Received: 8 April 2020 Revised: 4 June 2020 Accepted: 10 July 2020

DOI: 10.1002/micr.30633

CASE REPORT

Total aesthetic reconstruction of postburn bilateral breast loss

using transverse myocutaneous gracilis free flaps: A case
report and literature review

uz Acartürk MD
Tahsin Og | Fuat Barış Bengür MD

University of Pittsburgh, Department of Plastic

Surgery, Pittsburgh, Pennsylvania
Correspondence
Tahsin Oguz Acartürk, MD, Associate
Professor of Plastic Surgery, University of
Pittsburgh, Department of Plastic Surgery,
3550 Terrace Street/6B Scaife Hall,
Pittsburgh, PA 15261, USA.
Email: dr.toacarturk@gmail.com
Abstract
Reconstruction of breast burns are challenging, as it includes both functional and
aesthetic components. Transverse myocutaneous gracilis (TMG) flap has been used
for postmastectomy breast reconstruction in the absence of abdominal donor site
availability. Use of this flap for the breast burns is limited. A 32-year-old female
sustained 54% second and third degree burns resulting with bilateral total breast
loss. Anterior and posterior thorax, upper and mid abdomen, neck, shoulders, and
bilateral upper extremities were also involved. Inner medial thighs had an ample
amount of tissue and had never been used as donor sites. The left TMG
(28 × 12 cm, 1,413 g) was used for right, and the right TMG (30 × 14 cm, 1,635 g)
was used for the left breast, 3 months apart. The contracture on the chest wall
was completely excised. Venous anastomosis to the venae commitantes was per-
formed using a 2.5 mm coupler, followed by an end-to-end arterial anastomosis to
the internal mammary artery. Flaps were inset in a fashion so that the inferior part
became the inframammary fold, and the anterior and posterior wings were joined
in the upper pole, creating a conical shape. Minimal wound dehiscence in the post-
operative course healed with dressing changes and both flaps survived completely.
Nipple reconstruction and areolar tattooing was performed. The patient was very
happy with the outcome at seventh year follow-up. TMG may be a valuable option
even in bilateral cases of microsurgical autologous free tissue transfer for total aes-
thetic reconstruction of postburn breast loss.

1 | I N T RO DU CT I O N shape, orientation, symmetry, natural feel, softness, smoothness,

In 1980, Bishop et al. stated that “treatment of the burned female
breast has been unsatisfactory” (Bishop, Fisher, & Bostwick 3rd, 1980).
Considering the advances made in plastic surgery in the last four
decades we can say that the reconstruction of the burned female
breast is still unsatisfactory. Rather than a simple “functional” release
of contracture and resurfacing of the skin, the concept of “aesthetic
reconstruction” becomes much more important (Shelley, Van Niekerk,
Cuccia, & Watson, 2006).
Recreating a harmonious breast should take into account the
basic principles of any breast surgery, as in size, projection,
natural inframammary fold (IMF), and preservation of sensation
and lactation, if possible. However, this is very difficult to
achieve in contracted tissues, and more so with total losses. Vari-
ous corrective techniques including local flaps or expansion of
the contracted tissues with the hope of placing implants have
been described (El-Otiefy & Darwish, 2011; Grishkevich, 2009;
Loss, Infanger, Künzi, & Meyer, 2002; Özgenel, Akin, Kahveci,
Turan, & Özcan, 2002; Ozgur, Gokalan, Mavili, Erk, &
Kecik, 1992). Unfortunately, they are far from providing optimal
results, especially when the tissue loss is advanced. Moreover,
the surrounding areas can also be affected in severe burns,

Microsurgery. 2020;1–6. wileyonlinelibrary.com/journal/micr © 2020 Wiley Periodicals LLC 1

2 ACARTÜRK AND BENGÜR

F I G U R E 1 Preoperative figures (a–e). Total absence of bilateral breasts and complete lack of any subcutaneous adipose tissue on the chest
wall and upper body. There is ample amounts of soft tissue in the lower body

F I G U R E 2 The design of the right TMG (a). Harvest of the left TMG, note that the saphenous vein is preserved (arrow), and pedicle (star) is
dissected as adductor longus is held and lifted (b). Inset of right TMG to the left breast (c). Inset of left TMG to the right breast (d). Note the wide
and complete excision of the skin graft, contracted subcutaneous tissues and muscle fascia. Once the contractures were released the resulting
defect was bigger than the expected and this should be anticipated in flap design
ACARTÜRK AND BENGÜR
leading to distortion of the anatomy, as well as limiting local
reconstructive options.
We present a case where bilateral total breast loss due to massive
severe burns was aesthetically reconstructed using sequential bilateral
free transverse myocutaneous gracilis (TMG) flaps.
2 | CASE REPORT
A 32-year-old female sustained 54% second and third degree burns,
due to assault with a flammable liquid as an act of domestic vio-
lence. Burns involved the anterior and posterior thorax, upper and
mid abdomen, neck, shoulders, and bilateral upper extremities.
Hands, face, lower abdomen, and bilateral lower extremities were
spared. After the initial lifesaving resuscitation, the patient under-
went serial debridements and skin grafting. The patient was evalu-
ated by our clinic, 1 year after discharge from the burn center, with
F I G U R E 3 Postoperative 3 years (a–c). Final result at postoperative 7 years, after two sessions of liposuction, nipple reconstruction, and
areolar tattooing (d–f). Note that the right thigh was used as a tissue-expanded free ALT flap for the neck reconstruction
3
a chief complaint of complete lack of bilateral breasts (Figure 1).
Examination showed total absence of bilateral breast, complete lack
of any subcutaneous adipose tissue on the chest wall, frail skin
grafts with tendency of wound formation, and clearly visible
pectoralis major muscles underneath the grafts. The patient's BMI
was 40.4 with a natural body habitus of lower body lipodystrophy
with extensive amounts of adipose deposition around hips, buttocks,
thighs, and legs. On bilateral anterior and lateral thighs, and but-
tocks, there were healed superficial scars consistent with prior skin
graft harvest. Inner medial thighs had an ample amount of tissue
and had never been used donor sites, keeping the skin free from
any scaring or pigmentary changes. The patient also indicated,
although this was the prior natural body habitus, it increased in size
after the incident, possibly due to weight gain, and the medial thigh
fullness hindered with the capacity to ambulate.
Sequential bilateral breast reconstruction using left TMG for the
right, and right TMG for the left were performed 3 months apart.
4 ACARTÜRK AND BENGÜR

Preoperatively the base of the breast was determined and the

Entire breast

Entire breast

Entire breast

Entire breast
anatomical position of the gracilis muscle was marked. This formed

aesthetic
Involved

subunit
a flap of 30 × 14 cm (weight, 1,635 g) for the right TMG, and
28 × 12 cm (weight, 1,413 g) for the left TMG (Figure 2).
The burn contracture on the chest wall was completely excised

Skin grafting and

of liposuction
down to the muscles. Venous anastomosis to the venae com-

contralateral

fat grafting/

Two sessions
Liposuction/

lipofilling

lipofilling
mitantes was performed using a 2.5 mm coupler, followed by an

Revisions
end-to-end arterial anastomosis to the internal mammary artery.

None
The flap was inset in a fashion so that the inferior part became the
IMF area, and the anterior and posterior wings were joined in the

flap necrosis and

wound infection
upper pole to create a conical shape. The donor site was closed pri-

Bilateral partial
Complications
marily as the leg was slightly brought to adduction. Each surgery
took approximately 7–8 hr.
Flaps survived completely with no anastomotic complications. Min-

None

None

None
imal wound dehiscence in flaps and donor sites healed with dressing
changes. Breast projection, position, consistency, and shape were very

12 months

23 months
Follow-up
natural. Removal of the deep burn scar and chest wall contracture

8 weeks

7 years
improved mobility and functionality on the bilateral upper extremities
as well as the neck. In addition, removal of the tissue in the inner upper

Abbreviations: ALT, anterolateral thigh; STSG, split-thickness skin grafting; TFL, tensor fascia lata; TMG, transverse myocutaneous gracilis.
thighs improved the patient's ambulation and sexual life.

Not mentioned
site closure
Two liposuction sessions were performed on the left breast to

Primarily

Primarily
optimize symmetry, which was followed by nipple reconstruction

Donor

STSG
and areolar tattooing. Patient was very happy with the outcome on
the seventh year follow-up (Figure 3).

Reconstructed site
Unilateral (right)

Unilateral (right)
3 | DISCUSSION

Bilateral

Bilateral
Aesthetic subunits of the breast were described to assist surgeons
in choosing more cosmetically attractive postmastectomy recon-

(right), 28 × 12 cm (left)
structive option (Spear & Davison, 2003). Same principle can also be
Literature review of postburn breast reconstructions with free flaps

applied to the postburn reconstruction. When the breast is affected

Size of the flap

24 × 11 cma

in total together with surrounding tissues, free tissue transfer might

45 × 7.5 cm

17 × 24 cm

be the only remaining option to achieve an aesthetic reconstruction 30 × 14 cm

of the entire breast unit. Cases in the literature were limited with
only three reports (Table 1) (Boehm et al., 2018; Tsai et al., 2004;
Weitgasser et al., 2018). The common denominator in these were
TFL/ALT (right)
Harvested flap

TMG (bilateral)

TMG (bilateral)
Split ALT (left)

the challenging nature of the burn involving multiple areas and

unavailability of local donor sites. Abdomen and back were burned,
limiting the application of well-known methods of postmastectomy
breast reconstruction. If a burn is devastating enough to cause
amputation of the breast, it is highly possible that surrounding tis-
Burned total

surface area

sues are also damaged. In addition, the burn on the upper abdomen
body

may create difficulty in mobilization, and primary closure of the

45%

80%

20%

54%

abdomen when a lower abdominal based flap was planned. There-

fore, it becomes necessary to use free flaps from lower extremities
Chuang, and Wei (2004)

Estimated from the figures.

as they are possibly spared.

Weitgasser et al. (2018)

Tsai et al. (2004) utilized the anterolateral thigh (ALT) flap for
Boehm et al. (2018)
Tsai, Yang, Mardini,

the entire breast subunit, however the lack of subcutaneous tissue

Current report

resulted in minimal projection and scar lines were crossing through

Reference
TABLE 1

the subunit, yielding a patchy appearance. Boehm et al. (2018) also

used a tensor fascia lata/ALT flap for a unilateral entire breast sub-
unit reconstruction. They successfully performed the reconstruction
a
ACARTÜRK AND BENGÜR
in accordance with the subunit principle, yet the contralateral breast
was not reconstructed in the same manner due to lack of available
donor site. Although the ALT area can be a viable option in dire cir-
cumstances, the quality of the subcutaneous adipose tissue is not in
concordance of natural breast tissue, as in abdominal or inner thigh
flaps. In addition, the surface characteristics of the flat ALT flap makes
it very difficult to mold into a native breast shape. Planning ahead and
efficient use of available tissue is important for reconstructive needs
in a tissue-depleted patient. In this report, the ALT was reserved for
resurfacing the patient's neck contractures, which was done as a later
procedure (Acartürk & Bengür, 2020).
Weitgasser et al. (2018) used bilateral TMGs for the reconstruc-
tion of bilateral entire breast subunits. However, their reconstruc-
tion was suboptimal as bilateral partial flap necroses occurred with
loss of natural shape, projection, and smoothness. In addition, they
used a triangular lip in the median area of the flap in order to
increase the weight and possibly the projection. However, this led to
scars crossing subunits, as well as poorly hidden transition lines,
resulting in a patchy contracted appearance. Their orientation was in
an upside down fashion, where the inferior part of the flap become
the superior pole. Both of those factors may have contributed to flap
failure that they have experienced. We used contralateral flaps to
facilitate a natural inset and a conical shape, which also made the
anastomoses easier. Although the flaps were at least three times
larger, we did not experience any necrosis. It might also be more
practical and safer to perform sequential procedures rather than
simultaneous bilateral reconstruction in burns. The chest wall defect
after excision of the contracted skin was so large that it could only
be reconstructed with another free flap if the primary flap
completely failed. Therefore, if both flaps were to be transferred at
the same time and either one of them fails, reconstruction of the
remaining massive defect would be extremely difficult in an already
tissue depleted patient. One other reason was to assure complete
adherence of one flap to the chest wall, so that it would not pull on
the incision site at the breast cleavage junction, had two flaps were
performed simultaneously. Consequently, second surgery should be
performed only when the survival of the first flap is certain and com-
plete healing is achieved. Value of donor tissue is very high in those
patient and surgeons should approach the reconstructions with
strict precautions.
TMG flap has been used for nonburn breast reconstruction in the
absence of abdominal donor site availability (Fattah, Figus, Mathur, &
Ramakrishnan, 2010; Nickl, Nedomansky, Radtke, Haslik, & shaping techniques, and reduction of donor site morbidity. Microsur-
Schroegendorfer, 2018; Park, Alkureishi, & Song, 2015). Advantages
include consistent pedicle anatomy, minimal donor site morbidity, no loss
of function, subcutaneous tissue quality consistent with natural breast,
hidden scar, two team approach, and ease of elevation. It is classically
reported to yield a small-to-medium size breasts (Arnež, Pogorelec,
Planinšek, & Ahčan, 2004). The current patient was unique, where the
intrinsic lower body lipodystrophy yielded large flaps enough to create
high volume breasts with superb projection, aesthetic shape, and natural
feel. The harvested tissues weighed 1,635 and 1,413 g, which represents
much larger flaps than reported in the literature (normally 250–400 g of
5
tissue; Patel & Ramakrishnan, 2017). We also demonstrated that using a
conventional TMG, the angiosome area could be fully harvested regard-
less of the size and weight. We were able to inset the flaps to reconstruct
entire breast subunits and place the transition lines on anterior axillary
fold on lateral; breast-to-sternum fold on medial; and IMF on inferior
aspects.
Free flaps in the reconstruction of the burned breast is under-
utilized. Surgeons should aim for aesthetic reconstruction rather than
creating a mound of tissue. This includes adhering to the subunit prin-
ciples even in challenging cases with contractures. TMG may be a
valuable option of microsurgical autologous free tissue transfer for
total aesthetic reconstruction of postburn breast loss.
OR CID
Tahsin O
guz Acartürk https://orcid.org/0000-0003-1484-5496
Fuat Barış Bengür https://orcid.org/0000-0002-6036-3458
RE FE RE NCE S
Acartürk, T. O., & Bengür, F. B. (2020). Reconstruction of burn contrac-
tures of the anterior neck with pre-expanded free anterolateral thigh
flaps. Injury, (in press), https://doi.org/10.1016/j.injury.2020.02.112
Arnež, Z. M., Pogorelec, D., Planinšek, F., & Ahčan, U. (2004). Breast recon-
struction by the free transverse gracilis (TUG) flap. British Journal of
Plastic Surgery, 57(1), 20–26. https://doi.org/10.1016/j.bjps.2003.
10.007
Bishop, J. B., Fisher, J., & Bostwick, J., 3rd. (1980). The burned female
breast. Annals of Plastic Surgery, 4(1), 25–30.
Boehm, D., Bergmeister, K., Gazyakan, E., Kremer, T., Kneser, U., &
Schmidt, V. J. (2018). Autologous breast reconstruction using a tensor
fascia lata/anterior lateral thigh-freestyle flap after extensive electric
burn: A case report. Annals of Plastic Surgery, 80(5), 503–506. https://
doi.org/10.1097/SAP.0000000000001429
El-Otiefy, M. A. E., & Darwish, A. M. A. (2011). Post-burn breast deformity:
Various corrective techniques. Annals of Burns and Fire Disasters, 24(1),
42–45.
Fattah, A., Figus, A., Mathur, B., & Ramakrishnan, V. V. (2010). The trans-
verse myocutaneous gracilis flap: Technical refinements. Journal of
Plastic, Reconstructive & Aesthetic Surgery, 63(2), 305–313. https://doi.
org/10.1016/j.bjps.2008.10.015
Grishkevich, V. M. (2009). Restoration of the shape, location and skin of
the severe burn-damaged breast. Burns, 35(7), 1026–1035. https://
doi.org/10.1016/j.burns.2008.12.008
Loss, M., Infanger, M., Künzi, W., & Meyer, V. E. (2002). The burned female
breast: A report on four cases. Burns, 28(6), 601–605. https://doi.org/
10.1016/S0305-4179(02)00073-6
Nickl, S., Nedomansky, J., Radtke, C., Haslik, W., & Schroegendorfer, K. F.
(2018). Optimization of breast reconstruction results using TMG flap
in 30 cases: Evaluation of several refinements addressing flap design,
gery, 38(5), 489–497. https://doi.org/10.1002/micr.30290
Özgenel, G. Y., Akin, S., Kahveci, R., Turan, Ş., & Özcan, M. (2002). Recon-
struction of burn-damaged female breasts. European Journal of Plastic
Surgery, 25(3), 152–155. https://doi.org/10.1007/s00238-002-
0360-1
Ozgur, F., Gokalan, I., Mavili, E., Erk, Y., & Kecik, A. (1992). Reconstruction
of postburn breast deformities. Burns, 18(6), 504–509. https://doi.
org/10.1016/0305-4179(92)90186-X
Park, J. E., Alkureishi, L. W. T., & Song, D. H. (2015). TUGs into VUGs and
friendly BUGs: Transforming the gracilis territory into the best second-
ary breast reconstructive option. Plastic and Reconstructive Surgery,
136(3), 447–454. https://doi.org/10.1097/PRS.0000000000001557
6 ACARTÜRK AND BENGÜR

Patel, N. G., & Ramakrishnan, V. (2017). Microsurgical tissue transfer in
breast reconstruction. Clinics in Plastic Surgery, 44(2), 345–359.
https://doi.org/10.1016/j.cps.2016.12.002
Shelley, O. P., Van Niekerk, W., Cuccia, G., & Watson, S. B. (2006). Dual ben-
efit procedures: Combining aesthetic surgery with burn reconstruction.
Burns, 32(8), 1022–1027. https://doi.org/10.1016/j.burns.2006.03.028
Spear, S. L., & Davison, S. P. (2003). Aesthetic subunits of the breast. Plas-
tic and Reconstructive Surgery, 112(2), 440–447. https://doi.org/10.
1097/01.PRS.0000070486.35968.38
Tsai, F. C., Yang, J. Y., Mardini, S., Chuang, S. S., & Wei, F. C. (2004). Free
split-cutaneous perforator flaps procured using a three-dimensional
harvest technique for the reconstruction of postburn contracture
defects. Plastic and Reconstructive Surgery, 113(1), 185–193. https://
doi.org/10.1097/01.PRS.0000096707.22461.8A
Weitgasser, L., Bahsoun, A., Amr, A., Brandstetter, M., Knam, F., &
Schoeller, T. (2018). A rare approach? Microsurgical breast reconstruc-
tion after severe burns. Archives of Plastic Surgery, 45(2), 180–184.
https://doi.org/10.5999/aps.2017.01039
How to cite this article: Acartürk TO, Bengür FB. Total
aesthetic reconstruction of postburn bilateral breast loss using
transverse myocutaneous gracilis free flaps: A case report and
literature review. Microsurgery. 2020;1–6. https://doi.org/10.
1002/micr.30633