Autologous breast reconstruction with the transverse myocutaneous gracilis flap: aesthetic improvements with tissue expansion before free flap transfer

Abstract

The transverse myocutaneous gracilis (TMG) flap provides an alternative to commonly used free flaps from the lower abdomen and buttocks for breast reconstruction. Excellent aesthetic results can be achieved in primary breast reconstruction after subcutaneous and skin-sparing mastectomy. However, in delayed breast reconstruction after mastectomy, an obvious skin island and conspicuous scars often compromise the final appearance. A two-stage approach with tissue expansion of the skin followed by free deepithelialised TMG flap reconstruction avoids these disadvantages and leads to improved aesthetic results. We treated two patients who asked for an autologous breast reconstruction after mastectomy due to primary breast cancer. Reconstruction with lower abdominal tissue was not feasible in one patient because of a previous abdominoplasty and in the other because of insufficient lower abdominal tissue. Both patients declined an implant-based breast reconstruction as well as a procedure using a flap from the buttock, favouring reconstruction with autologous tissue from the superior inner thigh. In the first stage, a tissue expander was inserted endoscopically assisted via a transaxillary approach. The expander was gradually filled over a 3-month period and finally replaced by a free deepithelialised TMG flap. The postoperative period was uneventful in both patients. We achieved satisfying results in both patients with good breast symmetry and uniform colour of the breast skin. Disadvantages and limitations of traditional one-stage breast reconstructions by free TMG flaps can be avoided by this two-stage approach. This reconstructive procedure leads to inconspicuous scars and a matching skin colour of both breasts.

Level of Evidence: Level V, therapeutic study.