Breast reconstruction by the free transverse gracilis (TUG) flap

We read with great interest the article from Arnez1.Arnez Z.M Pogorelec D Planinsek F Ahcan U Breast reconstruction by the free transverse gracilis (TUG) flap.Br J Plast Surg. 2004; 57: 20-26Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar and colleagues and were pleased to see their breast reconstruction series with this very useful flap, which we used since 1996 mainly for traumatic cases.2.Wechselberger G Schoeller T Bauer T Schwabegger A Ninkovic M Rainer C Ninkovic M Surgical technique and clinical application of the transverse gracilismyocutaneous free flap.Br J Plast Surg. 2001; 54: 423-427Abstract Full Text PDF PubMed Scopus (64) Google Scholar After gaining more experience with this flap we started in 2000 using it for breast augmentations and then breast reconstructions.3.Schoeller T Meirer R Otto-Schoeller A Wechselberger G Piza-Katzer H Medial thigh lift free flap for autologous breast augmentation after bariatric surgery.Obes Surg. 2002; 12: 831-834Crossref PubMed Scopus (45) Google Scholar, 4.Wechselberger G Schoeller T The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction.Plast Reconstr Surg. 2004; (in press)Google Scholar Since then we have accumulated a series of 27 breast reconstructions with this flap and we have added several modifications to the original described technique from Yousif,5.Yousif N.J Matloub H.S Kolachalam R Grunert B.K Sanger J.R The transverse gracilis musculocutaneous flap.Ann Plast Surg. 1992; 29: 482-490Crossref PubMed Scopus (161) Google Scholar which we would like to share with the readers and the authors. We include nearly the entire muscle length into the flap not only to add volume to it but mostly to avoid a possible slight contour deformity from the remaining distal muscle bulk in slim patients. Such a distal muscle detachment can be done using a stab incision for tendon release. We do not try to identify a special perforator with Doppler but include the fascia over the adductor muscles. This ensures sufficient blood supply to the skin island via the perifascial anastomotic network even in the absence of a visible perforator. The transverse skin island orientation contributes to the widely ignored anatomic borders of the dermatosomes and angiosomsomes on the thigh, which are similar to the zebra strips. That is also the reason why the longitudinally orientated skin island often fails whereas much larger skin islands will work in the transverse fashion. Since we found the search for a specific perforator not necessary we have placed the proximal border of the skin island exactly into the groin with dorsal extension to the infragluteal fold which helps to hide the scar in a natural crease. As a further modification we have shifted the entire island towards the back, meaning that the donor scar just starts over the adductor longus tendon and ends with the end of the infragluteal fold making the scar invisible from the strict anterior aspect. Harvesting a much longer (from the palpable adductor longus tendon to the end of the infragluteal fold) skin island allows us to reduce its width, which might help preventing the reported wound dehiscence. We found the bilateral reconstruction an ideal indication for this flap, because it provides much more volume than half a Tram-flap. Beside the easy, quick, safe and straight forward flap dissection the low donor site morbidity is a major advantage. We appreciated the honesty of their reported failure case very much. Since we also used a TMG-flap to replace a failed flap we would like to point out that on special occasions the inclusion of the greater saphenous vein into the flap for additional venous drainage and thus higher take rate is justified while the distal part of this vein can easily be harvested for a possible interposition graft without further donor site. We would like to congratulate the authors for their beautiful results and we hope that this flap will gain a wider popularity beyond the Austrian and Slovenian borders.