As physician experience with microvascular breast reconstruction advances, operative times and complication rates decrease and the benefits of autogenous reconstruction with minimal morbidity outweigh the risks.

Figure 1. A 52-year-old female with right breast cancer.

Advantages include the creation of a more natural-looking breast using the patient’s tissue that avoids the use of implants. When the lower abdominal wall provides the tissue for reconstruction, one can see an improvement in the appearance of the donor site.


Donor site selection is usually based on the tissue requirement at the recipient site. Several donor sites have been described for breast reconstruction. By far the most common is the lower abdominal wall.

Transverse rectus abdominis myocutaneous (TRAM) flaps were introduced to clinical practices in the 1980s and quickly gained popularity among patients and physicians.1,2 TRAM refers to the transverse orientation of the skin and fat taken from the lower abdomen, which is supplied by blood vessels that come through the rectus abdominis muscle.

A “pedicled” TRAM flap uses skin and fat of the lower abdomen, which is elevated with the underlying rectus abdominis muscle and rotated to the chest. The skin and fat are supplied by the “pedicle” of muscle, which carries and protects the blood vessels.

Figure 2. A 52-year-old female 6 weeks postoperative after having right total skin and nipple-sparing mastectomy and immediate DIEP reconstruction.

By the late 1980s, the advantages of the microsurgical (“free”) TRAM flap were recognized. As microsurgery became more widespread clinically, the free TRAM became a more common procedure.3-5

A free TRAM has several advantages compared with a pedicled TRAM. The flap is supplied by the same perforators as the pedicled TRAM, but the perforators are harvested with a much smaller portion of muscle and get their blood supply from the deep inferior epigastric vessels, which is a much more direct blood supply. Because of this, the free TRAM flap has a more robust blood supply, so more tissue can be safely transferred.

Better blood supply also means that free TRAM flaps have a lower incidence of fat necrosis than pedicled TRAM flaps and can be used with greater confidence in high-risk patients, such as those who have undergone radiation.

In addition, only a part of the muscle is used, which results in less damage to the abdominal wall and a faster return to normal activities.

Lower abdominal wall flaps were some of the first microsurgical flaps to be described. The deep inferior epigastric system was recognized as a potential source, and muscle-sparing flaps using deep inferior epigastric perforators were reported as early as 1979.6 It was not until the 1990s that this flap was described in breast reconstruction.

Case Studies

  1. A 52-year-old female with right breast cancer, preoperative and 6 weeks postoperative right total skin and nipple-sparing mastectomy and immediate DIEP reconstruction.
  2. A 59-year-old female with a history of left breast carcinoma previously treated with lumpectomy, radiation, and axillary dissection. She developed local recurrence of carcinoma of the left breast 13 years after the initial treatment. She underwent bilateral mastectomies and immediate breast reconstruction with DIEP flaps. Subsequently, she underwent nipple reconstruction and nipple/areolar tattooing.
  3. A 46-year-old female underwent left mastectomy and immediate reconstruction with a pedicled TRAM flap at an outside institution. Shortly thereafter, she was diagnosed with right breast cancer and underwent right mastectomy and immediate reconstruction with a gracilis longitudinal myocutaneous flap.


The increasing popularity of the deep inferior epigastric perforator (DIEP)7 and superficial inferior epigastric artery (SIEA)8 flaps has been due to many factors.

These flaps share the advantages of all the lower abdominal flaps—typically, they provide adequate tissue for breast reconstruction; the donor-site scar is usually well hidden; and for many patients, the sacrifice of the lower abdomen results in an aesthetic enhancement. An additional advantage: The abdominal wall muscles and nerves are spared, leading to decreased postoperative pain, a shorter hospital stay, and faster recovery from surgery.9-10

In many patients, the abdominal wall is unable to be used for breast reconstruction, either because of previous surgery or because the patient has an insufficient amount of subcutaneous fat in that location. In such patients, the search for other autogenous donor sites leads quickly to the lower body, particularly the gluteal areas and the medial and lateral thighs.

Gluteal flaps were first described as musculocutaneous flaps, which incorporated a portion of the gluteus maximus muscle.11,12 Recently, these flaps have been described as perforator flaps based on either the superior or inferior gluteal arteries.13,14

Figure 3. A 59-year-old female with a history of left breast carcinoma, previously treated with lumpectomy, radiation, and axillary dissection. She developed a local recurrence of carcinoma of the left breast 13 years after her initial treatment.

Flap harvest must be performed in the prone or lateral decubitus position, adding significant complexity to cases requiring bilateral flap harvest. The incisions are well hidden in clothing, but can be obvious otherwise. In some cases, unilateral harvest creates a noticeable contour deformity and/or asymmetry. Nonetheless, for many patients who desire autogenous reconstruction, GAP flaps are the best option.

The tensor fascia lata (TFL) musculocutaneous flap has been used frequently as a rotational flap to reconstruct areas around the hip, buttock, and lower abdominal wall.15 It was also one of the first flaps to be described as a free flap,16 and the musculocutaneous flap has been described for breast reconstruction.17

Figure 4. Ten months following bilateral mastectomies and immediate breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. She subsequently underwent nipple reconstruction and nipple/areolar tattooing.

More recently, this flap has been harvested as a perforator flap.18 The perforator flap leaves a smaller contour deformity than the musculocutaneous flap, although the scar is arguably more readily visible than that created following gluteal flap harvest. We have used the TFL perforator flap for breast reconstruction, but found suitable perforators in only 50% (one of two flaps).

Figure 5. A 46-year-old female was diagnosed with right breast cancer shortly after undergoing left mastectomy and pedicle-TRAM reconstruction.


The gracilis muscle was initially described as a pedicled muscle flap. Its use as a microvascular flap has a rich history, both as a small muscle used to cover smaller wounds and as a functional muscle for facial reanimation and extremity motor reconstruction.19,20

In 1992, Yousif et al21 described the use of the gracilis muscle with a transverse skin paddle for various defects, including a case of breast reconstruction.

Recently, Wechselberger et al22 and Arnez et al23 have reported their favorable experience with this procedure for breast reconstruction.24

In patients with a favorable ratio of medial thigh tissue to desired breast volume, the gracilis myocutaneous flap has several advantages. The flap dissection is straightforward and relatively rapid. Flap-vessel length is adequate, particularly if the dissection of the vessels extends to their origin.

The flap can be harvested with the patient in the supine position. The donor-site scar is well hidden. The contour deformity created at the donor site is usually minor and considered favorable by most patients. From a functional standpoint, the loss of the gracilis muscle is not noticeable by even the most active patients.

Figure 6. Postoperative view 10 months following right breast reconstruction with gracilis myocutaneous flap, and left breast reconstruction with pedicle TRAM.

The medial thigh subcutaneous fat can be safely dissected overlying the gracilis muscle through either a longitudinal or transverse incision. I favor the longitudinal incision for several reasons. In more than 75 procedures using the longitudinal incision to harvest the gracilis muscle for microvascular procedures, I have experienced no significant wound or scar complications.

The proximal end of the longitudinal incision is several centimeters distal to the pubic bone, thus positioning the healing wound and eventual scar away from the perineum. There is little or no chance of scar contracture causing discomfort or distortion of the labia, which has been reported following medial thigh lift incisions.25

Designing the flap longitudinally eliminates the need for complex closure techniques to avoid scar widening.26 The longitudinal flap design results in a scar on the posterior aspect of the medial thigh, which keeps the scar well hidden. In our experience, the longitudinally oriented flap provides as much tissue bulk as a flap oriented in the horizontal position, without creating a significant contour deformity.

By designing the skin island to be directly over the muscle belly, reliable skin island blood supply extends to at least 50% of the length of the medial thigh, which is more than enough skin for most breast reconstruction cases.

Figure 7. Oblique view of right thigh donor site.


Patients who can tolerate a 3-to-4-hour procedure are potential candidates for microvascular breast reconstruction. Otherwise, healthy older patients can tolerate such longer operative times and hospitalizations, although their overall recovery time is longer.

Preoperative discussion with such patients should include a thorough overview of the prolonged rehabilitation experienced by many older patients. Despite such warnings, many highly motivated older patients are very pleased with the results of microvascular breast reconstruction.

Obese patients have a higher rate of complications following breast reconstruction with pedicled or microsurgical flaps.27-29 Preoperative counseling should include a frank discussion of such risks. Caution is advised with any patient with a body mass index greater than 30.

Microvascular breast reconstruction provides well-vascularized tissue, which results in a lower rate of fat necrosis than pedicled flaps. Nonetheless, fat necrosis occurs in 5% to 10% of patients undergoing DIEP and other microvascular flaps. Microvascular thrombosis occurs in 2% to 4% of cases, with an overall success rate approaching 99%.30

Gabriel M. Kind, MD, FACS, is board certified, received his undergraduate degree from Dartmouth College, and attended Northwestern University Medical School in Chicago. He was trained in general surgery at Rush Presbyterian St. Luke’s Medical Center, and plastic and reconstructive surgery at Northwestern University–McGaw Medical Center. He can be reached at (415) 565-6884.


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  2. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69(2):216-225.
  3. Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg. 1989;83(5):828-841; discussion 842-844.
  4. Schusterman MA, Kroll SS, Weldon ME. Immediate breast reconstruction: Why the free TRAM over the congenital TRAM flap? Plast Reconstr Surg. 1992;90:255.
  5. Kind GM, Mustoe TA, Rademaker AW. Abdominal wall recovery following TRAM flap: A functional outcome study. Plast Reconstr Surg. 1997;99(2):417-428.
  6. Holmstrom H. The free abdominoplasty flap and its use in breast reconstruction. Scand J Plast Surg. 1979;13:423-427.
  7. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32.
  8. Arnez ZM, Khan U, Pogorelec D, Planinsek F. Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg. 1999;52: 276.
  9. Kroll SS, Miller MJ, Chung DC, et al. Comparison of the costs of DIEP and TRAM flaps. Plast Reconstr Surg. 2001;107:338.
  10. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg. 1997;50(5):322-330.
  11. Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Plast Reconstr Surg. 1976;56(2):178-181.
  12. Paletta CE, Bostwick J III, Nahai F. The inferior gluteal free flap in breast reconstruction. Plast Reconstr Surg. 1989;84:875-883.
  13. Allen RJ, Treece C Jr. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg. 1995;95:1207.
  14. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with gluteal artery perforator (GAP) flaps. A critical analysis of 142 cases. Ann Plast Surg. 2004;52(2):118-125.
  15. Nahai F, Hill L, Hester TR: Experiences with the tensor fascia lata flap. Plast Reconstr Surg. 1979;63(6):788-799.
  16. Hill H, Nahai F, Vasconez L. The tensor fascia lata myocutaneous free flap. Plast Reconstr Surg. 1978;61(4):517-528.
  17. Elliot TF. The lateral transverse thigh free flap for autologous tissue breast reconstruction. Perspect Plast Surg. 1989;3:80-85.
  18. Deiler S, Pfadenhauer A, Widmann J, Stützle H, Kanz KG, Stock W. Tensor fasciae latae perforator flap for reconstruction of composite Achilles tendon defects with skin and vascularized fascia. Plast Reconstr Surg. 2000;106(2):342-349.
  19. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap. Plast Reconstr Surg. 1976;57(3):294-303.
  20. Manktelow RT, Zuker RM. Muscle transplantation by fascicular territory. Plast Reconstr Surg. 1984;73(5):751-757.
  21. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992;29:482.
  22. Wechselberger G, Schoeller T, Bauer T, et al. Surgical technique and clinical application of the transverse gracilis myocutaneous free flap. Br J Plast Surg. 2001;54(5):423-427.
  23. Arnez Z, Pogorelec D, Planinsek F,. Ahcan U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57(1):20-26.
  24. Wechselberger G. Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg. 2004;114(1):69-73.
  25. Candiani P, Campiglio GL, Signorini M. Fascio-fascial suspension technique in medial thigh lifts. Aesthetic Plast Surg. 1995;19(2):137-140.
  26. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112-1122.
  27. Spear SL, Ducic I, Cuoco F, Taylor N. Effect of obesity on flap and donor-site complications in pedicled TRAM flap breast reconstruction. Plast Reconstr Surg. 2007;119(3):788-795.
  28. Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications after microvascular breast reconstruction: experience with 1195 flaps. Plast Reconstr Surg. 2006;118(5):1100-1109; discussion 1110-1111..
  29. Garvey PB, Buchel EW, Pockaj BA, Gray RJ, Samson TD. The deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients. Plast Reconstr Surg. 2005;115(2):447-457.
  30. Kind GM, Buntic RF, Buncke GM, Cooper TM, Siko PP, Buncke HJ Jr. The effect of an implantable Doppler probe on the salvage of microvascular tissue transplants. Plast Reconstr Surg. 1998;101(5):1268-1273; discussion. 1274-1275.