Article Text

Download PDFPDF
The vertical gracilis myocutaneous flap for breast reconstruction in a massive weight loss patient
  1. Martin Söderman,
  2. Jørn Bo Thomsen and
  3. Jens Ahm Sørensen
  1. Department of Plastic and Reconstructive Surgery, Odense University Hospital, Odense, Denmark
  1. Correspondence to Dr Martin Söderman; Martin.Soderman{at}rsyd.dk

Abstract

The number of patients undergoing bariatric surgery is increasing worldwide. Different types of free flaps are often used for breast reconstruction following mastectomy. We present a not previously described case using a vertical myocutaneous gracilis flap for breast reconstruction in a massive weight loss patient. The patient was a 61 year-old woman who previously had a lumpectomy for an in situ ductile carcinoma of her left breast. Subsequently the patient underwent a full mastectomy in 2020 due to a recurrence. The massive weight loss population poses a challenge in reconstructive surgery, due to their higher risk of complications. However, we still believe free flaps should be considered as a valid option for breast reconstruction in these patients. Due to the often increased size of perforator vessels in these patients, other flaps may prove more suitable than the usually preferred ones.

  • plastic and reconstructive surgery
  • breast surgery

Statistics from Altmetric.com

Background

The number of patients undergoing bariatric surgery is increasing worldwide.1 These patients are more prone to complications following surgery than the background population.2 Several different types of free flaps are well described for breast reconstruction following mastectomy, such as the deep inferior epigastric perforator flap (DIEP), the superficial inferior epigastric artery flap, the profunda artery perforator flap, the transverse myocutaneous gracilis (TMG) flap and the inferior/superior gluteal artery perforator flap.3 We present the first case, to our knowledge, of a massive weight loss (MWL) patient having breast reconstruction using a vertical myocutaneous gracilis (VMG) flap.

Case presentation

The patient, a 61-year-old woman, previously had a lumpectomy for an in situ ductile carcinoma of her left breast. Subsequently the patient underwent a full mastectomy in 2020 due to a recurrence (figure 1). In 2016 the patient underwent a gastric sleeve operation, leading to a weight loss from a maximum weight of 130 kg to 87 kg, equivalent to a body mass index (BMI) reduction from 47 to 31.

Figure 1

The patient preoperatively.

Investigations and treatment

In April 2021 the patient was examined in the outpatient clinic. The patient wished for an autologous breast reconstruction. The patient had already had a lower body lift including a fleur-de-lis abdominoplasty, which meant that we would not be able to use the deep inferior epigastric artery perforator flap, due to a lack of donor tissue and perforators in the abdomen. The patient had a sufficient amount of excess tissue on her thighs, which were found suitable as donor sites for the autologous breast reconstruction. The patient suffered from lymphoedema in her left thigh following a previous knee replacement surgery, so we opted for the right thigh as donorsite. Three perforators were identified in close proximity to the gracilis muscle by colour Doppler ultrasonography and were found suitable as donor vessels.

The skin island was designed vertically as a standard thigh lift above the location of the gracilis muscle. The skin was incised along the lateral border of the peroperative markings. The underlying soft tissue was dissected to the gracilis fascial sheath, while doing so the great saphenous vein was identified and spared. The vascular pedicle was identified between the adductor longus and magnus muscles (figure 2). The vascular pedicle was carefully dissected towards its origin from the medial branch of the circumflex femoral artery. The muscular branch to the gracilis, from the anterior branch of obturator nerve, was also identified. The gracilis muscle was isolated through further dissection. Hereafter, a skin incision was made along the medial marking of the skin and subcutaneous dissection was carried out. The inferior part of the gracilis muscle was transected and the flap was raised in a distal to proximal direction. The gracilis muscle was then transected at its origin, leaving the flap attached only to the vascular pedicle and nerve.

Figure 2

Intraoperative raising of the vertical myocutaneous gracilis flap. Mosquito forceps presenting the donor vessels.

Flap perfusion was evaluated using the HyperEye Medical System after intravenous administration of indocyanine green.

Simultaneously the mastectomy scar was removed and the skin flaps were raised to create a pocket for the reconstruction and flaps insertion. The recipient internal mammary vessels were accessed through the pectoralis major muscle and by removing the costal cartilage at the level of the third costa. One artery and vein were identified as suitable recipient vessels.

The donor vessels and the nerve attached to the VMG flap were then transected. The VMG was moved to the recipient site and the vessels were anastomosed under the microscope using a nylon 9.0 suture for the artery and a 1.5 mm vein coupler for the vein. The flap was then placed under the superior skin flap and shaped and de-epithelialised accordingly. The flap was shaped using 3.0 braided absorbable sutures, and 3.0 absorbable monofilament sutures were used for skin closure. Two drains were placed laterally and a microdialysis catheter was installed in the flap. The donor site was closed as it would in a standard thighplasty, without drains. The patient was given compression garments to reduce the risk of donor site complications. Compression garments were worn day and night for 6 weeks, then during the day for another 6 weeks.

During the first postoperative day the patient developed a haematoma at the recipient site that required surgical intervention. A small bleeding was identified in the major pectoral muscle. During the second postoperative day, one of the drains could be removed. On the fourth day following surgery the remaining drains were removed and the patient was discharged.

Outcome and follow-up

The patient was seen in our outpatient clinic 2 weeks after surgery. The patient was also seen 3 months postoperatively for a final evaluation of the result and was offered planning of eventual revisional surgery, nipple reconstruction and thighplasty on the contralateral thigh. Both the reconstructed breast and the donor site were presented with satisfying results (figures 3 and 4). However, due to unwanted hair growth on the reconstructed breast the patient was offered laser hair removal therapy.

Figure 3

The patient at the 3 months follow-up.

Figure 4

The donor site preoperatively and at the 3 months follow-up.

Discussion

The VMG flap was initially described as a cross-legged flap in 1972 by Orticochea.4 The technique was modified by McCraw et al in 1976, using a pedicled flap for vaginal reconstruction.5 The same year the first free VMG flap was described by Harii et al for reconstruction of the face and the lower limb.6

Since then there has been a shift towards the use of the TMG flap. This is most likely due to a combination of, a better understanding of the vascular anatomy,7 a more reliable skin paddle, faster dissection and a smaller scar.

To our knowledge, this is the first case describing the use of a VMG flap for breast reconstruction in a MWL patient. The TMG flap has previously been used for breast augmentation in a small case series of MWL patients,8 and is well described for breast reconstruction in the non-MWL population.3

The DIEP flap is often considered the gold standard for breast reconstruction of the medium to large sized breasts in the non-MWL population. It has a good volume of soft tissue, giving excellent outcomes and a rather low donor site morbidity. Some patients would even argue that the donor site improves after harvesting the excess tissue. The TMG flap harvested from the upper medial thigh is an excellent option for reconstruction of smaller breasts, as it is possible to harvest 200–400 g of tissue. Just as for the DIEP flap the donor site morbidity is rather low. Both the DIEP flap and the TMG can be used for unilateral and bilateral primary and secondary reconstructions.

What is truly interesting with the case presented is that it showcases that free flaps can be suitable for breast reconstruction in the MWL population. The often larger perforators in combination with excess tissue enable a different approach to reconstructive breast surgery. It is possible to harvest bigger flaps compared with the non-MWL population. Depending on the type of body-contouring surgery the MWL patient has been through, different flap options can be lost, due to lack of tissue and possibly loss of donor vessels, for example, loss of the DIEP flap option after an abdominoplasty.

It also opens up for the possibility of combining body-contouring surgery of certain areas with concomitant breast reconstruction.There is a need for further studies comparing the outcome of free flaps and other means of reconstructive breast surgery in the MWL population, both with regard to complications and aesthetic outcomes.

We believe that free flaps should be considered a viable option for autologous breast reconstruction in MWL patients. However, meticulous care should be taken when choosing cases, due to the increased risk of postoperative complications in this patient group. Measures should be taken to decrease the risks as much as possible prior to surgery, for example, cessation of smoking, BMI <30 and well-regulated/treated comorbidities. Furthermore, one should take into consideration the possible need for further/revisional surgery when choosing the reconstructive modality aiming to keep the number of surgeries as low as possible. Our case will most likely require a contralateral thighplasty to achieve symmetry, and possibly a nipple reconstruction. In this case the left thigh would not be ideal for a free flap, due to the lymphoedema; otherwise the left thigh could have posed a possible rescue flap if the primary flap was unsuccessful. One could therefore argue that for this particular patient the left thighplasty for symmetry could have been carried out during the same procedure. However, we chose not to do this to reduce time for surgery as well as surgical stress.

Patient’s perspective

At the 3-month follow-up, the patient was asked to share her experience.

“Ever since I got breast cancer and had to have my breast removed, I have had problems with the scar. It used to be very tight and causing me pain and I even had problems lifting my arm fully.

I actually came here for a consultation regarding my thighs, and I mentioned the problems with the scar. This was when the doctor brought up that there might be a possibility for me to have breast reconstructive surgery. I was very happy and excited to hear this, since I did not think it would be possible for me to get this type of surgery, due to my previous surgeries. I was given a lot of information regarding the surgery, possible complications and long surgery time. I was also informed that it was not routine surgery. Despite all of this information I was never in doubt whether or not I should accept the surgery.

Following surgery I felt very well taken care of at the hospital. All staff members were very kind and took a lot of interest in me and the surgery I have had.

I am very happy with the result, but to be honest what I am most grateful for is that all the pain I used to have is gone. The only thing I am not fully satisfied with is that there now is growing hair on my chest. So I am very happy that I will be referred to laser treatment for this. Currently I do not want further surgery, like a new nipple or correction of my other thigh.

Overall I could not be happier that I decided to accept this surgery.”

Learning points

  • Free flaps are a viable option for breast reconstruction in massive weight loss (MWL) patients.

  • The excess tissue in MWL patients in combination with often larger perforators enables novel and interesting reconstructive options.

  • Meticulous patient selection is mandatory when performing breast reconstructing using free flaps in MWL patients.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors MS: writing and revising manuscript, taking pictures, follow-up with case patient. JBO: writing and revising manuscript. JAS: initiating the project, writing and revising manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.