re: The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1993 May;30(5):480.

3. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg. 2004 Jul;114(1):69-73.

4. Schoeller T, Huemer GM, Kolehmainen M, Otto-Schoeller A, Wechselberger G. A new "siamese" flap for breast reconstruction: the combined infragluteal-transverse myocutaneous gracilis muscle flap. Plast Reconstr Surg. 2005 Apr;115(4):1110-7.

5. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004 Jan;57(1):20-6.

6. Schoeller T, Wechselberger G. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004 Jul;57(5):481-2.

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