title: The transverse myocutaneous gracilis flap: technical refinements.
abstract: 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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: St. Andrew's Centre for Plastic Surgery, Broomfield Hospital, Court Road, Chelmsford, Essex, CM1 7ET, UK. adelfattah@doctors.org.uk
authors.forename: Adel
authors.initials: A
authors.lastname: Fattah
authors.forename: Andrea
authors.initials: A
authors.lastname: Figus
authors.forename: Bhagwat
authors.initials: B
authors.lastname: Mathur
authors.forename: Venkat V
authors.initials: VV
authors.lastname: Ramakrishnan
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000098:blood supply* / Q000637:transplantation*; D011446:Prospective Studies; D013524:Surgical Flaps / Q000098:blood supply*; D013848:Thigh / Q000098:blood supply*; D020858:Tissue and Organ Harvesting / Q000379:methods; D014182:Transplantation, Autologous; D016896:Treatment Outcome