Transverse Musculocutaneous Gracilis Flap for Treatment of Capsular Contracture in Tertiary Breast...

Transverse Musculocutaneous Gracilis Flap for Treatment ofCapsular Contracture in Tertiary Breast Reconstruction

Petra Pulzl, MD,* Georg M. Huemer, MD,Þ and Thomas Schoeller, MDþ

Abstract: Capsular contracture is a common complication associated withimplant-based breast reconstruction and augmentation leading to pain, dis-placement, and rupture. After capsulectomy and implant exchange, the problemoften reappears.

We performed 52 deepithelialized free transverse musculocutaneousgracilis (TMG) f laps in 33 patients for tertiary breast reconstruction or aug-mentation of small- and medium-sized breasts. The indications for implantremoval were unnatural feel and emotion of their breasts with foreign bodyfeel, asymmetry, pain, and sensation of cold. Anyway, most of the patientsdid not have a severe capsular contracture deformity. The TMG flap is formedinto a cone shape by bringing the tips of the ellipse together. Dependingon the contralateral breast, the muscle can also be shaped in an S-form to getmore projection if needed. The operating time for unilateral TMG flap breastreconstruction or augmentation was on average 3 hours and for bilateral pro-cedure 5 hours. One patient had a secondary revision of the donor site dueto disruption of the normal gluteal fold. Eighty percent of the unilateral TMGflap reconstructions had a lipofilling procedure afterward to correct smallirregularities or asymmetry.

The advantages of the TMG flap such as short harvesting time, incon-spicuous donor site, and the possibility of having a natural breast shape makeit our first choice to treat capsular contracture after breast reconstruction andaugmentation.

Key Words: therapy for capsular contracture, TMG flap, breast

(Ann Plast Surg 2013;00: 00Y00)

Most of breast reconstructions are performed with implants, asit is a simple method with short operating time. On the other

hand, breast reconstruction can be performed using autologous tissue,which is frequently harvested from the abdomen leading to donor-site scarring. This method requires more surgical skills and longeroperating times. The advantages of the reconstructed breast are amore natural feeling and a stable result.

Breast reconstruction and augmentation with implants havebeen performed for approximately 40 years despite the well-knownrisks of capsular formation and contraction resulting in a firmperiprosthetic fibrous capsule, leading to an unpleasant firmness ofthe breast and displacement of the implant.1 The etiology of capsu-lar contracture is multifactorial. Many studies have investigated the

relationship between contracture and implant surface texture, bac-terial colonization, location of implant placement, and type of im-plant filler material. Capsular contracture is the main complication inpostmastectomy tissue expander and implant breast reconstruction inpatients requiring radiotherapy.2,3

Contracture can compromise the aesthetic outcome, result inpain, breast deformity, and often necessitate further operations.4 Forpatients with moderate to severe capsular contracture (Baker gradesIII and IV), partial or total capsulectomy with implant exchangecan be an option. However, we have seen many patients with recur-rent capsular contracture. Those who desire the maintenance of theirbreast volume are advised to autologous tissue reconstruction, whichis defined as tertiary breast reconstruction.

Flaps used in breast reconstruction can also be used for pureaugmentation.5Y9 In 2002, we first described the use of the transversemusculocutaneous gracilis (TMG) flap for breast augmentation inpatients after massive weight loss following bariatric surgery.6 Bruneret al7 used autologous tissue transplantation [transverse rectus abdominusmyocutaneous/deep inferior epigastric perforator (TRAM/DIEP)] in6 patients with symptomatic capsular contracture, 2 patients hadaugmentation mammaplasty for aesthetic reason. Allen and Heitland8

reported in 2003 approximately 20 autogenous augmentation mamma-plasty using DIEP, superior gluteal artery perforator (SGAP), and su-perficial inferior epigastric artery (SIEA) flaps.

We use a deepithelialized free TMG flap for tertiary breastreconstruction or augmentation of small- and medium-sized breasts.The purpose of this article was to demonstrate our results with theTMG flap in the treatment of capsular contracture after skin-sparingmastectomy and implant reconstruction and after breast augmenta-tion. We believe that this type of flap offers distinct advantages, whichmakes it our first choice.

PATIENTS AND METHODSBetween 2006 and 2011, we performed 52 TMG flaps in

33 patients for tertiary breast reconstruction or augmentation afteroccurring capsular contracture. Thirty patients underwent tertiarybreast reconstruction after skin-sparing mastectomy and implantreconstruction, whereof 14 had bilateral reconstruction (Fig. 1). Twopatients of the 16 unilateral reconstructions had a double TMGflap (Fig. 2). Two patients underwent bilateral breast augmentation(Fig. 3) and 1 patient had tertiary breast reconstruction on one sideand augmentation on the other. All breast cancer cases had beenmultifocal ductal carcinoma in situ patients who do not receive radio-therapy according to our protocol. The patients’ age ranged from 24 to 67years (median, 46 years). All patients were operated on using a 2-teamapproach with 1 team carrying out removal of the implant and prepar-ing the recipient vessels and the other team harvesting the flap. Duringf lap anastomosis, the second team closed the donor site simultaneously.The indications for implant removal were unnatural feel and emotionof their breasts with foreign body feel, asymmetry, pain, and sensationof cold. Anyway most of the patients did not have a severe capsularcontracture deformity (Table 1). The volume of implants replacedby TMG flaps ranged from 220 to 380 mL. Patient satisfaction wasevaluated by late follow-up visit. The mean follow-up was 4.3 years.

BREAST SURGERY

Annals of Plastic Surgery & Volume 00, Number 00, Month 2013 www.annalsplasticsurgery.com 1

Received August 13, 2012, and accepted for publication, after revision, March 20,2013.

From the *Department of Plastic, Reconstructive and Aesthetic Surgery, InnsbruckMedical University, Innsbruck; †Section of Plastic and Reconstructive Surgery,Linz General Hospital, Linz, Austria; and ‡Department of Hand-, Micro- andReconstructive Surgery, Marienhospital Stuttgart, Stuttgart, Germany.

Presented at the 49th Annual Meeting of OGPARC, 42nd Annual Meeting ofDGPRAC, and 16th Annual Meeting of VDAPC in Innsbruck, Austria,September 29YOctober 1, 2011.

Conflicts of interest and sources of funding: none declared.Reprints: Petra Pulzl, MD, Department of Plastic, Reconstructive and Aesthetic

Surgery, Innsbruck Medical University, AnichstraQe 35, A-6020 Innsbruck,Austria. E-mail: petra.puelzl@i-med.ac.at.

Copyright * 2013 by Lippincott Williams & WilkinsISSN: 0148-7043/13/0000-0000DOI: 10.1097/SAP.0b013e3182933dc2

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

SURGICAL TECHNIQUEThe implants were removed using the preexisting incision. After

capsulotomy, only thick parts of the capsule were excised. The surgicaltechnique of TMG flap harvesting (Fig. 4) is already described in theprevious TMG flap literature.10,11 In all cases, the internal mammaryvessels were used as recipient vessels, as the anatomy of the TMGpedicle was highly consistent with the known literature with an aver-age pedicle length of 6 to 8 cm, that enables a good flap positionif anastomosed to the internal mammary vessels. In the 2 patients withdouble TMG flap, the second TMG flap was connected to the thora-codorsal vessels. The skin flap is deepithelialized and the flap is formedinto a cone shape by bringing the tips of the ellipse together. Dependingon the contralateral breast, the muscle can also be shaped in an S-form toget more projection if needed. Thus, a natural ptosis can be achievednearly the anatomical form of an implant (Figs. 5 and 6). Regarding theposition of the vascular pedicle, it is recommended to take the contra-lateral TMG flap and to perform vascular anastomosis before shapingthe flap. In patients with small or ptotic breasts and no demand forcontralateral surgery, the TMG flap is inserted without shaping as thepocket is determined and 100% filled with the flap. Skin closure of thedonor site is performed in the way of a medial thigh lift. For flapmonitoring, we used an oxygen probe.

RESULTSWe had no flap failure, 4 patients had to be taken back to the

operating room for evacuation of hematomas. The operating time forunilateral TMG flap breast reconstruction or augmentation was onaverage 3 hours and for bilateral procedure 5 hours. Average har-vesting time for the f lap was 40 minutes. One patient had a second-ary revision of the donor site due to disruption of the normal glutealfold. Eighty percent of the unilateral TMG flap reconstructions hada lipofilling procedure afterward to correct small irregularities orasymmetry. Patient satisfaction was high due to a more natural shapeand feel of their breasts. This was evaluated by late follow-up visitby the simple questions: Have you been satisfied with the result? Wasthe problem solved without need for further aesthetic improvement?No further attempts were made to analyze the aesthetic outcome.

DISCUSSIONMost publications7,8,12Y18 about tertiary autologous breast re-

constructions after failed implant reconstruction and augmentationreported about using free microvascular abdominal tissue transfer(TRAM/DIEP/SIEA) followed by SGAP, IGAP flap and only 2 pub-lications17,18 also reported the utilization of the TMG flap in a smallnumber of patients.

FIGURE 1. A and B, Patient with capsular contracture (Baker I/II) after bilateral implant breast reconstruction. C, After tertiarybilateral breast reconstruction with TMG flaps.

Pulzl et al Annals of Plastic Surgery & Volume 00, Number 00, Month 2013

2 www.annalsplasticsurgery.com * 2013 Lippincott Williams & Wilkins

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Most patients with implant dissatisfaction are demanding amore natural appearance and feel in the augmented breast withptosis, softness and the possibility to change with ageing. Levineet al18 reported approximately 191 patients with 284 tertiary breastreconstructions after unsatisfactory implant reconstruction. Mostpatients complained of an unnatural feel and appearance of their

breasts, and did not have a severe capsular contracture deformity(Baker III/IV), nor had they undergone radiation. In their study, 41%of patients desiring removal of their implant-based reconstructionhad only Baker I or Baker II grade capsular contracture and 63% ofthem were removed with the chief reported motivation that the pa-tient desired a ‘‘more natural’’ appearance. Visser et al17 reported

FIGURE 2. A and B, Patient with capsular contracture (Baker III/IV) after implant breast reconstruction of the right breast. C and D,After tertiary breast reconstruction with double TMG flap.

FIGURE 3. A, Patient with capsular contracture (Baker III/IV) after bilateral implant breast augmentation. B, after tertiary bilateralbreast augmentation with TMG flaps.

Annals of Plastic Surgery & Volume 00, Number 00, Month 2013 TMG Flap for Capsular Contracture of Breast

* 2013 Lippincott Williams & Wilkins www.annalsplasticsurgery.com 3

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

approximately 42 women who underwent 61 tertiary autologous breastreconstructions after failed implant reconstruction using 47 DIEP, 10mini-TRAM, and 4 TMG flaps. Physical discomfort caused by im-plants (Baker grade II or III capsular contracture) and dissatisfactionwith the aesthetic result were the main patient motivations to opt forautologous breast reconstruction; 45% needed additional surgery toimprove outcome, patient mean satisfaction score was 7.8 of 10.

Interestingly most patients did not have a severe capsular con-tracture deformity (Fig. 1). Because we are currently the centers withthe worldwide highest volume of TMG flap transfers (9400 TMGs),patients with even slight discomfort with implants get in contactwith patients who received happily their TMG flap and demand thesame procedure. We think that after appearance of capsular contrac-ture, the indication for TMG flap reconstruction should be placedbecause recurrent capsular contracture is very likely after partial ortotal capsulectomy with implant exchange. On the basis of the highfailure rates of implant-based breast reconstruction, we propose co-operation with other breast centers and suggest them to performpostmastectomy tissue expander placement. The patient can receiveany neoadjuvant therapy or radiotherapy and upon completion re-placement with TMG flap can be arranged in our reconstructive unit.

In our opinion, the TMG flap offers distinct advantages thatmake it our first choice in the treatment of capsular contractureafter skin-sparing mastectomy and after breast augmentation.11 Theanatomy is highly consistent with an average pedicle length of 6 to8 cm, which is similar to the SGAP flap19 and long enough to anas-tomose to the internal mammary vessels. Modern preoperative imag-ing technologies have been proven to be beneficial for DIEP flaps but

are not necessary for TMGs due to its accurate constant anatomy.The dissection of this f lap is straightforward compared with a per-forator such as the DIEP flap, harvesting time can be less than45 minutes if the surgeon is familiar with the anatomy. For furtherreduction of operating time, a 2-team approach is possible. Closure ofthe donor-site takes another 20 minutes. The operating time for uni-lateral TMG flap breast reconstruction can be less than 3 hours, this issignificant less than in perforator f lap reconstruction, in particular inSGAP or IGAP flap bilateral reconstruction when the patient is turnedand redraped twice. Operating time in bilateral TMG breast recon-struction or augmentation can be approximately 5 hours. For this rea-son the TMG flap is also suitable for elder or sick women, who areoften concerned about long operating times.

The absolute benefit of the TMG flap is its shaping possibil-ity depending on the contralateral breast shape (Fig. 5). In breastswhen projection is desirable, the flap is formed into a cone shape withthe possibility to shape the muscle in an S-form in addition to getfurther projection. In elder patients with ptotic breasts who do notdesire a contralateral mastopexy or patients with small breasts, the flapis inserted without shaping. This kind of breast shaping is not possibleby using the DIEP or other perforator f laps. In case of large breasts,the experienced surgeon has the possibility to use a double TMG flapfor single breast reconstruction. Concerning TMG size, we suggestto overcorrect f lap volume approximately 10% compared with theimplant, as over the year the breast will shrink caused by atrophy ofthe muscular part of the TMG flap. Eighty percent of the unilateralTMG flap reconstructions had a lipofilling procedure afterward tocorrect small irregularities or asymmetry. This is definitely high, butwe think that lipofilling is an excellent method to bring our recon-structive result to perfection. The operation is simple and less invasivefor the patient.

In contrast to Gurunluoglu et al15 who used deepithelializedfree f laps from the lower abdomen after implant removal, totalcapsulectomy and prophylactic subcutaneous mastectomy, we exciseonly thick parts of the capsule after capsulotomy.16 We establisheda softening of scars and capsule tissue after treatment with autolo-gous tissue. Baran et al20 reported that retained capsules would mostlikely disappear in time if the capsule is not stimulated by the implant.

In 2004, Hamdi et al21 reported about bilateral autogenousbreast reconstruction using 98 DIEP and 8 SGAP flaps, a tertiarybreast reconstruction was performed in 18 patients. The average op-erating time was 10 hours. The DIEP f lap was their first choice forbilateral breast reconstruction, the SGAP flap was the alternativefor thin patients or for those with multiple scars on the abdomen. Thedissection of the superior gluteal pedicle was described a bit difficultand technically more demanding. They found the scar quite accept-able. We subscribe to a view of Levine et al19 that the SGAP flap candisrupt the esthetic unit of the buttock. Therefore, Levine et al19

prefer the IGAP flap in simultaneous bilateral breast reconstruc-tion in a series of 22 patients. Operating time was 9 hours, the av-erage buttock scar quality score was satisfactory, but 38% of the

TABLE 1. Indications for Implant Removal

ForeignBody Feel Asymmetry Pain

Sensationof Cold

Capsular Contracture

Baker I-II Baker III-IV

Implant reconstruction

Bilateral (14 patients) 9 2 12 5 9 5

Unilateral (16 patients) 12 14 13 4 10 6

Augmentation (2 patients) 2 2 1 2

Both (1 patient) 1 1 1 1

FIGURE 4. Preoperative skin marking of the TMG flap.

Pulzl et al Annals of Plastic Surgery & Volume 00, Number 00, Month 2013

4 www.annalsplasticsurgery.com * 2013 Lippincott Williams & Wilkins

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

patients had a secondary revision of the donor site. We think this isa definitely high complication rate compared with the TMG flap. Wereported about short- and long-term TMG flap donor-site morbidityin autologous breast reconstruction in 2011.22 The main problemsof the TMG donor site were the visibility of the scar from behindwith a disruption of the normal gluteal fold, that can easily becorrected,23 the loss of sensation around the scar and the sensitivity ofthe scar to pressure and cold.22

In case of autogenous augmentation, mammaplasty after re-current capsular contracture the TMG flap is our first choice for thefollowing reasons: Most of the patients with implant augmentation areyoung and slight with no adequate tissue bulk at the abdomen. In mostcases, the capsular fibrosis occurs bilaterally; therefore, a bilateral

symmetrical donor site with minimal donor-site morbidity is desirable.In augmentation cases with inframammary incision, it is necessary toextend the preexisting incision within the fold to get better surgicalaccess resulting in longer scars without aesthetic impairment. Thenumber of patients with TMG flap augmentation is small, becausethe use of free flaps for aesthetic purposes is not a reproducibletechnique and the financial costs are high. The assurance company willnot pay for that operation except for patients who had severe reasonsfor meeting the costs in primary augmentation. Therefore, the place-ment of implants in breast augmentation is unquestionably the firstoption, but free tissue transfer should be considered in select patientsfor whom implants are undesirable or in the situation of recurrentcomplications.

FIGURE 5. Flap shaping plan.

FIGURE 6. Intraoperative TMG flap shaping.

Annals of Plastic Surgery & Volume 00, Number 00, Month 2013 TMG Flap for Capsular Contracture of Breast

* 2013 Lippincott Williams & Wilkins www.annalsplasticsurgery.com 5

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

CONCLUSIONSThe TMG flap offers distinct advantages in the treatment of cap-

sular contracture after implant-based breast reconstruction and aug-mentation. Short operating time, shaping possibility to achieve anatural ptosis nearly the anatomical form of an implant with naturalfeel and emotion and minimal functional donor site make it our firstchoice.

REFERENCES1. Woerdeman LA, Hage JJ, Hofland MM, et al. A prospective assessment of

surgical risk factors in 400 cases of skin-sparing mastectomy and immediatebreast reconstruction with implants to establish selection criteria. PlastReconstr Surg. 2007;119:455Y463.

2. Lipa JE, Qiu W, Huang N, et al. Pathogenesis of radiation-induced capsularcontracture in tissue expander and implant breast reconstruction. PlastReconstr Surg. 2010;125:437Y445.

3. Spear SL, Boehmler JH, Bogue DP, et al. Options in reconstruction the irra-diated breast. Plast Reconstr Surg. 2008;122:379Y388.

4. Weintraub JL, Kahn DM. The timing of implant exchange in the developmentof capsular contracture after breast reconstruction. Eplasty. 2008;8:e31.

5. Van Landuyt K, Hamdi M, Blondeel P, et al. Autologous breast augmentationby pedicled perforator flaps. Ann Plast Surg. 2004;53:322Y327.

6. Schoeller T, Meirer R, Otto-Schoeller A, et al. Medial thigh lift free flap forautologous breast augmentation after bariatric surgery. Obes Surg. 2002;12:831Y834.

7. Bruner S, Frerichs O, Schneider W, et al. Autologous tissue transplantation(TRAM/DIEP) as an option of therapy in capsular contracture. HandchirMikrochir Plast Chir. 2004;36:362Y366.

8. Allen RJ, Heitland AS. Autogenous augmentation mammaplasty with micro-surgical tissue transfer. Plast Reconstr Surg. 2003;112:91Y100.

9. Peek A, Muller M, Ackermann G, et al. The free gracilis perforator flap: an-atomical study and clinical refinements of a new perforator flap. PlastReconstr Surg. 2009;123:578Y588.

10. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis flap:a valuable tissue source in autologous breast reconstruction. Plast ReconstrSurg. 2004;114:69Y73.

11. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneousgracilis flap for breast reconstruction: guidelines for flap and patient selection.Plast Reconstr Surg. 2008;122:29Y38.

12. Feng LJ, Mauceri K, Berger BE. Autogenous tissue breast reconstruction in thesilicone-intolerant patient. Cancer. 1994;74(suppl 1):440Y449.

13. Spiro SA, Marshall D. Bilateral TRAM flaps for the reconstruction of thepost-implantectomy/capsulectomy breast deformity. Aesthetic Plast Surg.1996;20:315Y318.

14. Yager JS, Chaglassian T. A method of breast reconstruction with adeepithelialized TRAM flap via the abdominal approach for failed implantsalvage in postmastectomy patients. Ann Plast Surg. 1997;39:178Y181.

15. Gurunluoglu R, Shafighi M, Schwabegger A, et al. Secondary breast recon-struction with deepithelialized free flaps from the lower abdomen for intrac-table capsular contracture and maintenance of breast volume. J ReconstrMicrosurg. 2005;21:35Y41.

16. Mosahebi A, Atherton D, Ramakrishnan V. Immediate bilateral autologousbreast reconstruction for silicone intolerance. Br J Plast Surg. 2005;58:714Y716.

17. Visser NJ, Damen TH, Timman R, et al. Surgical results, aesthetic outcome,and patient satisfaction after microsurgical autologous breast reconstructionfollowing failed implant reconstruction. Plast Reconstr Surg. 2010;126:26Y36.

18. Levine SM, Lester ME, Fontenot B, et al. Perforator flap breast reconstructionafter unsatisfactory implant reconstruction. Ann Plast Surg. 2011;66:513Y517.

19. Levine JL, Miller Q, Vasile J, et al. Simultaneous bilateral breast reconstructionwith in-the-crease inferior gluteal artery perforator flaps. Ann Plast Surg.2009;63:249Y254.

20. Baran CN, Peker F, Ortak T, et al. A different strategy in the surgical treatmentof capsular contracture: leave capsule intact. Aesthetic Plast Surg. 2001;25:286Y289.

21. Hamdi M, Blondeel P, Van Landuyt K, et al. Bilateral autogenous breastreconstruction using perforator free flaps: a single center’s experience. PlastReconstr Surg. 2004;114:83Y89; discussion 90Y92.

22. Pulzl P, Schoeller T, Kleewein K, et al. Donor-site morbidity of the transversemusculocutaneous gracilis flap in autologous breast reconstruction: short-termand long-term results. Plast Reconstr Surg. 2011;128:233eY242e.

23. Huemer GM, Dunst KM, Schoeller T. Restoration of the gluteal fold by adeepithelialized skin flap: preliminary observations. Aesthetic Plast Surg.2005;29:13Y17.

Pulzl et al Annals of Plastic Surgery & Volume 00, Number 00, Month 2013

6 www.annalsplasticsurgery.com * 2013 Lippincott Williams & Wilkins

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.