Case 11: Pushing the Limits of Unilateral Autologous Breast Reconstruction: Bilateral TMG Flap with Immediate Nipple-Areolar-Complex Reconstruction
Keywords: Autologous breast reconstruction, breast reconstruction, TMG flap, NAC reconstruction, Nipple-Areolar-Complex Reconstruction, bilateral
Authors: Oliver Didzun (MD), Adriana Panayi (MD) and Amir K. Bigdeli (MD). BG Ludwigshafen, Germany
A 59-year-old female with a history of an extensive ductal carcinoma in situ (DCIS, staged as pTis m(DCIS), pN0 (0/1, sn), L0, V0, Pn0, R0) of the right breast was subjected to a skin-sparing mastectomy and sentinel lymph node excision, accompanied by the immediate implantation of a tissue expander. Three months postoperatively, the patient presented at our institution seeking consultation for autologous breast reconstruction due to a progressive and painful foreign body sensation in her right breast. The patient had no familial history of breast cancer and no prior incidents of thrombotic events. Notably, her medical history was significant for the presence of carotid artery plaques, with no other pre-existing conditions reported.
Before and after
Patient examination
Upon clinical examination, the patient was found to be in satisfactory overall health, with a body weight of 67 kg and a height of 1.70 meters, resulting in a (BMI) of 23.2 kg/m2. A notable finding was the asymmetry between the breasts, with the right breast being a size C cup and the left a size D cup. The right breast exhibited a horizontally oriented scar on its anterior surface, accompanied by the absence of the nipple-areolar complex (NAC). There was no evidence of capsular contracture. Palpation of the skin envelope over the expander revealed a moderate skin thickness, with the expander being palpable and eliciting pain upon examination. Moreover, the left breast showed pseudoptosis. The measurements for the right breast indicated a breast width of 16.5 cm and a projection of 7 cm, with the NAC being absent. The patient’s abdomen was noted to be slim, with minimal excess tissue. The thighs were found to have adequate tissue availability for potential reconstructive procedures. There were no visible or palpable scars, nor any signs of tissue damage on the thighs or abdomen.
Pre-Operative Considerations
Autologous breast reconstruction, particularly in patients with lean physiques and limited abdominal adipose reserves, remains a significant challenge for plastic surgeons. The use of combined free flaps offers an innovative approach for single-stage reconstruction to achieve considerable breast volume. The following preoperative considerations were taken into account: 1. Painful tissue expander and asymmetry: Clinical assessments confirmed the presence of a painful tissue expander in the right breast, along with noticeable asymmetry. These findings, aligned with the patient’s desire for a surgical resolution to alleviate discomfort and preserve the aesthetic integrity of the right breast, underscored the need for further reconstructive procedures. 2. Requirement for symmetry: The detection of pseudoptosis in the left breast indicated the necessity for reduction mammoplasty to achieve symmetry after reconstruction of the right breast. The aim was to minimize the number of surgical interventions. 3. Implant-based reconstruction concerns: Given the patient’s previous experience of discomfort and pain with the tissue expander, along with a heightened risk of capsular contracture and a preference for a natural outcome, implant-based reconstruction was considered not suitable. 4. Flap reconstruction evaluation: The patient’s lean physique, characterized by limited abdominal and thigh tissue and the need for substantial volume to match the tissue expander, led to the evaluation of various flap options. 4.1 Deep Inferior Epigastric Perforator (DIEP) flap and latissimus dorsi flap The DIEP flap was deemed impractical due to inadequate abdominal tissue, even when attempting to harvest it as a bipedicled (double-pedicle) DIEP flap. Similarly, a pedicled latissimus dorsi flap, which would have required implant augmentation, was discounted for its insufficient volume contribution. 4.2 Unilateral Transverse Musculocutaneous Gracilis (TMG) or Profunda Artery Perforator (PAP) flap: A Unilateral Transverse musculocutaneous Gracilis (TMG) or Profunda Artery Perforator (PAP) flap was considered a suboptimal choice due to its inadequate volume contribution. This insufficiency could necessitate multiple lipofilling procedures, increasing the likelihood of complications such as fat necrosis, infections, and a reduced success rate of grafting. 4.3 Bilateral PAP-flap: A bilateral PAP-flap was considered for its volume potential but ultimately deemed less desirable due to the risk of unfavorable scarring on the posterior thigh. 5. Selection of Bilateral TMG-flap: Preoperative planning favored the bilateral TMG-flap strategy for its ability to provide adequate volume while minimizing the need for post-reconstruction lipofilling. This option promised moderate donor-site morbidity and discreet scarring on the inner thighs.1,2 The intact breast envelope also enabled immediate NAC reconstruction, reducing the necessity for additional surgeries and facilitating flap monitoring. The decision-making process involved extensive discussions with the patient, focusing on the advantages and disadvantages of each reconstructive option, anticipated outcomes, potential complications, and the impact on quality of life. Additionally, the patient was informed about the potential for intraoperative adjustments to the planned procedure should a more suitable option arise.
Step 1: Preoperative planning
The preoperative planning stage involved precise delineation of the scar tissue designated for excision and positioning of the new nipple-areola complex as well as marking the bilateral TMG flap.
Step 2: Flap harvesting
TMG flap harvesting was carried out on both inner thighs, with the skin paddles each measuring 15 cm in length and 6 cm in width, to guarantee a tension-free wound closure and to maximize volume extraction. Simultaneously, a second surgical team prepared the recipient vessels after expander removal and capsulotomy, ensuring efficiency.
Step 3: Flap positioning
The flaps were meticulously positioned to conform to the breast’s natural shape, ensuring tension-free anastomosis to the right internal mammary artery and vein. To mimic the physiological appearance of the breast, the muscle was folded, and the flaps were oriented horizontally and attached to each other. This configuration was achieved by positioning the contralateral TMG flap inferiorly and the ipsilateral TMG flap superiorly. A Charrière drain was then placed along the medial axillary line.
Step 4: Microsurgical anastomoses
To guarantee the adequate perfusion of both flaps, end-to-end arterial and venous anastomoses were performed to the right internal mammary artery and vein. The recipient vessels were bisected, and the inferior TMG flap was first anastomosed to the lower section. This was followed by anastomosing the superior TMG flap to the upper section. Prior to anastomosis, the vessels had been carefully prepared by excising the medial segment of the third costal cartilage up to the sternal joint, allowing for precise placement of the anastomoses and an optimal length of the vessels. For enhanced venous patency, venous coupler devices were employed.
Step 5: Flap adaptation
The subcutaneous fat, muscle, and dermal tissues of the flaps were adapted to one another using resorbable sutures (Monocryl 4-0). This technique significantly minimizes the risk of unintentional displacement.
Step 6: Flap insertion
The TMG flaps were carefully inserted to achieve sufficient breast volume and ensure optimal positioning.
Step 7: Technique Overview
Schematic illustration of the flap harvest technique, donor- site preparation, and its flap positioning.
Step 8: NAC Reconstruction and holding threads
The position for the new nipple-areolar complex was marked out, and the design for the skate-flap was outlined for immediate reconstruction. Notably, the upper TMG flap was utilized for the upper portion of the NAC and the predominant portion of the nipple itself, while the lower TMG flap contributed to the lower portion. Additionally, the remaining skin was carefully deepithelialized. To maintain the integrity of the reconstruction and counteract the effects of gravity, holding threads were placed around the upper breast pole. This ensures the flaps remain securely in position, preventing postoperative volume loss in the upper breast.
Step 9: Wound Closure
Wound closure was executed using resorbable sutures (Monocryl 4-0). Simultaneously, the skate flap was shaped for the reconstruction of the NAC. Adequate perfusion was confirmed, and ongoing monitoring of both TMG flaps was established through the new NAC.
Step 10: Follow-up (3 months) – Front view full body
The TMG flaps and the reconstructed NAC have healed completely, showing no signs of wound healing disorders or flap necrosis. The patient reports being pain-free and expresses satisfaction with the aesthetic outcome of the right breast. Furthermore, both donor sites have healed well, with no complications or disturbances in wound healing observed. At the 3-month follow-up, the patient has successfully resumed daily activities without any limitations. However, due to a persistent asymmetry between the breasts (with the right being smaller than the left), a further reduction mammoplasty on the left breast is planned to achieve symmetry.
Step 11: Follow-up (3 months) – Upper body
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Step 12: Follow-up (3 months) – Upper body 2
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Step 13: Follow-up (3 months) – Side view
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Post-Operative Plan
– Hourly flap perfusion monitoring by the surgical team for the initial 48 hours post-surgery. – Early mobilization with physiotherapy support from day one, complemented by compressive leg wrapping. – Drain removal once the flow rate decreases to less than 30ml per day. – Removal of holding threads scheduled for day seven post-operation. – Custom-made compression garments, including pants with a pad for the inner thigh region to prevent seroma and hematoma, and a compression bra, to be worn for 6 weeks postoperatively. – Patients are advised to avoid straining the right arm and thighs for 6 weeks to ensure optimal healing. – Outpatient monitoring with follow-up visits planned at two weeks, six weeks, three months, and 12 months post-surgery to assess recovery progress and address any concerns.
- Successfully achieved a favorable aesthetic and functional outcome, ensuring the patient remains pain-free, all within a single surgery.
- Preserved a high breast volume in a patient with limited abdominal fat reserves.
- Employed immediate NAC reconstruction to facilitate initial flap monitoring and reduce the need of additional surgeries.
- Ensured minimal long-term donor-site morbidity, highlighting the procedure’s efficiency.
- The concurrent use of two independent free flaps for breast reconstruction, while innovative, demands considerable microsurgical expertise and experience from the surgical team.
- The necessity for two separate free flaps extends the duration of surgery, potentially increasing patient risk and recovery time.
- The procedure entails performing at least four microsurgical anastomoses within a constrained space, heightening the possibility of microvascular complications.
- Particularly for patients engaged in activities like horseback riding, careful selection is crucial due to the potential for postoperative strength loss in leg adduction.
- Comprehensive preoperative blood testing, including checks for covert coagulopathies and baseline hemoglobin levels, is essential to minimizing surgical risks and ensuring patient safety.
References
- Siegwart LC, Bolbos A, Haug VF, Diehm YF, Kneser U, Kotsougiani-Fischer D. Donor Site Morbidity in Unilateral and Bilateral Transverse Musculocutaneous Gracilis (TMG) Flap Breast Reconstruction: Sensation, Function, Aesthesis and Patient-Reported Outcomes. J Clin Med. 2021 Oct 29;10(21):5066.
- Christopoulos G, Khoury A, Sergentanis TN, Mackey SP, Jones ME. Bilateral Transverse Upper Gracilis Flaps for Unilateral Breast Reconstruction: A 4-Year Retrospective Study of the “2-in-1” Technique and a Systematic Review With Meta-analysis. Ann Plast Surg. 2022 Oct 1;89(4):400-407.