Online Article with Dr. Karen Horton of Women's Plastic Surgery - Neko Cheri and NC Mag Online

I was recently interviewed by Neko Cheri about my experience being a woman Plastic Surgery and in starting my practice and business in San Francisco.  

  

  

Neko Cheri is the creator of NC Mag, "The intelligent woman's guide to sophisticated living", an online publication for women, by women.

She also hosts a live online talk radio show, Neko Cheri LIVE on Blog Talk Radio.  Check her out!

  

The full article including links to my website and additional information can be read here:

INTERVIEW QUESTIONS DR. KAREN HORTON:

Q:        WHAT PROMPTED YOU TO START YOUR OWN PRACTICE, AND HOW LONG HAVE YOU BEEN IN BUSINESS?

            I completed a long, but very rewarding 16 year road of University study to become a Plastic Surgeon, and started my private practice in Plastic Surgery in 2006.  I am one member of a unique, all-woman Plastic Surgery practice, "Women's Plastic Surgery".  See our website www.womensplasticsurgery.com for more information. 

            Starting your first job at the age of 35 was quite different from many of my friends from college and peers in the community; however I wouldn't have done it any other way!  I am exciting to get out of bed each day and to go to work, something that many others can't relate to! 

            When considering the options for employment, I considered different types of practice, including academic University life, an HMO setting (like Kaiser Permanente), a large group practice, or private practice. 

            For me, private practice was the best fit, in that it enabled me to develop a specialized practice, focusing on the areas of Plastic Surgery I am most passionate about, and to deliver the best patient care, in a personal setting. 

             

Q.        WHAT IS YOUR AREA OF EXPERTISE?

            I am a Board-Certified Plastic Surgeon and Reconstructive Microsurgeon, practicing in the Pacific Heights area of San Francisco.  I specialize in both reconstructive surgery and cosmetic surgery for women.  Visit my bio for additional info about my background and training. 

            At least half of my practice focuses on breast cancer reconstruction, using new techniques that are not yet widely performed in the United States.  One technique for reconstruction of the breast involves a single-stage procedure using an implant, giving women a natural result without the need for multiple surgeries.  Another novel technique involves Microsurgery to reconstruct the breast using the body's own tissue, usually from the lower abdomen or inner thigh area.  This option avoids the use of implants, and provides a permanent, soft and living tissue reconstruction, while adding the benefit of a tummy tuck or a thigh lift! 

            The other part of my practice focuses also on women, many of them Moms!  The "mommy makeover" spectrum of procedures rejuvenates a woman's body after she has completed childbearing.  This type of surgery usually focuses on the breasts and body.  There are permanent changes after pregnancy such as breast deflation or drooping, loss of abdominal muscle tone, and/or excess skin and fat in the middle section or thighs.  Many of my patients are personal trainers, who also need a little help once they are mothers!

            A mommy makeover can include a breast lift, breast augmentation or breast reduction, depending on the changes of pregnancy and your specific aesthetic goals.  Because the muscles of the abdominal wall are permanently separated after pregnancies (particular after multiple children or twin pregnancies), a million sit-ups will not help!  A tummy tuck ("abdominoplasty") and/or liposuction is often recommended to bring the abdominal muscles back together in the midline, and to recreate a flat belly.

            Lastly, I see patients for general Plastic Surgery concerns: moles, skin cancers, and other body concerns.  Labiaplasty is one procedure I particularly enjoy!  Redundant labia minora tissue (inner lips of the female external genitalia) that hangs lower than the labia majora (outer lips) is trimmed for both cosmetic concerns and sometimes for pain during intercourse. 

Q:        WHAT WOULD YOU SAY IS THE MOST SIGINIFICANT ADJUSTMENT THAT WOMEN HAVE AFTER SURGERY?

            Any body-modifying surgery can have a major impact on body image and self-esteem.  Hopefully, the change is a positive one!  However, just like a drastic haircut, there can be a "body image adjustment" period or temporary feeling of remorse after surgery.  I counsel my patients at their initial consultation that this adjustment period of potential feelings of uneasiness, anxiety or "what have I done?" is completely normal and common after surgery.  It can take some time to adjust to your body after any surgery, and the most healthy approach is to acknowledge how you are feeling and to communicate this to your loved ones who are assisting you after surgery. 

Q:        IT SEEMS THAT PLASTIC SURGERY IS A MALE DOMINATED INDUSTRY HOW HAVE YOU BECOME SO SUCCESSFUL?

            Many women come to see me after doing an internet search because I am a woman Surgeon.  I think many women feel most comfortable discussing their bodies, their body image and self-esteem, and their personal goals for surgery with another woman - with the same anatomy, and who can relate to them as a peer as well as their doctor. 

            I give every single patient who walks through the door or my practice my full attention and absolute care.  I get to know my patients intimately, and strive to understand them as a whole person.  I explore how their desire to modify a part of their body will affect their life, health, wellness and spirit, and I encourage realistic goals and objectives for surgery. 

            Each of my patients is given my personal cell phone number, and my patients are encouraged to contact me directly with any questions or concerns, no matter how big or small. 

Q.        WHAT HAS BEEN THE MOST CHALLENGING PART OF STARTING YOUR PLASTIC SUGERY BUSINESS?

            In Medical School and Residency, we are given NO business teaching or training!  Subsequently, it is a crash course in self-employment for most Physicians.  I am still learning about running a business, managing employees, hiring and firing, overseeing the books, etc!  Sometimes I wish I could just wake up with an MBA degree and naturally understand it all.  My business aptitude is a work in progress, but I'm enjoying the journey. 

Q:        WHAT ARE SOME OF THE MILESTONES YOU HAVE ACHIEVED IN THE PAST YEAR?

            In the past year, I have helped literally hundreds of women become whole again after breast cancer, feel sexy and youthful again after pregnancy or aging, and to be more comfortable and confident in their own skin.  This provides such gratification to me; it's almost a bonus that I get to make a living doing this!

            Within five months of starting my practice in July 2006, I was covering my overhead and starting to make a profit, which is a feat in itself!  Since then, I have maxed out my practice schedule, and am fully booked in the operating room and in the office.  I now officially need to focus on "working smarter, not harder". 

Q.        WHAT IS THE MOST COMMON MISCONCEPTION ABOUT PLASTIC SURGERY?

            Any Plastic Surgery operation is a major deal.  Each procedure involves cutting and sewing, bruising, downtime, discomfort, and healing time.  Reality shows and celebrity gossip magazines often portray Plastic Surgery in an unrealistic light, minimizing the downtime and sensationalizing the results.

            In addition, many Hollywood celebrities who have had more than their share of cosmetic procedures (no names needed!), look abnormal and have lost their natural beauty.  The best Plastic Surgery does not make you look different, does not distort your facial features, and is not overtly obvious to any passer-by.  Most women seeking surgery in my office want a natural result, without looking "fake" or "done". 

Q.        WHAT ADVICE WOULD YOU GIVE TO A YOUNG WOMAN LOOKING TO WORK IN YOUR FIELD?

            I had very few female Mentors during my training.  My father is a General Surgeon and was a breast cancer specialist, who undoubtedly influenced me, although he was a workaholic and hardly ever around!  My mother held a Ph.D. in Biochemistry, and instilled in my sisters and me the conviction that "you can be anything you want in life, except a Daddy!"

            I was raised to believe that I could achieve just about any career goals I wished, as long as I received good grades in school and worked hard.  My parents encouraged me to investigate other career fields, based on my interests of art and drawing, such as architecture and fine arts.  However, medicine and surgery was the best fit for me, based on my fascination with the human body, science and figuring out the way things work!

            A career in Plastic Surgery is difficult to enter and is fiercely competitive.  In Canada, my birthplace and location of training, only ten training spots are available each year, and the competition is intense.  Four years of undergraduate University, four years of Medical School, five to six years of Plastic Surgery Residency, and often a final year of Fellowship training are necessary before you can start your own practice. 

            I encourage students who are interested in learning more about Plastic Surgery to shadow me in the office and the operating room, and I regularly mentor young females who are considering a career in Medicine. 

Q.        WHAT IS THE REWARDING PART OF YOUR OCCUPATION?

            The most rewarding aspect of my career is helping people in an intimate and emotional way, every single day!  Plastic Surgery enables me to use my brain, my hands, my creativity and artistic talents, and my compassion and caring nature in the best possible way.  Helping others truly is my calling, and Plastic Surgery is the venue!

Q.        WHAT TRENDS TO SEE HAPPENING IN YOUR INDUSTRY?           

            Many non-surgical aesthetic treatments are increasingly being offered as an alternative to, or as an adjunct to surgery. 

            Examples are Botox, Dysport and other injectable agents that decrease muscle contraction and eliminate wrinkles, injectable fillers that help to fill lines in the face, that decrease the effects of aging around the eyes, and plump the lips or cheeks, and "laser"-type treatments that can help to tighten skin without surgery and to improve abnormal pigmentation of the skin.

            Nonsurgical treatments such as these can be a little less expensive than surgery, and can be a great option for women who are not ready for a facelift or eyelid lift surgery.  However, the effects are usually temporary, and over time, the expenses can add up!   Surgery sometimes is the correct answer; your Plastic Surgeon can help to determine which options will best achieve your goals!

Q.        HOW DO YOU SEE YOUR PRACTICE EXPANDING IN THE NEXT 5 YEARS?

            I will always be committed to breast cancer patients, and I intend to continue to perform breast reconstruction for women facing cancer throughout my career.  At this point in my practice, I am already extremely busy, I'm tired, but I'm thrilled about this! 

            I would like to expand my "mommy makeover" cosmetic practice and help many more Moms achieve their body image and self-esteem goals via surgery (once they have achieved their maximal results with a health diet and regular exercise).

            I am now ready to train a "Fellow" (fully trained Plastic Surgery graduate) and teach them all I know, and to eventually take on a Junior Associate in my practice!  I also plan to hire a Physician Assistant to enable me to be as efficient as possible and to share my responsibility with inpatient hospital rounds, office preoperative visits, phone calls, and weekend call. 

            I hope to start my own family soon, and having someone I have personally trained and trust to care for my patients in the same manner and degree as I do, will enable me to best juggle work and a family life.  I look forward to that challenge!

Q.        HOW HAS SOCIAL NETWORKING AFFECTED YOUR FIELD?

            There is a great deal of inaccurate information and gossip on the internet, particularly regarding Plastic Surgery.        

            I am active on Twitter and Facebook, and I use these resources as a way to reach out to other and to educate, inform and empower women (and men!) about what Plastic Surgery is and isn't, to discuss some of the latest controversies in Plastic Surgery, and to get the word out there about new surgical techniques that are the latest and greatest!

            I think social networking is great, as long as it is used with respect and professionalism.  Many of my patients "follow" me online, and it's important to remember that once an opinion or message is posted, it is out in cyberspace forever! 

Step-by-step animation about breast augmentation surgery!

The American Society of Plastic Surgeons (ASPS) has developed a new series of videos that detail the steps in many different Plastic Surgery procedures.  

One of my favorites is the animation on breast augmentation using silicone implants and a subglandular (under the breast approach).  This is the technique that I most commonly use for breast augmentation in my patients. 

 

 

 
Watch the animation here! (silicone implants, under breast incision)

The ASPS is a wonderful resource for individuals interested in learning more about Plastic Surgery in an unbiased approach, without emphasizing one particular surgeon or technique.

Only Board-Certified Plastic Surgeons can become members of the ASPS.  Learn more here.

To see additional before-and-after pictures of breast augmentation, visit our website gallery!

How are breast implants put in the body?

Breast implants can be inserted through a variety of incisions:

1.       In the fold under the breast (inframammary)

2.       Around the areola (periareolar)

3.       Through the areola and around the nipple (transareolar)

4.       Through the armpit (trans-axillary)

5.       Via the belly button (trans-umbilical)

Inframammary fold (IMF) incisions preserve the function of the function of the breast, namely breastfeeding and pleasure.  I use this incision most commonly for breast augmentation surgery.  

When an incision is made in the fold under the breast, the scar lies in a natural crease and does not tend to stretch or be raised, as can happen in other areas.  All structures leading to the nipple and areola (milk ducts, nerves, blood vessels) remain intact.  In addition, once an implant is inserted, it is probable during a woman's lifetime that another surgery may be required (to change the implant, remove it later in life, perform a breast lift with drooping, etc.).  Therefore, the scar is already present and this can be used again as an incision in the future.  

Many other incisions used for breast augmentation are only a one-time option, with the IMF incision required in the future.  The IMF scar is hidden in bras and even triangle-top string bikinis, and will only be visible up close when the breasts are lifted.

Peri-areolar incisions are usually around the bottom of the areola, the pigmented circle that surrounds the nipple.  There are bacteria that live in this area, and vital milk ducts and nerves in this region.  By definition, some of these structures will be divided (cut) during surgery, resulting in a higher risk of complications (infection, numbness, inability to breast feed, etc.).  In addition, if a woman makes raised scars, they may be visible beneath a tight shirt or through a bathing suit. 

Trans-areolar incisions also cut through breast tissue and/or ducts, blood vessels or nerves.  Nipple retraction can also result from scar tissue that normally forms after surgery.  For these reasons, I would not recommend this for most women. 

Trans-axillary breast augmentation makes an incision in the armpit, or axillary area.  This is often a one-time incision, that creates a scar in the area where most women shave, and is also a site of normal bacterial growth (hence deodorant use!).  The incidence of infection can potentially be higher, and this incision cannot be reused in the future for addition other surgery. 

Trans-umbilical breast augmentation (TUBA) is more of a gimmick than routine approach.  A long tube and scope with a camera must be tunneled beneath the skin of the belly button all the way to the area under the breast.  If there are any complications during surgery such as bleeding, or if the surgeon cannot adequately visualize what they are doing, a second incision must be made in the IMF.  Only a tightly rolled up saline-filled breast implant can be used (not silicone implants), it is also a one-time incision, and a long band of scar tissue beneath the skin is possibly visible after surgery - a permanent deformity.  I would never recommend this option to any of my patients. 

The SAFETY and science of breast implants and SILICONE!

Most women who come to see me in consultation for breast augmentation have one major question:  "Is silicone safe???" 

I spend a great deal of time and effort in my practice educating women about their options for surgery, and when discussing breast augmentation, I emphasize that all implants, both saline- and silicone-filled, are SAFE.

In fact, silicone breast implants are the most extensively studied implantable medical device in the history of medical devices! 

All breast implants have a silicone shell; the fill material is what differs.  For most of my patients, I recommend silicone specifically, because it can have a more natural look and feel. 

The website breastimplantanswers.com is an excellent resource for women to learn all about breast implants.  I send each woman I see in consultation to this site to do some "homework" and to learn more about this medical device.

Here are some excerpts from the site (I encourage you to also visit the website for additional information):

Silicone is a highly versatile substance that has many medical uses. Different types of silicone have been used for decades in a variety of medical devices, such as pacemakers and artificial joints.

Learn more about the technology and innovation behind silicone and silicone gel-filled breast implants 

Silicone gel-filled breast implants are among the most extensively studied FDA-approved medical devices in existence. In the United States alone, Allergan has examined the safety of silicone gel-filled breast implants in more than 80,000 women.

For more detailed information, please read the complete safety information

The United States Food and Drug Administration (FDA) approved silicone gel-filled breast implants after reviewing a vast amount of scientific data. These data consisted of results from extensive preclinical testing, four years of data on 715 women from Allergan's Core Clinical Study, and a European study that evaluated implant rupture prevalence rates beyond 10 years1. In addition, countless published, peer-reviewed studies and research support the safety of silicone and silicone gel-filled breast implants. The FDA also considered in their decision the opinions of advisory panels made up of outside experts.

Read the Core Study results

Breast augmentation is a personal decision for a woman, and one that should not be taken lightly.  I encourage all women to educate themselves about the safety and science of breast implants before considering any surgical procedure.  

Free bonus gift (value $225) for my patients who choose silicone breast implants!!!

 I am happy to announce that Allergan, the company that manufactures Natrelle silicone breast implants, is offering a free bonus gift to each of my patients who receive silicone breast implants, effective January 2010!

Call my office and speak to Mary at 415-923-3067 for more information. 

Schedule your appointment now. Ask your doctor if LATISSE® (bimatoprost opthalmic solution) 0.03% is right for you. Prescription only. Get free trials of VIVITÉ® Vibrance Therapy and LATISSE® *Offer expires 6/30/10 or while supplies last. Good for augmentation patients only.

Power Women Magazine's Blogtalk Radio - Dr. Karen Horton as featured guest!

I was recently interviewed by Power Women Magazine for a full live hour, discussing the latest in Plastic Surgery for women, both cosmetic and reconstructive.

Click this link to listen to the interview!

Power Women Magazine Where Power Women can network Dr. Karen Horton Dr. Karen Horton has invited you to the event 'Dr Karen Horton' on Power Women Magazine! Log in to listen to my online radio interview tomorrow (Tuesday) - 9 a.m. PST, PowerWomenMagazine.com! I will be discussing the latest in Plastic Surgery for women. Karen Horton, MD, MSc, FRCSC Time: October 27, 2009 from 11am to 12pm Location: www.blogtalkradio.com/powerwomenmag Organized By: Dee Jones Event Description: Dr Karen Horton will be speaking on women and plastic surgery See more details and RSVP on Power Women Magazine: http://powerwomenmagazine.ning.com/events/event/show?id=2871844%3AEvent%3A6521&xgi=0kl7ziWtD2JBXK About Power Women Magazine Power Women Magazine is an online publication about women by women for women and issues important to women worldwide. 392 members 348 photos 9 songs 38 videos 37 discussions 201 Events 108 blog posts

Online Plastic Surgery consultations: Convenience or Trouble?

A recent New York Times article discussed the potential merits and pitfalls of online consultations for Plastic Surgery procedures. 

This led me to think about my own practice.  I am currently listed on a number of websites that drive potential patients to my practice, from breast augmentation:

• LookingYourBest.com
• BreastImplants411.com
• BreastImplantsUSA.com

...to liposuction, tummy tucks, and other related sites where people can post questions and hear back from real Plastic Surgeons on their opinion about surgery.

I post my direct email (khorton@womensplasticsurgery.com) on these types of sites, and encourage potential patients to contact me directly with questions or comments. 

In response, I always send them a personal email reply with general information about my practice and advice to make an appointment to SEE ME in person, for a formal consultation, a full history and physical examination, and my surgical opinon about whether they are even a candidate for the procedure they believe they are seeking. 

Any initial questions about procedure cost and scheduling can be answered by my Patient Coordinator, whom contactees are also encouraged to call.

When I meet these patients in person, often the procedure they were seeking (for example, liposuction of the abdomen) may not in fact the appropriate procedure to achieve their aesthetic goals (an abdominoplasty, or tummy tuck may be indicated if they have rectus diastasis - separation of the rectus abdominis mucles in the midline from pregnancies).  Only an in-person evaluation can allow me to make this determination.

Some patients seeking Microsurgical breast reconstruction such as the DIEP/SIEA or TUG flap travel far and wide for surgery, and come from another state or even country for their surgery.  My Coordinator in these cases will often ask patients to send confidential photographs of their torso so that I can get a general idea of whether they are even a candidate for a free flap.  From here, we would consider asking them to make a trip to see me in the office for further evaluation. 

However, patients are still instructed that they will need to fly into San Francisco for a formal consultation and the standard 45-90 minute visit with me and the remainder of the office staff to fully learn about the procedure, its risks and benefits, potential complications and expected outcomes of surgery.  They would then plan their procedure and return for surgery in the future.

I feel that giving advice over the phone, over the internet, or via just looking at photographs is not only risky for the doctor or patient, but can provide a false diagnosis or sense of security. 

Medicolegally, potential Plastic Surgery patients seen to be seen and examined, in person, for proper documentation and examination, careful planning for surgery, and the best possible results.  

How is bra cup size determined???

With all the press lately on Heidi Montag's current new breasts ('DDD', or 'F'), and her apparent desired increase ("an 'H', for Heidi!" - her words), it was brought to my attention that most people don't know how bra cup size for a woman's breasts is determined!

Many women (and men) don't quite understand the difference between the number (34, 36, 38, etc.) and the letter cup size ('A', 'B', 'C', 'D', etc.)!  Eight in ten women also do not wear the correct bra size. 

The following will explain how how bra and cup size is calculated: 

Measuring Bra Size  

1.  Bra Size (the NUMBER, or the "band" size)
Measure around your body under your breasts at the level of the breast fold, in inches (in the U.S.). Other countries use centimeters (cm) - see the charts below.

2.  Cup Size (The LETTER, or the "bust" size)
Measure around the fullest part of your breasts, also in inches.

This is the tricky part, and the reason why you may fit several different bra cup sizes, depending on the amount of lift that the bra provides. Many women develop droop to their breasts, and may be a 'B' without any push-up, a 'C' with a little underwire, or even a 'D' with some major lift by a bra. See below and try on different styles and types of bras to understand this better!

Bra Size Charts

Based on the difference in inches between your band and your bust circumference, you can calculate your bra cup size in letters:

Keep in mind that as like dress sizes and designer clothes, many stores may fit women's breasts differently. For instance, based on my patients' comments alone, Victoria's Secret often fits women as a 'C', whereas Nordstrom bras often fit the same women as a 'D'!

Custom bras or specialty stores can cost a bundle!  However, investing in a good bra can sometimes help to avoid Plastic Surgery, if a simple "lift" in clothes is what you are looking for!



However, if you desire the effect of a push-up bra or additional padding, a breast augmentation may be an option for you.  Be sure to visit a Board-Certified Plastic Surgeon with extensive experience in breast evaluation and breast surgery to learn more!

TUG (Inner Thigh) Flap Microsurgical Breast Reconstruction

 The following is an excerpt from a chapter I recently authored for an upcoming textbook.  It is written in medical lingo.  A version that uses more regular language more suitable for the general public will soon be posted on the Women's Plastic Surgery website.  All surgical photographs have been removed, as they may be upsetting to some readers; only diagrams are shown for educational purposes.  Read on to learn more about the TUG (inner thigh flap)!:

Introduction to the TUG Flap

            The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous (TUG) flap blood supply provides an autologous donor area with several qualities complimentary to microvascular breast reconstruction.  The gracilis flap is an exciting alternative to abdominal, back or buttock tissue flaps for reconstruction of a natural looking and soft, shapely breast. 

            The gracilis muscle has a consistent and reliable blood supply, and has been well described (1, 2).  The transverse upper gracilis flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection to the breast reconstruction.  The characteristics and skin color of the TUG flap allow for immediate nipple-areola reconstruction in both immediate reconstruction following skin-sparing mastectomy and in delayed breast reconstruction alike.  TUG flap microvascular breast reconstruction is an excellent option for patients who desire autologous reconstruction and who do not have adequate abdominal donor tissue or who do not desire abdominal scars.

History

            Use of the transverse upper gracilis (TUG) myocutaneous flap for breast reconstruction was first described as a single breast reconstructive case in 1992 (3).  The cutaneous territory of the gracilis myocutaneous flap was demonstrated by anatomic and injection studies to lie perpendicular to the muscle in its proximal third, transverse and parallel to the medial groin crease.  Based on the direction of exit of cutaneous perforators in the superomedial thigh region, the transverse cutaneous skin paddle of the gracilis muscle has since been accepted as dominant, much like the lower transverse paddle of the rectus abdominis muscle (3).  Perforators extending through the gracilis muscle vascularize the area reaching from over the adductor magnus and sartorius muscle anteriorly to the midline of the thigh posteriorly (4).  

            Although the vertical paddle of the gracilis has been used for breast reconstruction (5), it is accepted as much less reliable (6), and has a more visible vertical scar.  We now offer inner thigh free flap reconstruction using the transverse skin paddle to patients without adequate abdominal donor tissue and to those patients that do not wish to have postoperative scars associated with abdominal tissue harvest. 

            The transverse upper gracilis flap technique is relatively straightforward, reliable and can be aesthetically superior to abdominal reconstruction in two significant ways:  1) it has the advantage of allowing for immediate nipple-areolar reconstruction, negating the need for secondary surgery and 2) coning of the flap into a projecting breast shape is simpler than for abdominal flaps.  By using a semi-lunar construction of the skin paddle, this flap provides excellent dimensions, good projection and can be contoured for immediate nipple areola reconstruction.  The aesthetics of this type of reconstruction can be excellent.

           

Transverse Upper Gracilis Flap Design

            The TUG flap is designed with a semi-lunar skin paddle transverse to the longitudinal axis of the gracilis muscle in the inner thigh (Figure 1)  The superior aspect of the flap is marked approximately one centimeter below the groin crease anteriorly and centrally, but extends well into the gluteal crease at the most posterior aspect.  Placement of the incision slightly below the crease avoids distortion of the labia majora with related symptoms, as can occur in medial thigh lift (7). 

            The anteroposterior length of the flap extends up to 28 centimeters.  The width of the flap is judged by pinching the inner thigh tissue with the thighs in adduction, using the maximum width that can be easily closed without tension.  The flap has been designed it as wide as 11 centimeters at the central axis over the gracilis muscle (Figure 6).  A pencil Doppler probe is used to confirm the location of perforating vessel(s) over the gracilis muscle and into the skin paddle (Figure 7). 

            The procedure is performed with the patient in the supine position, with the thigh abducted and the knee flexed.  The flap is harvested with the patient in well padded OB-GYN operative stirrups, which facilitates dissection and closure of the posterior aspect of the wound. 

            The anterior thigh incisions are made first.  The posterior branch of the saphenous vein is harvested with the flap (Figure 2), and any anterior venous branches are left in situ although they can be included in the skin paddle if needed.  Lymph nodes are avoided and are left in situ to avoid the risk of lower extremity lymphedema.

            Anterior flap dissection proceeds superficial to the muscular fascia until the medial/posterior edge of the adductor longus is encountered (Figure 3).  Beveling of subcutaneous adipose tissue is used to maximize the bulk taken with the flap.  The deep fascia is incised longitudinally and the space between the adductor longus and gracilis muscle is separated and the vascular pedicle to the gracilis is identified.  Pedicle dissection proceeds proximally to the origin from the superficial femoral artery.  Posterior dissection then continues superficial to the muscular fascia, entering the deep fascia at the posterior aspect of the gracilis.  Pedicle length ranges from 6 to 8 cm.

            The gracilis muscle is transected superiorly and inferiorly, commonly taking only a portion of muscle lying directly beneath the flap (Figure 4).  Additional inferior muscle length may be optionally included for enhanced flap volume.  Usual flap elevation time is approximately 45 minutes or less.

            Following pedicle division, absorbable sutures are used to maintain flap coning and achieve projection (Figures 5 and 8).  The gracilis muscle may additionally be used to increase projection by securing it posteriorly behind the adipose tissue, with predictable postoperative muscle atrophy.  In immediate reconstructions, the mastectomy specimen is weighed and measured for comparison with the TUG flap, typically an appropriate match in terms of volume and dimensions.  Flap projection has often been greater than the native mastectomy specimen (Figure 9).

            The flap is deepithelialized except for an areolar circle in immediate reconstructions (Figure 9d and Figure 10), and completely deepithelialized in nipple-sparing mastectomy.  An areolar circle is created and accentuated by a circumareolar incision for delayed reconstructions, deepithelializing and burying of the superior flap beneath the native mastectomy skin (Figure 11).

            Microvascular anastomosis is usually to the internal mammary system beneath the third or fourth costal cartilage.  Following coning, the pedicle enters the undersurface at the center of the flap, enabling inset of the flap in any orientation desired (Figure 12).  Postoperative flap assessment includes clinical and external pencil Doppler monitoring if the flap is exposed, in addition to continuous implantable venous Doppler probe monitoring.

            The inner thigh donor area is closed with interrupted sutures in the deep fascia (7), interrupted deep dermal and continuous subcuticular skin sutures over a suction drain exiting from the superior aspect of the thigh wound.

            Immediate nipple-areolar reconstruction is performed by folding the semilunar flap and accentuating the apex of the resultant standing cone as the area of maximum projection using interrupted horizontal mattress sutures (Figure 10).  Care is taken not to create excessive suture tension to avoid circulatory compromise to the nipple reconstruction.  An areola circle is drawn, and skin surrounding this circle is deepithelialized and buried beneath the mastectomy flaps prior to microvascular anastomosis.  The naturally darker pigment of inner thigh defines the areolar reconstruction. 

            Patients are placed on post-operative aspirin as an anticoagulant for one month and allowed to ambulate at two to three days postoperatively.  Hospital stay averages five to seven days.

Discussion

            Autologous abdominal soft tissue reconstruction after mastectomy, although becoming more common, comprised less than a quarter of breast reconstructions performed in the United States in 2008 (8).  The deep inferior epigastric perforator (DIEP) free flap was performed in only 7.5% of reconstructions in that year. 

            The reason for the relative scarcity of soft tissue reconstructions relative to implant reconstructions is not clear; however the complexity of microsurgical reconstruction and the technical difficulty of perforator flap harvest may contribute to the lack of widespread acceptance.  Many patients do not need or desire abdominoplasty at the same time as having a breast reconstruction.  As such, the potential aesthetic perk (9) of abdominal perforator flap harvest may be considered a drawback.  In addition, abdominal flap scars are not insignificant, including the umbilical scar which is visible in currently fashionable low-cut jeans and swim suit bottoms.

            Advantages of gracilis muscle as a microvascular transplant include low donor-site morbidity, a concealed donor scar, constant anatomy with large-diameter vessels, and the potential for a neurosensory flap as well as a large skin paddle.  Anatomic studies (3, 6) have revealed the angiosome of the upper gracilis muscle to lie at right angles to the muscle, in a transverse direction.  As such, the generous size of the transverse skin island that can be harvested with the gracilis allows for shaping of the flap in a circular and cone-like fashion, more closely mimicking natural breast anatomy than the relatively flat projection of abdominal flaps (10).  The inner thigh flap also avoids the relatively visible scar on the lower abdomen together with a numb area below the umbilicus, sequelae of abdominal perforator flaps (11).  The quality of inner thigh tissue is soft and similar to abdominal flaps and breast tissue, unlike the firm, fibrous and stiffer texture of buttock flaps.  Some patients' body habitus clearly favors the inner thigh flap over abdominal flaps, based on their natural depostion of adipose tissue (Figure 13). 

            The conical apex at the central portion of the folded inner thigh flap constructs nipple projection using subdermal fixation sutures at the time of reconstruction.  The resulting nipple areola in our opinion can be aesthetically superior to those reconstructed with local flaps or skin grafts.  Inner thigh skin naturally has slightly darker pigmentation than the skin of the chest or torso, and when contracted and allowed to pucker slightly it can appear even darker.  This color difference with breast skin allows for a natural areolar reconstruction that can be later augmented using medical tattooing if desired (Figures 14 and 15). 

            Early reports of the TUG flap described coverage of defects in the head and neck, lower extremity and thoracic region (12).  Schoeller (13) described a ‘medial thigh lift free flap’ for bilateral autologous breast augmentation after bariatric surgery.  Arnez (14) reported 7 immediate TUG flap breast reconstructions, for ‘small’ or ‘moderate’-sized breasts with sufficient medial thigh tissue, who declined scars in other donor sites.  Wechselberger and Schoeller (15) performed 12 TUG flaps in 10 patients for immediate breast reconstruction.  Fansa (16) reported 32 flaps and Scheoller (11) published a large series of 154 flaps for breast reconstruction in immediate and delayed settings for breast reconstruction, without immediate nipple-areolar reconstruction.  For bilateral reconstructions, the transverse gracilis flap has been suggested to surpass the DIEP flap because of a better concealed donor scar and easier harvest (11).  We have also recently submitted our early data for publication (12). 

Inner Thigh Flap Donor Site          

            Although other autologous tissue reconstruction options are available to patients with previous abdominal tissue harvest or in very thin patients (18), in many of these patients, the inner thigh flap can be used.  Unlike loss of the rectus abdominis muscle, loss of the gracilis muscle is not associated with the risk of abdominal hernias, bulging or functional donor site complications.  The greatest drawback of the inner thigh flap is the inner thigh scar; yet its location near the groin crease is readily concealable in all clothing except swim suits or underwear (19) (Figure 16).

            Tissue expanders and breast implants, latissimus muscle flaps with implants, the inferior gluteal artery free flap, and superior gluteal artery free flap have all been well described as alternatives to abdominal flaps, and the inner thigh flap presents an additional option to these choices.  It is inherent that all autologous soft tissue reconstructions require creation of a donor site and donor area scarring, to some degree.  Certainly, wound complications at the inner thigh donor site necessitating dressing changes are an annoyance for patients as are seromas, and although frequent, this complication is relatively minor.  Patients receive preoperative counseling and full informed consent about this possibility.  In all cases, our patients have been quite satisfied with the final results of their TUG flap reconstructions. 

Gracilis Perforator Flaps

            The inner thigh skin can be harvested as a perforator flap based on the vascular pedicle to the gracilis muscle (19-22).  However, donor site hernia and functional loss are not accepted complications of gracilis muscle flap harvest and are not compelling indications to spare the gracilis muscle.  Despite reports of successful transfer of gracilis perforator flaps, inclusion of the gracilis muscle in the TUG flap has been suggested to potentially provide more tissue volume, to increase safety of monitoring the skin paddle, and to allow rapid harvest with minimal functional donor site morbidity (15).  Anatomic studies of the proximal cutaneous perforator vessels of the gracilis muscle (23) suggest that it is safer to include the gracilis muscle for transfer of tissue in the TUG flap distribution. 

            Gracilis perforator flaps are smaller than the dimensions available for TUG flaps, unless an extended dissection including some gracilis muscle is performed (22).  These authors do not support a clear clinical advantage of preserving the gracilis muscle.  The clinical indication and advantage of the perforator flap is therefore a thin and pliable flap (22), perhaps better suited to extremity coverage.  Although safe applicability of gracilis perforator flaps have been demonstrated, the required longer and more tedious dissection should be weighed against the rapid, easy and routine dissection of a more bulky musculocutaneous gracilis flap. 

            Gracilis perforator dissection would potentially spare loss of donor muscle in the thigh, but functional advantages are not clear, and there may be increased risk to flap circulation as well as increased operating time.  Inclusion of gracilis muscle in TUG flap is suggested to provide more tissue volume, increase safety and allow rapid flap harvest with minimal functional donor site morbidity (23).  In addition, the gracilis muscle does add some bulk to the reconstruction, an advantage in patients with minimal thigh subcutaneous fat.  Certainly, harvesting this flap as a perforator flap is an option, but one that we do not currently see as advantageous. 

             It has been recommended that the saphenous cutaneous venous system be harvested with the perforator flap to enhance venous drainage (19), but we have only required the saphenous system for venous outflow in one patient that had poor internal mammary drainage.  This outflow may have been helpful in our other patient that developed some delayed venous insufficiency.  Nevertheless, saphenectomy can be a cause of morbidity (24) while the need for secondary venous drainage in this series has been rare. 

Summary

            The transverse upper gracilis flap can be used for microsurgical breast reconstruction in patients with previous abdominoplasty, inadequate abdominal tissue, or in patients that object to abdominal or buttock scars.  The inner thigh flap offers an autogenous tissue reconstructive option after mastectomy with excellent projection, the potential for immediate nipple-areolar complex reconstruction, and a favorable donor scar position and quality. 

            The TUG flap has significant advantages in addition to its pleasing final reconstructive appearance.  The gracilis muscle pedicle and harvest are extremely reliable and straightforward, and are familiar to most Microsurgeons.  No intraoperative repositioning is required as often for flaps from the buttocks or back, and a two-team approach is facilitated by dissection of the contralateral thigh during mastectomy.  Since TUG flap design allows immediate nipple areola reconstruction, the need for tattooing, local flaps or skin grafting may be obviated.  In some patients, the medial thigh lift may be considered an aesthetic perk of this procedure.  The inner thigh flap has become a favorite in our armamentarium of microvascular breast reconstruction choices. 

            Candidates for the inner thigh gracilis flap include patients desiring autologous breast reconstruction; those with sufficient superomedial thigh tissue; previous abdominoplasty or DIEP, SIEA or TRAM flap harvest; previous abdominal surgery precluding use of abdominal tissue for reconstruction; or very thin or athletic patients without sufficient abdominal or buttock donor tissue.

References (see full publication - to be posted)