Transverse Upper Gracilis Flap for Breast Reconstruction

Adeyiza O. Momoh

ANATOMY

The flap is based on the medial circumflex femoral vessels, which branch off the profunda femoris vessels.
The ascending branch of medial circumflex femoral reliably perfuses the gracilis muscle and skin/adipose tissue of the upper medial thigh, extending from just medial to the femoral neurovascular bundle to the midline of the posterior infragluteal region.
The flap pedicle is located at the anterior border of the gracilis and can be found approximately 8.5 cm inferior to the pubis.¹

The pedicle length is relatively short averaging 6.7 cm, with an average arterial diameter of 2.2 mm and average venous diameter of 2.3 mm.

FIG 1 • A-F. Patient with left breast cancer who is to undergo bilateral mastectomies with immediate autologous breast reconstruction. She has limited tissue for an abdominal-based flap reconstruction. Her thigh soft tissue is a good option for small-sized breast reconstructions.

Anterior to the gracilis muscle, the pedicle runs deep to the adductor longus muscle and comes off the profunda femoris just anterior to the adductor longus.
A transverse skin paddle measuring 30 × 10 cm is possible²; a vertical skin paddle extension positioned directly over the central aspect of the gracilis can be included to gain additional volume¹ (FIG 2).

PATIENT HISTORY AND PHYSICAL FINDINGS

A detailed medical history is necessary given that there is a potential for a lengthy operation under general anesthesia.
The surgeon should be aware of all medications that might have an impact on the operation and recovery such as anticoagulants, tamoxifen, and chemotherapeutic medications; also important to assess is the patient’s smoking history and the presence of hypercoagulable conditions.
The history should then focus on details of the patient’s breast pathology and reasons for mastectomy. This should also include information on neoadjuvant or planned adjuvant treatment following mastectomy in the setting of immediate reconstruction.
Prior treatments to the breast and chest wall including radiation therapy and the time from the last treatment should be discussed in cases of delayed breast reconstruction.

FIG 2 • Illustration demonstrating the flap skin paddle design and vascular anatomy.
Information on prior operations to the chest or breast and the potential donor sites (in this case the thighs) should be elicited.
In addition to the breast examination assessing breast size, degree of ptosis, and base width, the patient should be asked about her desired breast size postreconstruction.
With an appreciation of the patient’s desired size, the medial thighs/posterior thigh can be assessed, palpating and gently pinching to determine the possibility of achieving the desired volume.

IMAGING

There is limited value to routine preoperative imaging of recipient vessels or the flap vasculature in the absence of a history that suggests potential compromise. CT angiography is currently the imaging modality of choice for recipient or donor-site vascular studies.

SURGICAL MANAGEMENT

The author performs immediate breast reconstruction with two teams, the oncologic and reconstructive team, working simultaneously. Flap harvest is performed while the mastectomies are performed.
The goal of the first operation is the free tissue transfer to establish the breast mound. In cases of unilateral breast reconstruction, contralateral procedures for symmetry are performed in a subsequent procedure.

Preoperative Planning

Appropriate referrals and consultations should be made for clearance and patient optimization prior to surgery based on the history and physical.
The risks and benefits of breast reconstruction using tissue from the medial thighs should be discussed, including the risk for flap loss, medial thigh scars that drift low onto the thighs and that could widen.
Preoperative markings of the breasts and thighs are performed prior to returning to the operating room.
Markings of breast landmarks including the midline and inframammary folds and the planned incisions for mastectomy are performed with the patient sitting.
The thighs are marked with the patient standing to visualize the inguinal and gluteal crease. The patient also externally rotates the thigh to aid with the markings. The upper marking is approximately 1 cm inferior to the inguinal and gluteal crease. A pinch test is performed just posterior to the gracilis to determine how far inferior the lower marking can be made over the medial thigh. This marking extends anterior and posterior, tapering to end medial to the femoral neurovascular bundle (anteriorly) and the midline of the posterior thigh.

Positioning

The entire procedure is performed with the patient in supine position. The arms are extended and secured to arm boards.
To aid with space for the two-team approach, the operating table is turned 180 degrees such that the patient’s head is furthest from the anesthesiologist.

Approach

Flap harvest is performed from an anterior to posterior approach, and the hips are flexed and externally rotated (frog legged) for portions of the case as needed (FIG 3).