Unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps.

INTRODUCTION: When the deep inferior epigastric perforator (DIEP) flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps and highlight specific technical considerations. METHODS: Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020. The average patient age was 50 years and the average body mass index (BMI) was 23.1 kg/m2. In all cases, the indication for surgery was breast cancer: 31 patients had immediate reconstruction, 11 had simultaneous axillary surgery and eight had primary contralateral symmetrising surgery. RESULTS: Of the 68 TUG flaps, 67 (98.5%) were successful. The mean operative time was 5 h 50 min (195-460 min) and the mean combined flap weight was 551 g (279-916 g). Eight patients returned to the operating theatre in the early post-operative period and five patients underwent secondary lipofilling to address contour deformities. Most commonly (n = 22), the flaps were oriented horizontally/obliquely, with one flap anastomosed medially to the internal mammary axis and the other anastomosed lateral to the subscapular system. The internal mammary artery perforators and serratus anterior artery provided the best vessel calibre match with the TUG vessels. CONCLUSIONS: Double TUG reconstruction is a safe and reliable option for unilateral breast reconstruction and is an important option when the DIEP flap is unavailable.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study.

BACKGROUND: Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction. METHODS: A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation. RESULTS: One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery. CONCLUSION: Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study.

BACKGROUND: The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction. METHODS: Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined. RESULTS: Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs. 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation. CONCLUSIONS: This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review.

Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity. The use of five separate recipient vessels is highlighted in a unique case of recurrent locally advanced breast cancer requiring multiple complex reconstructions using free tissue transfer. A 56-year-old lady presented for delayed breast reconstruction one year after radical mastectomy for locally advanced lobular breast cancer. Despite wide resections, local chest-wall recurrence five times necessitated five microsurgical reconstructions, using separate recipient pedicles: internal mammary vessels, thoracodorsal vessels, serratus branch of thoracodorsal vessels, intercostal vessels and thoracoacromial vessels. All flaps survived completely, without donor or recipient complications. There has not been a subsequent recurrence at 6 months since last reconstruction. The purpose of this report is to present the first reported case of microsurgical chest wall reconstruction using five separate free flaps requiring anastomosis to multiple recipient vessels for anterior chest wall coverage, to present a literature-based and clinical review of the regional vascular anatomy of the anterior chest wall, and to present an operative approach algorithm. In such complex cases, this understanding can facilitate a streamlined approach to management. © 2014 Wiley Periodicals, Inc. Microsurgery 37:66-70, 2017.

A systematic review of intraoperative process mapping in surgery.

Process mapping has been identified as a strategy to improve surgical efficiency but has been inconsistently applied in the literature and underutilised in surgical practice. In this journal, we recently described our utilisation of these approaches when applied to breast reconstruction. We showed that in surgery as complex as autologous breast reconstruction, process mapping can improve efficiency, and may improve surgical teaching, education and audit. The intraoperative period specifically is an area that can be applied not only to breast reconstruction, but to a much broader range of surgical procedures. A systematic review was undertaken of the databases Ovid MEDLINE, Allied and Complementary Medicine Database, Embase and PsychINFO. Manual searching of the references from articles identified was also conducted. Data items relating to the review aims were extracted from articles' methods, applications, and outcomes. A descriptive analysis was carried out to synthesise the information on the current usage of process mapping in the intraoperative period. Seventeen of 1,488 studies were eligible for review, with all of non-randomised study design. Studies had overlap in components of the intraoperative period to which process mapping was applied. Common areas of improvement were identified. Outcome measures were assessed in ten studies that implemented interventions based on the improvement areas to increase surgical efficiency. As such, process mapping has been used as part of larger quality improvement methods, albeit with inconsistent nomenclature, to improve surgical efficiency. While it has been applied to a range of surgical specialties, there is a lack of application to the surgical component of the intraoperative period. Greater consistency in the reporting and description of process mapping will enable further research for evidence of its benefits.

The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes.

BACKGROUND: Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature. METHODS: A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew's Centre for Plastic Surgery & Burns from January 2009 to December 2014. RESULTS: Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001). CONCLUSIONS: The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits to anastomotic couplers, and suggests that these may be the gold standard for venous microanastomosis. With increasing experience with their use and technological advances, these outcomes may continue to improve.

Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications.

BACKGROUND: The approach and operative techniques associated with breast reconstruction have steadily been refined since its inception, with abdominal perforator-based flaps becoming the gold standard reconstructive option for women undergoing breast cancer surgery. The current study comprises a cohort of 632 patients, in whom specific operative times are recorded by a blinded observer, and aims to address the potential benefits seen with the use of computer tomography (CT) scanning preoperatively on operative outcomes, complications and surgical times. METHODS: A prospectively recorded, retrospective review was undertaken of patients undergoing autologous breast reconstruction with a DIEP flap at the St Andrews Centre over a 4-year period from 2010 to 2014. Computed tomography angiography (CTA) scanning of patients began in September 2012 and thus 2 time periods were compared: 2 years prior to the use of CTA scans and 2 years afterwards. For all patients, key variables were collected including patient demographics, operative times, flap harvest time, pedicle length, surgeon experience and complications. RESULTS: In group 1, comprising patients within the period prior to CTA scans, 265 patients underwent 312 flaps; whilst in group 2, the immediately following 2 years, 275 patients had 320 flaps. The use of preoperative CTA scans demonstrated a significant reduction in flap harvest time of 13 minutes (P<0.013). This significant time saving was seen in all flap modifications: unilateral, bilateral and bipedicled DIEP flaps. The greatest time saving was seen in bipedicle flaps, with a 35-minute time saving. The return to theatre rate significantly dropped from 11.2% to 6.9% following the use of CTA scans, but there was no difference in the total failure rate. CONCLUSIONS: The study has demonstrated both a benefit to flap harvest time as well as overall operative times when using preoperative CTA. The use of CTA was associated with a significant reduction in complications requiring a return to theatre in the immediate postoperative period. Modern scanners and techniques can reduce the level of ionising radiation, facilitating patients being able to benefit from the advantages that this preoperative planning can convey.

Three routine free flaps per day in a single operating theatre: principles of a process mapping approach to improving surgical efficiency.

BACKGROUND: Breast reconstruction is a multi-stage process, involving many individual procedures and many healthcare professionals which take the patient through from diagnosis of breast cancer to the completion of cancer treatment and ultimate breast reconstruction. With an experience of over 3,000 autologous breast reconstructions, we have refined both our surgical technique and overall approach to breast reconstruction to improve the efficiency in free flap based breast reconstruction surgery. METHODS: Through a process mapping approach similar to that employed by large-scale industry, we have broken down free flap based breast reconstruction into multiple smaller processes. By looking at various steps as a simple component of the whole, we have improved our theatre efficiency to maximize patient throughput and improve our outcomes for breast reconstruction patients. RESULTS: Since beginning free flap breast reconstruction surgery, we have improved overall efficiency by applying a process mapping approach. In our early experience, we undertook a single patient undergoing breast reconstruction with a free flap per theatre list, moving to two patients having breast reconstruction, and now carry out three free flap based reconstructions in a single theatre per day as a routine. Specific times are demonstrated, with no increased complication rate. CONCLUSIONS: Through clearly defined processes, operative efficiency in autologous breast reconstruction can achieve three free flaps per day in a single theatre.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping.

BACKGROUND: Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome. METHODS: A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap. RESULTS: Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged. CONCLUSIONS: Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

Modern use of smartphone applications in the perioperative management in microsurgical breast reconstruction.

BACKGROUND: Advances in mobile telecommunication, improved mobile internet and affordability have led to a significant increase in smartphone use within medicine. The capability of instant messaging, photography, videography, word processing, drawing and internet access allow significant potential in this small portable device. Smartphone use within medicine has grown tremendously worldwide given its affordability, improved internet and capabilities. METHODS: We have searched for apps specifically helpful in the perioperative care of microsurgical breast reconstructive patients. RESULTS: The useful apps have been subdivided: (I) communication apps-multimedia messaging, WhatsApp, PicSafeMedi: allow efficient communication via text, picture and video messages leading to earlier assessment and definitive management of free flaps; (II) storage apps-Notability, Elogbook: electronic storage of patient notes and logbooks of case which can be shared with others if required; (III) educational apps-FlapApp, Touch Surgery, PubMed on tap: step by step guides to surgical procedures to aid learning and medical journal database; (IV) flap monitoring app-SilpaRamanitor: free flap monitoring app based on photographic analysis for earlier detection of compromised flaps. CONCLUSIONS: There has been remarkable growth in smartphones use among surgeons. Apps are being developed for every conceivable use. The future will be in wearable smart devices that allow continuous monitoring with the potential to instigate change should deviations from the norm occur. The smart watch is the start of this digital revolution.

Increasing options in autologous microsurgical breast reconstruction: four free flaps for 'stacked' bilateral breast reconstruction.

For autologous breast reconstruction, there are cases where one free flap cannot provide the volume of tissue required, and the concept of 'stacked' bilateral deep inferior epigastric artery (DIEP) flaps was developed, in which hemi-abdominal flaps are raised on each deep inferior epigastric artery (DIEA), and both flaps transferred to the chest. In cases of bilateral breast reconstruction, stacked flaps may be required to achieve volume replacement, however options are not described. We demonstrate the use of stacked free flaps for bilateral breast reconstruction, using one DIEP flap stacked with one transverse upper gracilis (TUG) flap for each side. A 49-year-old woman, with BRCA1 mutation, presented for risk reduction mastectomies. Flap design was planned to achieve maximal projection and primary nipple reconstruction. This was able to be achieved by using the DIEP flap de-epithelialised and completely buried, with the flap orientated with the pedicle on its superficial surface, and the TUG flap lying superficially with its skin paddle used for nipple reconstruction and able to be monitored clinically. There were no flap or donor related complications and good aesthetic outcomes were achieved. This technique offers a further option in microsurgical breast reconstruction for patients in whom there is a paucity of abdominal tissue for reconstruction.

Microsurgical Reconstruction of Large Oncologic Chest Wall Defects for Locally Advanced Breast Cancer or Osteoradionecrosis: A Retrospective Review of 26 Cases over a 5-Year Period.

BACKGROUND: Locally advanced breast cancer (LABC) and chest wall osteoradionecrosis (ORN) often require extensive and composite tissue resection, including muscles, ribs, pleura, and lung parenchyma. As such, these cases necessitate complex reconstructive procedures for skeletal chest wall reconstruction and soft tissue resurfacing of extensive defects. Traditional local and regional flaps are often inadequate, and many such cases are prospectively labeled "unresectable." METHODS: We report a single-center experience with the microsurgical reconstruction of such defects over a 5-year period. Between 2007 and 2011, 1,077 microvascular reconstructive cases following breast cancer resection were performed, of which 26 cases comprised LABC or ORN requiring reconstruction. Surgical indications, defect parameters, choice of reconstruction, and outcomes were assessed. RESULTS: Thirty free flap microsurgical reconstructions were undertaken in 26 cases, with a 96.2% flap survival rate. Complications were low, and mean hospital stay was 8.7 days. An algorithmic approach to management is presented. CONCLUSION: Wide resection and microvascular free tissue transfer provide versatile solutions for the reconstruction of extensive chest wall defects. With good reported perioperative outcomes even in advanced cases, surgical resection of LABC may offer a useful approach in difficult and/or palliative cases.

Solid organ transplantation from hepatitis B virus-positive donors: consensus guidelines for recipient management.

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non-liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti-HBc+) donors. Organs from anti-HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non-liver recipients but is not recommended in immune non-liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost-effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.

Intraoperative esophageal Doppler hemodynamic monitoring in free perforator flap surgery.

Goal-directed fluid therapy optimizes cardiac output and flap perfusion during anesthesia. Intraoperative esophageal Doppler (ED) monitoring has been reported as more accurate and reliable, demonstrating improved surgical outcomes compared with central venous pressure and arterial catheter monitoring. A prospective study of patients undergoing free perforator (deep inferior epigastric artery perforator/anterolateral thigh) flap surgery with intraoperative ED monitoring (51 patients) or central venous pressure monitoring (53 patients) was undertaken. Fluid input included crystalloids, colloids, or blood products. Fluid output included urine, blood, or suctioned fluid. Postoperative fluid balance was calculated as fluid input - output. Fluid input between groups was not different. Fluid output was greater in the ED group (P = 0.008). The ED group showed less fluid balance (P = 0.023), less anesthetic time (P = 0.001), less hospital stay (mean 1.9 days; P = 0.147), less monitoring and flap complications (P = 0.062). ED monitoring demonstrated no monitoring complications, provides a favorable postoperative fluid balance, and may reduce flap complications and hospital stay.

Venous perforators in DIEAP flaps: an observational anatomical study using duplex ultrasonography.

BACKGROUND: The DIEAP flap has gained popularity for breast reconstruction worldwide. Despite DIEAP flap arterial anatomy being well known, venous congestion is still an important complication and the literature on DIEAP flap venous anatomy is lacking. Venous drainage is less predictable and research on venous perforators is of increasing interest. The aim of this study was to investigate the anatomical distribution, diameters and relationships between arterial and venous perforators and their source vessels using Duplex ultrasonography, in order to evaluate the potential benefits of pre-operative evaluation of DIEAP flap venous perforators. METHODS: Prospectively, 140 patients undergoing DIEAP flap breast reconstruction, were pre-operatively assessed using Duplex ultrasonography for location and diameter of arterial and venous perforators, DIEA, DIEV, and SIEV. Perforators were plotted laterally and inferiorly from the umbilicus. Means were compared using t-tests. Pearson's correlation coefficients were calculated. RESULTS: We identified 702 arterial and 355 venous perforators in 280 lower hemi-abdomens. No venous perforators were identified in 9 (6.5%) patients; none on the right in 25 (17.9%) and none on the left in 36 (25.7%). Venous perforators were larger on the right (p=0.031) but DIEV and SIEV diameters were not statistically different on either sides. The diameters of DIEA, DIEV, perforating arteries and veins were correlated, but unrelated to the diameter of the SIEV. When a medium/large perforator vein is identified first, there is a 93.5% chance of finding an associated medium/large perforator artery; this reduces to 69.8% when a medium/large perforator artery is first identified. CONCLUSIONS: There is no correlation between the sizes of perforator veins and DIEV, and the size of the SIEV. Our data suggests that first identifying a medium/large venous perforator increases the chances of finding a better suitable perforator complex. Pre-operative evaluation of venous perforators may be of great interest for its potential clinical benefits.

The 'round-the-clock' training model for assessment and warm up of microsurgical skills: a validation study.

Microsurgery is an essential technique in free flap reconstructions today. The technical skills involved require a learning curve, which may be affected by the current issues of limited training resources and patient safety. We describe a study on the value of a microsurgery training device as an assessment and warm up tool in basic microsurgery skills. Forty volunteers with different levels of microsurgery experience performed a microsurgical 'round-the-clock' exercise on the training device three consecutive times. Video-recordings of these performances were rated by two blinded independent assessors using a modified Global Rating Scale to assess basic microsurgery skills on the following parameters: steadiness, instruments handling and speed. Time to complete a round was also recorded objectively. The Kruskal-Wallis test was used to analyse the construct validity of the parameters assessed between the groups of level of microsurgery experience. Crohnbach's coefficient alpha was used to determine the reliability index of the independent assessors. All participants improved their time on consecutive rounds of the exercise. A median of 82 s (range 6-583 s) improvement in time between the first and third round was observed. Different mean performance time could be identified between the groups, but individual speed did not correlate significantly with microsurgery experience. Assessment of microsurgery skills using the modified Global Rating Scale demonstrated statistically significant differences for instruments handling (p=0.03) and speed (p=0.01) between the groups with regard to microsurgery experience, and improvement in the parameters assessed for all groups. Difference in steadiness (p=0.07) was not significant amongst the juniors. Consultants performed better than juniors but, at all levels of experience, significant improvement in skills was demonstrated after practice. The 'round-the-clock' microsurgery training device is an inexpensive and readily available valid tool that provides a useful warm up exercise and instant assessment of basic microsurgical skills.

The transverse myocutaneous gracilis flap: technical refinements.

UNLABELLED: Autologous free tissue transfer is an ideal method for breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the gold-standard procedure worldwide. However, in selected patients this flap cannot be performed to achieve satisfactory outcomes. The transverse myocutaneous gracilis (TMG) flap is one of the most recent additions to the armamentarium of breast-reconstructive surgeons. This flap can provide adequate autologous tissue with a hidden scar. Since its description for breast reconstruction in 2004, no series have been published and its recognition is still lacking. The main criticism of this flap is the lack of volume that can be achieved and the potential for donor morbidity. We report upon a 2-year experience with the use of TMG flaps for breast reconstruction, assessing the potential indications and introducing some technical refinements in order to expand the role of this flap in breast reconstruction. MATERIALS AND METHODS: Information regarding all TMG flaps performed in the period between January 2006 and December 2007 was prospectively collected. Indications and outcomes were reviewed. The surgical technique was revised and standardised to achieve a routine set-up. RESULTS: During the study period, 19 TMG flaps were performed in 12 patients (seven double procedures: five bilateral cases and two stacked flaps for unilateral breast reconstruction). One flap was lost 9 days postoperatively. Follow-up ranged from 6 months to 2 years. We detail our surgical technique and describe refinements to speed up flap harvest, increase flap volume, optimise flap inset and minimise donor-site complications. CONCLUSION: Although the DIEP flap is still our preferred choice for breast reconstruction, the TMG flap is suitable as a first-line option in small-to-moderate breasted women or as a second-line choice for larger-breasted women for whom the DIEP flap may not be the preferred choice. It is also a reliable salvage flap in cases of previous flap failure.