Despite the growing use of autologous breast reconstruction with medial thigh-based free flaps, such as transverse upper gracilis (TMG) or profunda artery perforator (PAP) flaps, these procedures are infrequently performed on patients with obesity. This systematic review and meta-analysis aimed to compare the frequency of seroma occurrence, a common complication after medial thigh flap surgery. Comparison was performed between TMG and PAP flaps, as well as medial thigh lifts (MTL), a procedure with a similar operative technique but which is typically offered to patients with a higher body mass index (BMI). Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we analyzed EMBASE, PUBMED, and MEDLINE data (English/German). The primary outcomes assessed were occurrence of seroma, as well as hematoma and wound dehiscence. Subgroup analyses explored age, BMI, and various surgical factors. This meta-analysis incorporated 28 studies, totaling 1096 patients. MTL patients had significantly higher BMIs, whereas seroma rates were similar among TMG, PAP, and MTL patients. The incidence of hematoma and wound dehiscence was also similar across the groups. In the metaregression analysis, factors such as age and BMI showed no significant correlation with seroma occurrence in all groups. This systematic review and meta-analysis identified comparable rates of seroma formation after TMG flap, PAP flap, and MTL procedures. Considering that this phenomenon occurred despite the elevated BMI of the MTL group, we propose that patients with higher BMI need not be excluded as candidates for autologous medial thigh-based breast reconstruction. Hence, these procedures should not be limited to small- to medium-sized breasts. Large-scale prospective studies are imperative to validate these conclusions and reveal the underlying factors contributing to seroma formation.

When the entire abdominal tissue is inadequate to match the contralateral breast volume and shape or in bilateral cases, the deep inferior epigastric perforator (DIEP) flap alone might not be adequate, even if bipedicled. In such cases, using combinations of donor sites is useful and more effective. We present our series of breast reconstruction using stacked DIEP and transverse upper gracilis (TUG) flaps to achieve better breast volume and shape. Between 2015 and 2021, 7 patients underwent reconstruction with stacked flaps. Three surgical teams performed the surgery simultaneously. Flaps were stacked and shaped on a table; the DIEP was de-epithelised completely and placed upside down with the pedicle anteriorly. A cranial extension of the DIEP pedicle was anastomosed in series to the TUG vessels. The TUG was coned and placed above the DIEP, the skin paddle was used both to create a new nipple-areola complex and for monitoring. The stacked flaps were anastomosed to the recipient vessels and buried under the mastectomy flaps. No flap losses were encountered. The aesthetic outcome was good or excellent and patients considered the surgery as an improvement for their self-appearance. In patients with loose skin and minimal fat, or in bilateral reconstructions, the presented procedure can be considered as a reliable approach to obtain a better breast shape and simultaneously improve body contouring in the donor sites.

BACKGROUND: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction.
METHODS: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings.
RESULTS: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site.
CONCLUSIONS: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.

OBJECTIVE: The transverse musculocutaneous gracilis (TMG) flap is as a valuable alternative in autologous breast reconstruction. The purpose of this study was to evaluate the donor site morbidity and secondary refinement procedures after TMG flap breast reconstruction.
METHODS: A retrospective study was conducted, including all patients who received TMG flap breast reconstructions, from January 2012 to August 2019. Primary outcomes were surgical site complications of the donor site and secondary refinement procedures carried out for aesthetic or reconstructive purposes for the medial thigh. Secondary outcomes of interest were lipofilling procedures for optimization of the reconstructed breasts.
RESULTS: Ninety-nine patients received 159 TMG flaps for breast reconstruction. Patients\' mean BMI was 23.5 (15.6-32.5) kg/m2. Bilateral breast reconstructions were performed in 60.6%. The mean flap volume was 330 (231-440) g. Surgical site complications occurred in 14.5% of the TMG donor sites and wound dehiscence was the most common complication (9.4%). Lymphedema occurred in 1.8% of the donor thighs. Aesthetic refinement procedures were performed in 25.2% on the donor thigh or contralateral thigh. Secondary lipofilling was performed in 54.1% of the reconstructed breasts and fat was harvested in only 11.9% from the legs.
CONCLUSIONS: The TMG flap breast reconstruction combines low donor site morbidity with adequate volume for appealing breast results, particularly in slim-to-normal weight patients. However, patients should be informed about the likelihood of secondary refinement procedures on the donor site and the need of lipofilling to optimize the breast shape and volume.

BACKGROUND: The transverse myocutaneous gracilis (TMG) flap has become a popular and reliable alternative for autologous breast reconstruction. Initially described as a valuable tissue source for women with low body-mass index, indications nowadays have widely expanded. The Western civilization demographic development with its aging population and the steady growing average BMI has led to increasing breast reconstructions with TMG flaps in overweight and aged individuals.
METHODS: A total of 300 TMG free flaps for unilateral autologous breast reconstruction were evaluated in the form of a retrospective double center cohort study. Data extraction, study group formation and statistical analysis (One-way analysis of variance (ANOVA), Pearson\'s chi-squared statistical analysis and relative risk calculation) were done specifically to evaluate age and BMI as risk factors for postoperative complications and outcome.
RESULTS: No significant differences in patients\' age and BMI in the complication groups compared to the no-complication group could be found. No significant difference regarding the occurrence of complications could be found in any of the formed risk-groups. No significant increase of minor-, major- or overall complications, flap loss or revision surgeries were found in the elderly patient groups or for patients with overweight.
CONCLUSIONS: Age and overweight do not significantly increase the risk for postoperative complications after breast reconstructions with free TMG flaps. The findings of this study support the fact that microsurgical breast reconstruction with a free TMG flap should not solely be reserved for younger patients and females with a lower BMI.

BACKGROUND: Limitations of the transverse upper gracilis (TUG) flap for autologous breast reconstruction include: short pedicle, modest volume, muscle sacrifice and a problematic donor site. The Profunda Artery Perforator (PAP) flap utilises large perforators posterior to the gracilis muscle. We describe our preliminary experience of its use and compare it to our large series of TUG flaps.
METHODS: Our technique has evolved from frog-leg to lithotomy position, and from an anterio-posterior to cranio-caudal raise. This allows either the descending branch of the inferior gluteal artery perforators (IGAP) or the TUG flap as alternatives should PAP perforators be unsuitable intra-operatively. A prospective database was utilised to compare TUG and PAP flaps undertaken 2010-2013.
RESULTS: 54 TUG and 22 PAP flaps were performed. 4 PAP flaps were converted to IGAP flaps and 1 to TUG intra-operatively. 97% of all flaps were successful. Mean flap weight was 295 g (TUG) and 242 g (PAP). Donor site complications for both series included seroma (4 TUG, 1 PAP) sensory disturbance (2 TUG, 1 PAP) and scar revision (3 TUG, 1 PAP).
CONCLUSIONS: Our preliminary experience of the PAP flap has not been universally favourable compared to the TUG flap. It is a more challenging flap to raise, which carries with it a learning curve, especially if raised in the supine position; we present our learning points for safer flap harvest, allowing the TUG as a bail out option. The benefits of the PAP include a longer pedicle, without the need to sacrifice muscle; the perforators should have a more defined and larger perfusion zone. The scar is better hidden, but we have not yet proven significant improvements to the donor site compared to the TUG flap.
METHODS: III.