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36 Transverse Upper Gracilis (TUG) Flap: AReliable Alternative forBreast Reconstruction
345
36.5 Flap Raise/Elevation: AStep-by-Step
Guide
1. Patient Positioning and Skin Incision. With the patient
lying supine on the operating table, the thigh is abducted
and the knee exed, while paying attention to pressure
areas around the ankle. Pressure sores and sciatica have
been reported as possible complications. Pneumatic calf
compression is used routinely for deep venous thrombosis prophylaxis (Figs.36.5 and 36.6). Staples can be used
to mark opposing margins of the skin paddle. A cold
blade is used to incise around the skin paddle markings.
2. Anterior Raising of the Flap. Flap raising is started on
the anterior aspect of the ap keeping the plane of dissection on the supercial fascia to avoid inadvertent harvest
of lymphatic tissues until the great saphenous vein comes
into view. Medial to the great saphenous vein the plane of
dissection changes (Fig.36.7). A deeper incision allows
visualising the adductor longus fascia, which is incised
and included in the ap. If a tributary of the great saphenous vein is seen crossing the skin paddle, this is divided
near the great vein and included with the harvest.
3. Superior Margin Dissection. While the fascia over the
adductor longus can be incised to be included of the ap
care must be taken to preserve the fascia over the gracilis
muscle for a 2–3cm superiorly to prevent the muscle contracting and skin perforators being damaged (Fig.36.8).
The plane can get deeper once again posterior to this
muscle. 2–3cm from the posterior midline care must be
taken not to divide the deep fascia to avoid injury to the
posterior cutaneous nerve of the thigh.
4. Inferior Margin Dissection. The thigh skin just inferior to
the incision can be undermined to augment the amount of
tissue harvested with the ap. Once more it is preferable to
respect the gracilis fascia when visualised (Fig.36.9).
Figs. 36.5 and 36.6 Positioning of patient with pillow under legs and
intermittent pneumatic compression devices on legs
Fig. 36.7 Anterior raising of skin paddle. A tributary to the great
saphenous vein can be taken with the ap
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J. E. Berner and A. Blackburn
Fig. 36.8 The gracilis muscle is identied
5. Identication of the Gracilis Pedicle. The loose areolar
tissue between the gracilis and adductor longus can be
released until the pedicle is visualised. It is advisable not to
discard any vessels until the gracilis pedicle is conrmed
as other muscle branches run in its vicinity (Fig.36.10).
6. Dissection around Gracilis Muscle. Once the position
of the pedicle has been conrmed, dissection through the
loose areolar tissue around the gracilis muscle can be performed superior and inferior to the vessels. (Fig.36.11).
7. Pedicle Dissection. The gracilis pedicle can be then dis-
sected following its course in between adductor longus
and magnus with the help of a Travers self-retaining
retractor. Obturator nerve branches to adductor longus
and should be spared as they run over the pedicle to avoid
untoward morbidity. Dissection is nished when the
medial circumex femoral artery is seen. Large branches
coming from the pedicle to adductor longus and magnus
need to be controlled using ligaclips (Fig.36.12).
Fig. 36.9 The ap can then be islanded by committing with the inferior and posterior incisions
8. Completion of Raising and Detachment. A mobile ped-
icle eases the rest of the gracilis muscle dissection.
Perfusion of the skin paddle can then be conrmed. The
gracilis muscle is then divided as proximal as possible
while protecting the pedicle. The process is repeated inferiorly. Even though muscle tends to atrophy, it can still
add volume to the ap and it is a suitable bed for future fat
grafting. Once ready for transfer, the artery and vein to
gracilis can be clipped and divided.
9. Closure of the Donor Site. A size 16 drain is placed in
the defect left by the gracilis harvest, exiting anteriorly in
the groin. Meticulous closure is key for donor site complication avoidance. We prefer to use skin staples as provisional closure, paying attention to address any potential
posterior dog ear deformity (Fig.36.13). Layered closure
from posterior to anterior, with interrupted 2–0 Vicryl and
3–0 Monocryl, is adequate.
36 Transverse Upper Gracilis (TUG) Flap: AReliable Alternative forBreast Reconstruction
Fig. 36.10 Retraction of the adductor longus muscle reveals the pedicle to the gracilis nerve along with the branch to gracilis from the obturator nerve
347
Fig. 36.11 The gracilis muscle can be retracted using two gauzes
which facilitates dissection through the areolar plain between adductor
longus and magnus muscles
Fig. 36.12 Dissection of the pedicle is complete when the source vessel is reached
Fig. 36.13 Temporary closure using staples allows avoiding a posterior dog ear deformity when suturing the donor site
348
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J. E. Berner and A. Blackburn
36.6 Core Surgical Techniques inFlap
Dissection
1. Patient Positioning and Skin Incision. Even though
raising does not take long for this ap, hyperabduction of
the hip and pressure sores in the lateral ankle area should
be avoided. An assistant holding the abducted thigh can
help avoid this issue.
2. Anterior Raising of the Flap. We perform most of the
skin paddle dissection using nger-switch diathermy in
coagulation mode. Dissection around the great saphenous
vein can be performed using Debakey forceps and tenotomy scissors.
3. Superior Margin Dissection: Trying to incorporate tis-
sues superior to this incision is usually pointless, as there
is minimal subcutaneous fat on the groin and gluteal
creases. As previously mentioned, injury to the posterior
cutaneous nerve of the thigh should be avoided.
4. Identication of the Gracilis Pedicle. The artery and
vein to gracilis enter the ap with its nerve, classically
described as forming a 45 degree angle.
5. Dissection around Gracilis Muscle. Finger dissection
superior and inferior to the pedicle allows freeing the
muscle circumferentially. A moist gauze can be used to
wrap around the gracilis muscle as a visual aid assisting
in the later dissection.
6. Pedicle Dissection. After identifying the vessels to graci-
lis, these can be dissected out using bipolar diathermy
and Debakey forceps. We reserve the use of ligaclips for
large branches only. Even though these provide adequate
control, they can also easily get in the way while dissecting under adductor longus. The heat-sinking technique
protecting the pedicle with the Debakey forces avoids
heat damaging it.
7. Completion of Raising and Detachment. We do not
routinely harvest the whole muscle, but some length can
be useful to ll the upper breast pole. It is advisable if
bilateral TUG aps are raised, that the surgeon detaching
the muscle does so at both sides. This allows harvesting
similar muscle length.
8. Closure of the Donor Site. We have recently adopted the
use of barbed sutures to accelerate donor site closure.
This is technically more difcult to get right compared
with interrupted stitching. We advise putting a few deep
2–0 vicryl stitches to preserve tissue alignment before
using the barbed suture.
36.7 Clinical Scenario
36.7.1 Bilateral TUG
A 56-year-old female patient previously treated for breast
cancer with bilateral skin-sparing mastectomies and implantbased reconstructions, presenting worsening capsular contracture (Fig. 36.14a). She was referred to our service for
consideration of salvage with bilateral autologous reconstruction. CT-angiography demonstrated lack of suitable
abdominal perforators, therefore decided to proceed with
bilateral TUG aps. A rst stage free ap surgery was performed, including monitoring skin paddles (Fig.36.14b) was
later followed by excision of the skin paddles under local
anaesthetic, nipple reconstruction with local ap and tattooing of the areola (Fig.36.14c).
36.7.2 Unilateral TUG
A 45-year-old female patient that underwent a skin sparing
mastectomy and immediate breast and nipple reconstruction
with a TUG ap (Fig.36.15a, b).
36 Transverse Upper Gracilis (TUG) Flap: AReliable Alternative forBreast Reconstruction
ab
c
349
Fig. 36.14 (a–c) Case of bilateral breast reconstruction with TUG aps
350
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J. E. Berner and A. Blackburn
ab
Fig. 36.15 (a, b) Case of unilateral breast reconstruction with TUG aps
36.8 Pearls andPitfalls
Pearls
• The transverse skin paddle of the TUG ap can be
modied to a more diagonal direction to avoid placing a posterior scar in a pressure area [13]. We have
used an L-shaped modication to increase the volume of this ap (approximately 30–40%) with good
results [14].
• The dissection of the pedicle as it reaches the medial
circumex femoral artery can be difcult as the
adductor longus needs to be retracted. If this step is
problematic the lateral septum of the adductor longus
can be opened up, allowing direct visualisation of the
gracilis pedicle as it reaches its source vessel [15].
• For immediate breast reconstruction cases, we prefer accessing the internal mammary vessels under
the fourth costal cartilage, as at this level there is
less calibre mismatch with the gracilis pedicle.
• For insetting this ap in immediate breast reconstruction cases, we prefer to place the anterior limb
of the ap medially and the skin paddle along the
bottom to recreate the medial, inferior and lateral
poles. The inferior gracilis muscle stump can be
secured in the upper pole, which usually requires
subsequent fat grafting.
• Immediate nipple reconstruction can be achieved
with a TUG ap [10] (Fig.36.16).
Fig. 36.16 Immediate nipple–areola complex reconstruction coning a
TUG ap
Pitfalls
• As previously mentioned, the muscle division is
best if performed by the same surgeon, so similar
volumes can be harvested.
• For delayed breast reconstruction, excessive coning
of the ap to increase projection can result in an
unnatural narrow breast.
• The operating microsurgeon should be prepared to
perform end-to-side arterial anastomosis if the vessel calibre mismatch is close to 3:1.
36 Transverse Upper Gracilis (TUG) Flap: AReliable Alternative forBreast Reconstruction
351
36.9 Selected Readings
1. ZM Arnez, D Pogorelec, F Planinsek, U Ahcan. Breast
Reconstruction by the Free Transverse Gracilis (TUG)
Flap. Br J Plast Surg. 2004 Jan;57(1):20-6.
Inceptional paper that later popularised the use of this
ap as a second option for breast reconstruction, demonstrating its safety and applications
2. Russe E, Kholosy H, Weitgasser L, Brandstetter M,
Traintinger H, Neureiter J, Wechselberger G, Schoeller
T. Autologous fat grafting for enhancement of breast
reconstruction with a transverse myocutaneous gracilis
ap: a cohort study. J Plast Reconstr Aesthet Surg. 2018
Nov;71(11):1557–62.
This outcomes study demonstrates the utility of adjunct
fat transfer to optimise results after TUG aps for breast
reconstruction
3. Saour S, Libondi G, Ramakrishnan V. Microsurgical
Renements With the Use of Internal Mammary (IM)
Perforators as Recipient Vessels in Transverse Upper
Gracilis (TUG) Autologous Breast Reconstruction. Gland
Surg. 2017 Aug;6(4):375–9.
The internal mammary vessels are the recipient of
preference. The TUG fap has a shorter pedicle than the
DIEP ap. Therefore, it is helpful to have recipient in the
wound
4. Fattah A, Figus A, Mathur B, Ramakrishnan VV.The transverse Myocutaneous Gracilis ap: technical renements.
J Plast Reconstr Aesthet Surg. 2010 Feb;63(2):305–13.
This article contains an excellent description of the
TUG ap raising technique
5. Park JE, Alkureishi LWT, Song DH.TUGs Into VUGs
and Friendly BUGs: Transforming the Gracilis Territory
Into the Best Secondary Breast Reconstructive Option.
Plast Reconstr Surg. 2015 Sep;136(3):447–54.
This paper describes some of the skin paddle modi-
cations for the TUG ap.
3. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger
JR.The transverse Gracilis musculocutaneous ap. Ann Plast Surg.
1992;29:482. https://doi.org/10.1097/00000637- 199212000- 00002.
4. Schoeller T, Wechselberger G. Breast reconstruction by the free
transverse Gracilis (TUG) ap. Br J Plast Surg. 2004;57:481.
https://doi.org/10.1016/j.bjps.2004.02.016.
5. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U.Breast reconstruction by the free transverse Gracilis (TUG) ap. Br J Plast Surg.
2004;57:20. https://doi.org/10.1016/j.bjps.2003.10.007.
6. Moller L, Berner JE, Dheansa B. The reconstructive journey:
description of the breast reconstruction pathway in a high-volume
UK-based microsurgical Centre. J Plast Reconstr Aesthet Surg.
2019;72:1930. https://doi.org/10.1016/j.bjps.2019.07.017.
7. Rozen WM, Patel NG, Ramakrishnan VV. Increasing options in
autologous microsurgical breast reconstruction: four free aps for
“stacked” bilateral breast reconstruction. Gland Surg. 2016;5:255.
8. Dayan JH, Allen RJ. Lower extremity free aps for breast
reconstruction. Plast Reconstr Surg. 2017;140:77S. https://doi.
org/10.1097/PRS.0000000000003944.
9. Sacak B, Gurunluoglu R. The innervated Gracilis muscle for
microsurgical functional lip reconstruction: review of the literature. Ann Plast Surg. 2015;74:204. https://doi.org/10.1097/
SAP.0b013e3182920c99.
10. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse Myocutaneous Gracilis ap: technical renements. J Plast
Reconstr Aesthet Surg. 2010;63:305. https://doi.org/10.1016/j.
bjps.2008.10.015.
11. Allen RJ, Haddock NT, Ahn CY, Sadeghi A. Breast reconstruction with the Profunda artery perforator ap. Plast Reconstr Surg.
2012;129:16e. https://doi.org/10.1097/PRS.0b013e3182363d9f.
12. Nicholas T, Haddock SST. Consecutive 265 Profunda artery perforator aps: renements, satisfaction, and functional outcomes.
Plast Reconstr Surg Glob Open. 2020;8 https://doi.org/10.1097/
GOX.0000000000002682.
13. Dayan E, Smith ML, Sultan M, Samson W, Dayan JH.The diagonal
upper Gracilis (DUG) ap: a safe and improved alternative to the
TUG ap. Plast Reconstr Surg. 2013;132:33–4.
14. Berner JE, Henton JMD, Blackburn A. The L-shaped modication of the transverse upper gracilis (TUG) ap. Eur J Plast Surg.
2020;43:1–6.
15. King ICC, Obeid N, Woollard AC, Jones ME.Maximizing length
and safety in gracilis free ap dissection. J Plast Reconstr Aesthet
Surg. 2016;69:1452–3.
References
1. Heckler FR. Gracilis Myocutaneous and muscle aps. Surg: Clin
Plast; 1980. p.7.
2. Zukowski M, Lord J, Ash K, Shouse B, Getz S, Robb G. The
Gracilis free ap revisited: a review of 25 cases of transfer to traumatic extremity wounds. Ann Plast Surg. 1998;40:141. https://doi.
org/10.1097/00000637- 199802000- 00006.
Medial Circumflex Femoral
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Artery: Gracilis Muscle Flap
RobertMiller, DariushNikkhah, andGraemeGlass
37
37.1 Introduction
The gracilis ap is a versatile option for regional and free
ap reconstruction. First published in 1952 by Pickrell as a
pedicle muscle ap for anal reconstruction [1] it was thereafter described as a pedicled musculocutaneous ap [2, 3] and
nally as a free ap in 1976 [4]. In the form of a free ap it
has become a well-established reconstructive option for
small extremity wounds, functional limb reconstruction and
facial reanimation. As a pedicle ap, it is used in groin, perineal and vaginal reconstruction. With a single dominant vascular pedicle supplemented by additional segmental minor
pedicles, it is a type II ap according the to the classication
of Mathes and Nahai [5].
The exibility of the gracilis ap lies with the fact that a
variable length of muscle may be harvested, from a short
segment centred on the dominant pedicle to the entire length
of the muscle including tendon. Further modications
include the addition of a portion of adductor longus muscle
as a chimeric ap [6] or the inclusion of a perforator-based
fasciocutaneous component based on a cutaneous perforator
Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/978- 3- 031- 07678- 7_37.
R. Miller (*)
Department of Plastics and Reconstructive Surgery, St. George’s
Hospital, London, UK
D. Nikkhah
Department of Plastics and Reconstructive Surgery, Royal Free
London Hospital NHS Foundation Trust, London, UK
University College London, London, UK
G. Glass
Attending Plastic and Craniofacial Surgery, Sidra Medicine,
Doha, Qatar
Plastic Surgery, Weill Cornell Medical College,
New York, NY, USA
e-mail: gglass@sidra.org
from the main pedicle. Moreover, with a single motor nerve
branch it may be utilized as a functional muscle ap. As it
can be raised either as a muscle ap or a musculocutaneous
ap, there is versatility in both volume and texture. Moreover,
the muscle will atrophy with time and is thus useful when
contour adaptation is important [7]. Importantly, with an
excellent donor site scar hidden in the medial thigh and
almost no power decit in thigh adduction post-harvest, the
use of this ap is without appreciable donor site morbidity.
37.2 Anatomy
The gracilis has a broad origin from the inferior portion of the
pubic symphysis and inferior ramus of the pubis with both
muscular and tendinous components. It then tapers into a
slender, at and thin muscle running supercially down the
medial thigh. In the proximal thigh, the gracilis is found
medial and posterior to the adductor longus (AL), of which
the proximal tendon can be easily palpated in the medial thigh
with the patient lying supine in a frog leg position. The distal
third of the muscle then runs posteriorly to the sartorius, and
anteriorly to the adductor magnus, as it passes posteriorly to
the medial femoral condyle along with the sartorius. The
gracilis inserts between the sartorius (anterior) and semitendinosus (posterior) tendons on the anteromedial aspect of the
proximal tibia, together forming the pes anserinus.
The gracilis is based on a single dominant vascular pedicle. Most commonly this is the terminal branch of the medial
femoral circumex artery, in turn arising from the profunda
femoris artery. However, the dominant pedicle may also arise
from the profunda femoris artery directly. On entering the
muscle, the artery divides, most commonly into three
branches [8] before ultimately forming anastomoses with the
minor pedicles. Additional minor pedicles are present with
the most common conguration consisting of two minor
pedicles [9] usually from the supercial femoral artery,
although the distal minor pedicle may arise from the popli-
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_37
353
354
R. Miller et al.
teal artery [9]. Usually the arterial pedicle is accompanied by
two venae comitantes which join prior to draining into the
profunda femoris vein. The length of the venous pedicle is
therefore 1–2cm shorter than the arterial pedicle, which is
approximately 7cm in length [6].
The presence of at least one skin perforator measuring
over 0.5mm has been reported in the majority of cases [8,
10]. Skin perforators are most consistently found over the
proximal third of the muscle, loosely associated with the
position of the dominant pedicle [8, 9, 11]. Predominantly,
the skin perforators pursue a musculocutaneous course but
septocutaneous (between gracilis and AL) skin perforators
have also been described.
Motor innervation to the gracilis is from a single anterior
branch of the obturator nerve (L2–4), which runs between
the gracilis and AL supplying both. The nerve can be found
deep to the vessels, entering the muscle approximately
1–1.5cm proximal (superior) to the pedicle [6, 12]. It may be
dissected under adductor longus [8] to its bifurcaton with the
posterior branch which supplies adductor magnus and (usually) adductor brevis. The posterior branch must be preserved. Typically, the distance from the point of entry into
gracilis and the bifurcation with the posterior branch is
4-5cm, in our experience, or 2–4cm from the obturator foramen. A sensory branch of the anterior obturator nerve supplying the medial thigh skin (medial cutaneous nerve of the
thigh) runs as a separate branch in tandem to the motor
branch [6].
An appreciation of the above anatomy is particularly
important when considering ap thinning in cases of facial
reanimation, for example. The muscle can be thinned but
great care must be taken when doing so to avoid compromising the vascular supply and/or nerve input to the portion of
the muscle designated to the ap.
37.4 Flap Design andMarkings
37.4.1 Marking
With the patient supine in a frog leg position (hip abducted
and the knee exed), the adductor longus tendon is clearly
palpated and marked. The gracilis can be palpated posterior/
inferiorly (approximately two nger breadths) to this in the
medial thigh. Its origin should be identied and marked from
the inferior portion of the pubic symphysis and inferior
ramus of the pubis. Finally, the medial tibial condyle should
be palpated and marked to indicate its insertion (Fig.37.1).
A line connecting the midpoint of the origin to the insertion
should be marked. The proximal two-thirds represent the
muscle component and the distal third the tendon.
Approximately 10cm distal to the inferior pubic symphysis
is marked as the most likely site of the pedicle and skin perforators, which enter the ap from the superior lateral aspect.
37.4.2 Flap Design
Flap design will depend on the indication. There are no signicant differences to ap design for a pedicle or free ap. If
the gracilis muscle alone is needed, an incision should be
marked approximately 2cm posterior to the main portion of
the muscle body, with or without a secondary incision
marked over the insertion. The length of the proximal incision and need for a secondary incision at the insertion will
depend on the length of muscle and tendon required, and
should be adapted accordingly.
37.3 Pre-Operative Investigations
Routine pre-operative imaging is not indicated. However,
angiography studies may be pertinent in patients with prior
upper thigh/ pelvic injury or surgery. It has been suggested
that pre-operative non-invasive angiography may be used to
predict the territory supplied by different pedicle arrangements, facilitating a safer approach to the design of composite tissue aps [13]. Similarly, while hand held-Doppler is
not used routinely pre- or intra-operatively for gracilis muscle harvest alone, it may be used to identify perforators when
incorporating a cutaneous component into gracilis ap
design [10].
Fig. 37.1 The adductor longus (AL) is palpated and then marked.
Approximately 2 cm posterior to this the gracilis is palpated and
marked. The course of the pedicle is also marked (black arrow)
37 Medial Circumex Femoral Artery: Gracilis Muscle Flap
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If a musculocutaneous ap is needed, an oval-shaped skin
paddle should be designed over the gracilis muscle. If a short
paddle is needed, this should be centred over the muscle
pedicle. If a longer paddle is required, this should be designed
as an extension of the short paddle to incorporate the most
reliable perforators. It should be remembered that the distal
skin paddle may be unreliable and careful evaluation of the
perforator arrangement is necessary as part of the approach
considered here [14]. The width of the ap should not exceed
the ability to close the skin directly without tension. This is
typically up to 5cm but the ‘nger grasp’ test to evaluate the
feasibility of primary closure is essential before committing
[6]. A transverse skin paddle design has also been described
[13, 15] which can be harvested as a musculocutaneous ap
or fasciocutaneous ap based on a mapped perforator [16].
355
37.5 Flap Raise/Elevation– AStep-by-Step
Guide
The patient should be positioned supine, with the knee exed
and the hip exed and abducted (externally rotated). In this
position the hip, knee and foot must be supported to stabilize
the position (Fig.37.2).
• Step 1. Incise the skin based on the above discussed
markings. If raising a musculocutaneous ap, incise just
the distal aspect or at the tendon insertion if harvesting
tendon.
• Step 2. Identify and preserve the great saphenous vein
(GSV) running obliquely over the AL and gracilis
(Fig.37.3).
• Step 3. Incise down to the gracilis muscle fascia
(Fig.37.4).
(a) If raising a musculocutaneous ap, incise down to the
gracilis tendon. Identify the gracilis as it runs distally
to insert between the sartorius and semitendinosus.
Fig. 37.2 Patient positioned in frog leg position
Fig. 37.3 Identication of the great saphenous vein (black arrow)
supercially
Identify the muscle and conrm that the designed
skin paddle is orientated over the muscle. Continue
the incision proximally and along the anterior border
of the skin paddle. Alternatively, a new proximal incision can be made on the anterior aspect of the skin
paddle.
• Step 4. Incise the fascia exposing the AL superiorly and
the anterior border of the gracilis inferiorly. Continue the
fascial incision exposing the required gracilis muscle
length (Fig.37.5).
• Step 5. Isolate the muscle from the surrounding tissue
using blunt dissection.
• Step 6. Gently retract the gracilis medially and superiorly
to help identify and protect the pedicle.
• Step 7. Separate the fascial connections between the gracilis and AL anterior medially, adductor magnus posterior
and sartorius distally until the pes anserinus.
• Step 8. Retract the AL laterally and superiorly/ anteriorly
to facilitate dissection of the neurovascular pedicle entering the muscle posteriorly (Fig.37.6).
(a) For the musculocutaneous ap, identify the AL-
gracilis septum and include this in the pedicle dissection (to include septocutaneous perforators. However,
also remember, the main pedicle may run a septocutaneous course).
• Step 9. Dissect the pedicle proximally as it runs between
the adductor longus and magnus, ligating branches to the
adductor longus (Fig.37.7).
• Step 10. Identify the motor nerve deep and separate to the
vessels (Fig. 37.8). Dissect the nerve to the required
length, if needed.
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