The Conjoined TUGPAP Flap for Breast Reconstruction: Systematic Review and Illustrative Anatomy

Abstract

Background: Although abdominally based flaps continue to be the gold standard for autologous breast reconstruction, alternative donor sites are necessary when the abdominal region is unavailable or inadequate for flap harvest. In this case, thigh-based flaps, such as the profunda artery perforator (PAP), transverse upper gracilis (TUG), or newly described TUGPAP, are thought to be reliable with low morbidity and satisfactory cosmesis. The objective of this study was to perform a systematic review of breast reconstruction with PAP, TUG, or TUGPAP, and present anatomy and surgical techniques through illustrative examples. Methods: A systematic review of the literature was conducted using PubMed, Embase, and Cochrane Library. Articles were included if they used a PAP, TUG, or TUGPAP flap for oncologic, traumatic, or congenital breast reconstruction in patients 18 years or older. Results: Forty-nine studies met inclusion criteria. Seven hundred five patients underwent 906 breast reconstructions with 1037 flaps (755 TUG, 230 PAP, and 52 TUGPAP). Mean patient age was 45.9 years. The mean flap weight for TUG, PAP, and TUGPAP flaps were 323.4, 346.9, and 437.0 g, respectively. The most common recipient vessel was the internal mammary artery in 821 flaps. The overall flap survival rate was 97.2% (1008/1037). TUG flaps had a significantly higher recipient and donor complication rate compared with both PAP (recipient: 18.1% versus 7.8%, P = 0.0001; donor: 25.8% versus 7.0%, P < 0.00001) and TUGPAP flaps (recipient: 18.1% versus 2.0%, P < 0.001; donor: 25.8% versus 7.7%, P < 0.01). Conclusion: The TUGPAP flap is a safe and effective alternative for autologous breast reconstruction when the abdominal donor site is unavailable.

The PUG Flap: Conjoined Profunda Artery Perforator and Upper Gracilis Flap for Breast Reconstruction

“… 4 , 5 Numerous alterations and refinements to the classic thigh flaps have been proposed to overcome these limitations, such as supine positioning, 5 flap markings below the groin creases, 5 and breast mound coning for more convenient nipple reconstruction. 6 Although each adjustment aids in improving outcomes, PAP and TUG flaps still only permit a limited flap volume. 6 , 7 Even the bipedicled TUGPAP flap, which has been demonstrated to add an average of 113.6 g and 90.1 g when compared with the TUG and PAP flaps, respectively, only offers a modest increase in breast size.…”

“…1,6 In 2021, Karir et al compared TUG, PAP, and TUGPAP outcomes and argued that such modest increases in volume may not be worth the added harvest time and dual anastamoses. 6 The conjoined PUG flap presented here alternatively uses a novel boomerang incision to increase flap volume through maximum tissue harvest. The mastectomy specimens measured 13.5 cm and 13 cm (right and left, respectively), whereas the paddles measured 20 cm medial to lateral.…”

“…6,7 Even the bipedicled TUGPAP flap, which has been demonstrated to add an average of 113.6 g and 90.1 g when compared with the TUG and PAP flaps, respectively, only offers a modest increase in breast size. 1,6 In 2021, Karir et al compared TUG, PAP, and TUGPAP outcomes and argued that such modest increases in volume may not be worth the added harvest time and dual anastamoses. 6 The conjoined PUG flap presented here alternatively uses a novel boomerang incision to increase flap volume through maximum tissue harvest.…”

Bilateral Transverse Upper Gracilis Flaps for Unilateral Breast Reconstruction

“…Transverse upper gracilis flap can generally include decent tissue volume for unilateral breast reconstruction in women with small to moderate breast size. Moreover, the addition of extra thigh tissue with a profunda artery perforator flap in an enlarged conjoined fashion has been also described as an alternative for recruiting increased volume 22 . To our knowledge though, this approach, compared with the 2-in-1 technique, involves a more strenuous perforator dissection, lags behind in volume, and leaves an extended, asymmetrical thigh scar.…”

“…Moreover, the addition of extra thigh tissue with a profunda artery perforator flap in an enlarged conjoined fashion has been also described as an alternative for recruiting increased volume. 22 To our knowledge though, this approach, compared with the 2-in-1 technique, involves a more strenuous perforator dissection, lags behind in volume, and leaves an extended, asymmetrical thigh scar. Interestingly, Saint-Cyr et al 23 have also presented in 2012 some modifications in an attempt to increase the TUG flap volume.…”