Breast reconstruction by the free transverse gracilis (TUG) flap.

The transverse upper gracilis (TUG) flap is a free musculocutaneous (type II) flap consisting of a segment of the proximal gracilis muscle and a 25x10 cm skin paddle oriented transversely. The vascular pedicle of the TUG flap is the ascending branch of the medial circumflex femoral artery with two venae comitantes. The pedicle length is 6 cm and the diameter of the artery is 1.6 mm. In the year 2002, seven patients had breast reconstruction by the free TUG flap. There were three primary and four secondary reconstructions. Five flaps totally survived, two flaps were lost (in the same patient).TUG flap is indicated in women who seek primary autologous reconstruction after a skin sparing mastectomy, have small or moderately large breasts, do not accept scars on the abdomen, back or gluteal region, who are large in hips and thighs and want a thigh lift. The vascular pedicle although short, permits easy anastomosis of matching vessel diameters to the internal mammary vessels. The main possible complication, other than thrombosis at the anastomosis, is wound dehiscence on the thigh with secondary wound healing. This can happen when the flap is wider than 10 cm.

Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap.

The lower abdominal wall has established itself as tissue that can mimic the breast to a high degree. Attention has, therefore, turned to harvesting and transferring this tissue, but with minimal donor site morbidity. We report on our experience with five transfers of this tissue based on the superficial inferior epigastric (SIE) vessels. This technique negates the harvest of any rectus muscle and thus its advantages become immediately obvious. The anatomy is reviewed as well as the techniques used. The limitations of this technique relate to the pedicle. The pedicle is shorter than the deep inferior epigastric (DIE) axis and presents itself on the anterior aspect of the tissue. However, these limitations can be overcome with simple adjustments.

Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity.

Reconstruction of the female breast following mastectomy has become commonplace. The number of donor sites have increased as the quest both for improving reconstruction and reducing morbidity continues. There are a number of donor sites which resemble breast tissue in terms of skin texture, suppleness and colour. The 'gold standard' for transfer in breast reconstruction, however, is the lower abdominal skin and fat. The tissue can be moulded into virtually any breast shape desired. The lower abdomen can provide enough material for total autologous reconstruction of small, moderate sized or even large breasts. This tissue can be transferred onto the chest wall for breast reconstruction using four vascular axes. These are the superior epigastric artery (SEA), the deep inferior epigastric artery (DIEA), a perforator of the deep inferior epigastric artery (DIEP) or the superficial inferior epigastric artery (SIEA). The main problem with the majority of these techniques is that they may be associated with significant donor site morbidity due to harvest of some or all of the rectus muscle. An order of decreased muscle harvest is as follows; pedicled TRAM > free TRAM > DIEP > SIEA. It is envisaged that morbidity will be reduced if the aponeurosis and musculature of abdominal wall is kept intact. This can be achieved in selected cases if the 'abdominoplasty' flap is harvested on the SIE vessels. We present a logical approach to harvesting the lower abdominal wall tissue in order to reduce donor site morbidity.