Plastic Surgeon and Reconstructive Microsurgeon San Francisco, … Session... · Karen M. Horton,...

Karen M. Horton, M.D., M.Sc., F.R.C.S.C.www.drkarenhorton.com

TUG (INNER THIGH) FREE FLAP BREAST RECONSTRUCTION:

What Plastic Surgery Nurses Need to Know!

Karen M. Horton, M.D., M.Sc., F.R.C.S.C.Plastic Surgeon and Reconstructive MicrosurgeonSan Francisco, California

American Society of Plastic Surgical Nurses 37th Annual ASPSN Convention

Denver, ColoradoSeptember 24, 2011

PRESENTATION OBJECTIVES

To introduce aesthetic goals and concepts in aesthetic breast reconstructionTo introduce the inner thigh (TUG) free flap as an option for Microsurgical breast reconstructionTo become familiar with intraoperative details of the TUG free flapTo view before and after images of immediate and delayed breast reconstruction using the TUG flap

INTRODUCTION

M.D. from University of TorontoMaster of Science, Cancer Research – Queen’s UniversityBoard Certified in Plastic Surgery Fellowship in Microsurgery – The Buncke Clinic, San FranciscoOne member of a unique all-women Plastic Surgery practice

WHY DO WE RECONSTRUCT THE BREAST?

By restoring the breast form and recreating symmetry, we can help reestablish:– Body image!– Self-esteem– Sense of femininity and

completeness– Ability to throw away an external

prosthesis!

GOALS OF BREAST RECONSTRUCTION

To recreate the breast form following removal, considering:

1. AESTHETICS 2. SYMMETRY3. LONGEVITY4. MINIMAL “MORBIDITY”

Without giving up FUNCTION = major muscles of the body

WHAT I ASK MY NEW PATIENTS

If we could wave a magic wand how would you WISH your breasts to be?– Larger?– Smaller?– Fuller?– Lifted?

Breast reconstruction should be viewed as an opportunity!– “Let’s make lemonade out of lemons!”

FROM A WOMAN’S PERSPECTIVE…

Finding the best fit of reconstruction procedure for the individual woman:– Body shape– Lifestyle– Details of cancer &

treatments

TIMING OF BREAST RECONSTRUCTION

IMMEDIATEIMMEDIATEIMMEDIATE DELAYEDDELAYED– Same time as

mastectomy – Spares breast skin

+/- nipple– Preserves natural

breast shape

– Performed after mastectomy or other treatments

– Possible at any time (>6 months post-RT)

– Must expand or replace contracted skin

METHOD OF BREAST RECONSTRUCTION

IMPLANT FLAP(the body’s own tissue)

IMPLANTS FOR BREAST RECONSTRUCTION

ADVANTAGES– Shorter operation time (1-2 hours)– Slightly shorter recovery time (4 weeks)– Usually a single scar on/under the breast

DISADVANTAGES– Capsular contracture (hardening), infection,

rupture, deflation– Less natural shape– Usually augment other breast for symmetry– Radiation increases complication risk

“AUTOGENOUS” TISSUE = FLAP RECONSTRUCTION

ADVANTAGES– Permanent, warm, soft, living tissue– Move, grow and age with you– Last forever! (versus implants)– Often indicated after radiation

DISADVANTAGES– Creation of a “donor site”– Additional scars, another surgical site– Longer surgery (3-5 hours)– Slightly longer recovery time (4-6 weeks)

FLAP RECONSTRUCTION

“FLAP” – Tissue from the body that has its own blood supply– Living tissue– Permanent reconstruction– Soft, warm– Lasts forever!– Can counteract radiation damage

FLAP DEFINITIONS

“DONOR SITE” = the area where the tissue is taken from:– Abdomen (DIEP, SIEA, TRAM)– Inner thighs (TUG)– Buttocks– Back– Outer thighs

SO, HOW DO WE CHOOSE A RECONSTRUCTION METHOD?

Need to consider the following factors:– Patient preferences and aesthetic goals– Body habitus, fat distribution– Lifestyle issues

Work, family responsibilities– Cancer details– Urgency of treatment

Days or weeks/months to plan?– Adjuvant therapies – ongoing or expected

Chemotherapy, radiation

WHEN IS THE BODY’S OWN TISSUE USED?

1. After radiation of the breast or chest wall

2. High chance of postoperative irradiation

3. Failed implant reconstruction

4. Patient preference

WHAT IS MICROSURGERY?

MICROSURGERY involves magnification to reconnect blood vessels or nerves under the microscope to reestablish blood flow– Requires special training in

microsurgery– Specialized equipment– Postoperative monitoring of

circulation

MICROSURGICAL BREAST RECONSTRUCTION

Microsurgical breast reconstruction can involve many potential donor sites:– Abdomen – Buttocks – INNER THIGH – Anterolateral thigh– Back– Other

MICROSURGICAL BREAST RECONSTRUCTION

The abdomen is most often used for flap breast reconstructionsWhen unavailable for microsurgical transfer– Previous

DIEP/SIEA/TRAM flap– Previous abdominoplasty– Extremely low BMI– Refusing abdominal scar

The inner thigh is our next option!

INNER THIGH (TUG) FLAP

Transverse Upper Gracilis (TUG) flapCrescentic flap of skin, fat, and some underlying muscleSame distribution as cosmetic inner thigh lift

INTRODUCTION:THE TUG FLAP

Inner thigh skin and fat based on the transverse upper gracilis (TUG)musculocutaneous blood supply provides tissue favorable to microvascular breast reconstruction– Described in 19921 – transverse skin

paddle dominant, more reliable than vertical orientation2

1. Yousif, N. J., Matloub, H. S., Kolachalam, R., et al. Ann Plast Surg 29: 482-490, 1992.2. Heckler, F. R. Clin Plast Surg 7: 27-44, 1980.3. Schoeller, T., Wechselberger, G. Br J Plast Surg 57: 481-482, 2004.

TRANSVERSE UPPER GRACILIS (TUG) FREE FLAP

The Transverse Upper Gracilis (TUG) flap was described by Yousif (1992)

– Single case of breast reconstruction1

Cutaneous territory of gracilis myocutaneous flap was demonstrated by anatomic and injection studies to lie perpendicular to the muscle in its proximal third, transverse and parallel to the medial groin crease

1Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Snager JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 29: 482, 1992.

TRANSVERSE UPPER GRACILIS (TUG) FLAP

Following this report, the classic vertical skin paddle harvest was largely abandoned in favor of the transverse upper skin paddle

TUG FLAP DESIGN

Semi-lunar skin paddleSuperior aspect of flap just below groin crease, extending to gluteal crease

– Not placed immediately in crease to avoid distortion of labia majora4

4. Lockwood, T. Plast Reconstr Surg 92: 1112-1122; discussion 1123-1115, 1993.

TUG FLAP SURGICAL TECHNIQUE

Crescent-shaped flapLength extends anteriorly from gracilis muscle, parallel and inferior to groin crease, posteriorly to just below gluteal foldWidth of flap 8-12 cm or maximum width easily closed without tension

TUG FLAP INTRAOPERATIVE DESIGN

TUG FLAP DESIGN

Pedicle length averages 6-8 cmExtent of gracilis muscle usually just immediately beneath flap

TUG FLAP DESIGN

Flap folded to cone flap and enhance projection– Additional gracilis

muscle may be folded behind flap if additional volume desired

TUG FLAP DESIGN

Flap weight usually corresponds to mastectomy specimen Flap projection often greater than native breast

TUG FLAP “CONING”

Flap folded and ‘coned’ to give projection to the flapSkin deepithelialized to bury beneath mastectomy flaps

TUG FLAP SHAPING

Deepithelialized with exception of areolar circle for immediate breast reconstructions

TUG FLAP MICROSURGERY

End-to-end anastomosis with internal mammary vessels in 3rd or 4th intercostal interspace

MICROVASCULAR ANASTOMOSIS

TUG FLAP INSET BENEATH MASTECTOMY SKIN

Deepithelialized portion of flap buried beneath mastectomy skinDelayed reconstructions –inner thigh skin used to reconstruct both lower pole of breast and NAC

IMMEDIATE NAC RECONSTRUCTION

Apex of standing cone accentuated using crossing horizontal mattress sutures to create nipple prominenceNaturally darker pigment of inner thigh defines areola

TUG DONOR SITE CLOSURE

Layered closure of donor site superficial fascial system similar to medial thigh liftSuction drain exiting from the superior aspect of thigh wound

TUG FLAP STUDY RESULTS

2004-2007: 35 inner thigh flaps in 21 patients

– 1 abdominoplasty/failed implant reconstruction

– 16 inadequate abdominal donor tissue

– 3 previous DIEP/TRAM– 5 chose TUG in lieu of

abdominal tissue

Patient age 32-64 years (average 49 years)All breast cancer or BRCA+6 previous radiation 18 patients (31 flaps) included immediate NAC reconstruction

– 20 immediate, 11 delayed cases

Median follow up 1 year

Flap weight 282-502 grams – Average 363 grams

Length 20-28 cm– Average 23.5 cm

Width 8-11 cm– Average 10 cm

All flaps survivedOne take-back at 12 hours for venous thrombosis– Thrombectomy and

vessel repair enabled complete flap survival without fat necrosis

6 donor site partial breakdowns (< 2 cm)– 3 healed by secondary intent– 3 debrided and closed under GA

4 patients (5 donors) seromasNo donor site functional lossAll patients resumed normal activity

TUG FLAP - DISCUSSION

Like other flaps, inner thigh available if abdomen insufficent5– Unlike rectus abdominis,

gracilis muscle harvest not associated with hernia, bulge or functional loss

Only drawback is the inner thigh scar

– Hidden in all clothing except swim suits or underwear6

5. Granzow, J. W., Levine, J. L., Chiu, E. S., et al. J Plast Reconstr Aesthet Surg 59: 614-621, 2006.6. Hallock, G. G. Plast Reconstr Surg 113: 339-346, 2004.

Patients are informed preoperatively of potential donor site complicationsAll women are satisfied with their final results

Gracilis muscle and pedicle harvest extremely reliable and straightforward

– Familiar to most Microsurgeons

No intraoperative repositioning required as often for gluteal flaps

WHY NOT A TUG “PERFORATOR FLAP”?

Free gracilis perforator flaps have been describedPeek (2002) performed breast reconstruction in 6 patients8

– Included minor pedicle with flap to achieve bulk

Hallock (2004) reconstructed upper/lower extremity and scalp defects9

– Skin grafting of donor sites required in some cases

8Peek A, Muller M, Exner K. [The free gracilis perforator flap for autologous breast reconstruction]. Handchir Mikrochir Plast Chir. 34: 245, 2002.9Hallock GG. Further experience with the medial circumflex femoral (gracilis) perforator free flap. J Reconstr Microsurg. 20: 115, 2004.

TUG “PERFORATOR FLAP”?

However, inclusion of gracilis muscle in TUG flap suggested to provide more tissue volume, increase safety and allow rapid flap harvest with minimal functional donor site morbidity6

Anatomic studies of the proximal cutaneous perforator vessels show variability in number, size and symmetry of perforators10

– Inclusion of some muscle recommended for reliable TUG flap transfer

6Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg. 114: 69, 2004.10Kappler UA, Constantinescu MA, Buchler U, Vogelin E. Anatomy of the proximal cutaneous perforator vessels of the gracilis muscle. Br J Plast Surg. 58: 445, 2005.

Inner thigh can be harvested as perforator flap7-10

Anatomic study of TUG perforators recommends including muscle in flap11:

– Functional advantages to sparing gracilis unclear– Potential increased risk to circulation– Increased operating time – No clear benefit of perforator flap

7. Peek, A., Muller, M., Exner, K. Handchir Mikrochir Plast Chir 34: 245-250, 2002.8. Hallock, G. G. Ann Plast Surg 51: 623-626, 2003. 9. Hallock, G. G. J Reconstr Microsurg 20: 115-122, 2004.10. Wechselberger, G., Schoeller, T.Plast Reconstr Surg 114: 69-73, 2004.11. Kappler, U. A., Constantinescu, M. A., Buchler, U., et al. Br J Plast Surg 58: 445-448, 2005.

For some patients, medial thigh lift an aesthetic perkImmediate NAC reconstruction obviates local flaps, skin grafting, tattooing

TUG FLAP STUDY CONCLUSIONS

The inner thigh flap is an alternative to the abdomen for immediate and delayed breast reconstructionEnables immediate NAC reconstruction

TUG FLAP STUDY CONCLUSIONS

TUG flap breast reconstruction is an excellent option in:– Women desiring

autologous microsurgical reconstruction

– Lacking adequate abdominal donor tissue

– Do not desire abdominal scars

ADVANTAGES OF THE TUG FLAP

1. Good flap projection and volume2. No functional consequences

from gracilis muscle harvest3. Benefit of medial thigh lift4. Patient position supine

throughout surgery5. Two-team reconstruction

possible 6. Scar position and quality

favorable and often hidden

TUG FLAP CANDIDATES

1. Patients desiring autologous breast reconstruction

2. Sufficient superomedial thigh tissue3. Previous abdominoplasty4. Previous DIEP / SIEA / TRAM flap harvest5. Previous abdominal surgery precluding use

of abdominal tissue for reconstruction6. Very thin or athletic patients without

sufficient abdominal donor tissue

CASE EXAMPLE 1

BILATERAL IMMEDIATE TUG FLAP RECONSTRUCTION

TUG FLAP STEP-BY-STEP CASE EXAMPLE

TUG FLAP PREOPERATIVE PLANNING

Breast boundaries marked preoperatively Inframammary folds and lateral border of breasts stapled before surgical prep

TUG FLAP INTRAOPERATIVE MARKINGS

Anterior and posterior borders of gracilis muscleWidth that is easily closed without tension (8-12 cm)Hand-held Doppler helps locate perforators

TUG FLAP INTRAOPERATIVE POSITIONING

Patient is positioned supine with leg(s) abducted, and hips and knees flexed

Contralateral flap commonly harvested to facilitate a two-team approach

TUG FLAP MICROSURGICAL DISSECTION

Subfascial elevation begins anteriorlyProceeds to intermuscular septum between adductor longus and anterior border of gracilisGreater saphenous vein identified and preservedUndermining of subcutaneous adipose maximizes bulk of tissue taken with flap

TUG FLAP MICROSURGICAL DISSECTION

Musculocutaneous or septocutaneous perforators entering flap identifiedPedicle dissection proceeds proximally to origin from superficial femoral artery to suit required pedicle length

CASE EXAMPLE 2

BILATERAL IMMEDIATE TUG FLAP RECONSTRUCTION

BEFORE AND AFTERBilateral Immediate TUG Flap Reconstruction

CASE EXAMPLE 3

BILATERAL DELAYED TUG FLAP RECONSTRUCTION

MATCH PATIENT ISSUES TO THE RECONSTRUCTIVE METHOD

Radiated, flat, stiff chest skin:– Implants too risky

Washboard stomach but inner thighs available:– TUG flap first choice

BEFORE AND AFTERTUG Flap Reconstruction

Preop 3 Months Postop

TUG FLAP DONOR SITE

6 Months Postop

CASE EXAMPLE 4

BILATERAL TUG FLAP RECONSTRUCTION –ONE IMMEDIATE, ONE DELAYED

MATCH PATIENT ISSUES TO RECONSTRUCTION METHOD

Bilateral reconstructionWants to be smaller & liftedMore inner thigh than abdominal tissue:– TUG flap

Radiated chest skin:– Implant too risky

BEFORE AND AFTERBilateral TUG Flap Reconstruction

Preoperative 7 Months Postop

BEFORE AND AFTERTUG Flap Donor Site

CASE EXAMPLE 5

BILATERAL NIPPLE-SPARING MASTECTOMY AND TUG FLAPS WITH A LIFT

MATCH PATIENT ISSUES TO RECONSTRUCTION METHOD

Does NOT want implants:

– Flap is an optionWants to be smaller & liftedBILATERAL reconstruction planned:

– TUG flaps the best option

BEFORE AND AFTERNSM & Immediate Bilateral TUG Flap Reconstruction

Preoperative 6 Weeks Postop

6 Weeks Postop 6 Weeks Postop

TUG FLAP DONOR SITE OPTIMIZATION

Place scars to fall within undergarments if possible

TUG FLAP DONOR SITE

6 Months Postop

SUMMARY – THE BREAST RECONSTRUCTION EXPERIENCEReconstruction of the breast can be a positiveexperience that can help restore self-image and self-esteem!

TUG FLAP BREAST RECONSTRUCTION

Breast reconstruction can and should be a positive experience, preserving body image and facilitating emotional recoveryThe TUG flap is an excellent reconstructive option for selected women facing breast cancer

ARTISTRY IN BREAST RECONSTRUCTION

Reconstruction of the breast is an individualized procedureNo single procedure is right for everyoneEach woman’s lifestyle and anatomy differsThe best reconstructive option takes into account a woman’s goals, the way she uses her body, and her unique situation

THANK YOU!

drhorton@drkarenhorton.com

Plastic Surgeon and Reconstructive Microsurgeon San Francisco, … Session... · Karen M. Horton,...

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