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• W3180830541 abstract "The use of medial thigh tissue for autologous breast reconstruction has evolved over the last couple of decades with the development of the transverse upper gracilis and the profunda artery perforator flaps as an alternative to the deep inferior epigastric perforator (DIEP) flap. Although thigh-based flaps are limited in volume and length,1 the high number of skin perforators in this area allows surgeons to create innovative and adaptable flap designs to overcome these shortfalls. The gracilis myocutaneous flap became popularized for breast reconstruction in the 1970s and continues to be utilized, given its relative ease of dissection and favorable donor site. The longitudinal design of the vertical upper gracilis flap was first described in practice; however, the flap was frequently plagued with unreliable distal cutaneous perfusion.2 Yousif et al.3 demonstrated the vascular territory for the perforator was better suited for a transverse orientation as a transverse upper gracilis flap, thus shifting the common practice to a horizontal pattern. The most notable drawback to the transverse upper gracilis flap remains its limited volume. Several modifications have been described in an attempt to maximize volume, including a combination of horizontal and vertical components as either an “L” or a “trilobed” pattern.1 Another medial thigh–based flap based on the profunda artery perforator was first described by Dr. Robert Allen in 2010. The profunda artery perforator flap offers several theoretical advantages to the transverse upper gracilis flap, including longer skin paddle, increased pedicle length, sparing of muscle and lymphatics, and slightly larger volumes. Ciudad et al.4 demonstrated the viability of the transverse upper gracilis profunda artery perforator flap, combining the transverse upper gracilis and profunda artery perforator pedicles into a single large flap. Bodin et al.5 found that adding this second pedicle to an upper gracilis flap increased perfusion to the posterior tip, allowing safer transplantation of large flaps. In this article, we expand on medial thigh–based flap innovation in a novel case using a vertically oriented, bipedicled flap, based on both the profunda artery perforator and the vertical upper gracilis pedicle, appropriately named the “PUG” flap. This flap maximizes medial thigh volume in a reliable vertical direction for breast reconstruction. A 40-year-old female patient undergoing bilateral nipple-sparing mastectomy sought immediate autologous reconstruction despite inadequate abdominal tissue for DIEP reconstruction alone. The PUG flap was conceived as an alternative to stacked DIEP/profunda artery perforator reconstruction, thus avoiding significant donor-site morbidity. The PUG flap would safely capture a large volume of the predominantly medially based adipose tissue in a vertical orientation. The PUG flap (Fig. 1) was designed and marked with a vertical pattern to incorporate vascular pedicles from both the medial circumflex femoral and profunda arteries. Preoperative computed tomography angiography was performed that confirmed the gracilis pedicle and profunda artery perforators.Fig. 1.: The PUG flap and its blood supply.The flap was prepared by first dissecting the perforating branch of the medial circumflex femoral artery along with the proximal gracilis. Next, the profunda artery perforator was identified posterior to the gracilis and dissected to adequate length. The flap was subsequently raised and inset. The internal mammary artery and vein were utilized as recipient vessels, after being divided to allow for anterograde and retrograde anastomoses. The vertical upper gracilis pedicle was anastomosed to the anterograde artery, and the vena comitans was coupled to the anterograde vein. Similarly, the profunda artery perforator pedicle was anastomosed to the retrograde artery and the vena comitans was coupled to the retrograde vein. [See Video (online), which demonstrates intraoperative bipedicle anastomoses to anterograde and retrograde internal mammary artery.] The flap was de-epithelialized, coned for increased projection, and inset to the chest wall, similar to other medial thigh–based flaps (Fig. 2). The PUG flap demonstrated excellent perfusion, including to the distal aspect of the skin paddle. {href:Single Video Player,role:media-player-id,content-type:play-in-place,position:float,orientation:portrait,label:Video.,caption:This intraoperative video clip shows bipedicle anastomoses to anterograde and retrograde internal mammary artery.,object-id:[{pub-id-type:doi,id:},{pub-id-type:other,content-type:media-stream-id,id:1_sv063ujz},{pub-id-type:other,content-type:media-source,id:Kaltura}]} Fig. 2.: The PUG flap following inset with demonstration of coning for increased breast projection.The PUG flap offers a novel approach to thigh-based breast reconstruction. Vertical orientation of the PUG flap maximizes available medial thigh tissue compared to the transverse upper gracilis flap, profunda artery perforator flap, or a combination of the two. The bipedicle nature of the PUG flap provides reliable perfusion for large-volume, thigh-based reconstruction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article." @default.
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• W3180830541 date "2021-07-07" @default.
• W3180830541 modified "2023-10-18" @default.
• W3180830541 title "Maximizing Volume from the Medial Thigh: Introducing the PUG Flap" @default.
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• W3180830541 doi "https://doi.org/10.1097/prs.0000000000008161" @default.
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