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Vascular Variations of the Transverse Upper Gracilis Flap in Consideration for Breast Reconstruction

Natoli, Noël Blythe MD; Wu, Liza C. MD

doi: 10.1097/
Breast Surgery

Purpose The transverse upper gracilis (TUG) myocutaneous flap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability.

Methods A retrospective review of records was performed on patients undergoing a TUG flap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.).

Results A total of 36 TUG flaps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of flap harvest.

Conclusions Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for flap dissection when the microsurgeon encounters such aberrancies.

From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA.

Received April 1, 2013, and accepted for publication, after revision, August 26, 2013.

Conflicts of interest and sources of funding: none declared.

Reprints: Noël Blythe Natoli, MD, Long Island Plastic Surgical Group, 999 Franklin Ave, Garden City, NY 11530. E-mail:

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