Preoperative volume estimation in transverse upper gracilis flap surgery: A pilot study

Published:April 19, 2021DOI:



      The transverse upper gracilis (TUG) flap provides a good alternative to the gold standard DIEP in breast reconstruction. However, flap volume estimates are subjective, making preoperative planning potentially challenging.

      Study aim

      To derive a reliable, accurate, and reproducible mathematical algorithm for the preoperative calculation of TUG flap volumes.

      Materials and Methods

      Nineteen consecutive patients with 30 TUG flaps were prospectively included. On the assumption that the TUG flap resembles two isosceles prisms, the formula of the volume of a prism was used to calculate their preoperative flap weights. These were then intraoperatively compared to the actual flap weights. A regression equation was calculated from the correlation analysis of 10 random flaps. This was then applied to the remaining 20 flaps to assess for improved reliability and weight prediction accuracy.


      The prism volume equation used to clinically calculate flap volumes was: Geometric flap weight = (h1bT)/2+ (h2bT)/2, (h = height, b = base, T = flap thickness); all in centimetres. Geometric and actual flap weights were found to be significantly correlated (r2 = 0.977) generating the following regression formula: predicted TUG weight = 0.924 × geometric weight + 26.601. When this was applied to the remaining 20 flaps, no significant difference was found (p = 0.625) between predicted and actual flap weights, demonstrating an increased accuracy of predicting flap volume.


      The proposed formula provides the clinician with a more accurate and reliable estimation of available TUG flap volume and may potentially aid with preoperative planning and patient consultations.


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        • Shay P.
        • Jacobs J.
        Autologous reconstruction following nipple sparing mastectomy: a comprehensive review of the current literature.
        Gland Surg. 2018; 7: 316-324
        • Buchel E.W.
        • Dalke K.R.
        • Hayakawa T.E.
        The transverse upper gracilis flap: efficiencies and design tips.
        Can J Plast Surg. 2013; 21: 162-166
        • Arnez Z.M.
        • Pogorelec D.
        • Paninšek F.
        • Ahčan U.
        Breast reconstruction by the free transverse gracilis (TUG) flap.
        J Plast Reconstr Aesthet Surg. 2004; 57: 20-26
        • Nickl S.
        • Nedomansky J.
        • Radtke C.
        • Haslik W.
        • Schroegendorfer K.F.
        Optimization of breast reconstruction results using TMG flap in 30 cases: evaluation of several refinements addressing flap design, shaping techniques, and reduction of donor site morbidity.
        Microsurgery. 2018; 38: 489-497
        • Locke M.B.
        • Zhong T.
        • Mureau M.A.M.
        • Hofer S.O.P.
        Tug ‘O’ war: challenges of transverse upper gracilis (TUG) myocutaneous free flap breast reconstruction.
        J Plast Reconstr Aesthet Surg. 2012; 65: 1041-1050
        • Seth A.K.
        • Allen Jr, R.J.
        Modern techniques and alternative flaps in microsurgical breast reconstruction.
        J Surg Oncol. 2018; 118: 768-779
        • Russe E.
        • Kholosy H.
        • Weitgasser L.
        • et al.
        Autologous fat grafting for enhancement of breast reconstruction with a transverse myocutaneousgracilis flap: a cohort study.
        J Plast Reconstr Aesthet Surg. 2018; 71: 1557-1562
        • Nanidis T.G.
        • Ridha H.
        • Jallali N.
        The use of computed tomography for the estimation of DIEP flap weights in breast reconstruction: a simple mathematical formula.
        J Plast Reconstr Aesthet Surg. 2014; 67: 1352-1356
        • Mohanna P.N.
        • Farhadi J.
        A method of preoperatively assessing the volume of abdominal tissue available for an autologous breast reconstruction.
        Plast Reconstr Surg. 2012; 129: 756e-757e
        • Razzano S.
        • Taylor R.
        • Schonauer F.
        • Figus A.
        How to assess the volume of a DIEP flap using a free online calculator: the DIEP V (volume) method.
        J Plast Reconstr Aesthet Surg. 2018; 71: 1410-1416
        • World Medical Association
        World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.
        JAMA. Nov 27 2013; 310: 2191-2194
        • Kwok A.C.
        • Simpson A.M.
        • Ye X.
        • Tatro E.
        • Agarwal J.P.
        Immediate unilateral breast reconstruction using abdominally based flaps: analysis of 3,310 cases.
        J Reconstr Microsurg. 2019; 35: 074-082
        • Patel N.G.
        • Ramakrishnan V.
        Microsurgical tissue transfer in breast reconstruction.
        Clin Plast Surg. 2017; 44: 345-359
        • Nahabedian M.Y.
        • Patel K.
        Autologous flap breast reconstruction: surgical algorithm and patient selection.
        J Surg Oncol. 2016; 113: 865-874
        • Hunter C.
        • Moody L.
        • Luan A.
        • Nazerali R.
        • Lee G.K.
        Superior gluteal artery perforator flap: the beauty of the buttock.
        Ann Plast Surg. 2016; 76: S191-S195
        • Fade G.
        • Gobel F.
        • Pele E.
        • et al.
        Anatomical basis of the lateral superior gluteal artery perforator (LSGAP) flap and role in bilateral breast reconstruction.
        J Plast Reconstr Aesthet Surg. 2013; 66: 756-762
        • Opsomer D.
        • Stillaert F.
        • Blondeel P.
        • Van Landuyt K.
        The lumbar artery perforator flap in autologous breast reconstruction: initial experience with 100 cases.
        Plast Reconstr Surg. 2018; 142: 1e-8e
        • Doval A.F.
        • Lamelas A.M.
        • Daly L.T.
        • et al.
        Deep inferior epigastric artery perforator flap breast reconstruction in women with previous abdominal incisions: a comparison of complication rates.
        Ann Plast Surg. 2018; 81: 560-564
        • Healy C.
        • Allen R.J.
        The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap.
        J Reconstr Microsurg. 2014; 30: 121-126
        • Zoccali G.
        • Rais D.S.
        • Farhadi J.
        How does autologous breast reconstruction impact downtime?.
        J Reconstr Microsurg. 2018; 34: 530-536
        • Elder E.
        • Brandberg Y.
        • Bjorklund T.
        • et al.
        Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study.
        Breast. 2004; 14 (10.008): 201-208
        • Bostwick III, J.
        Available tissue reconstruction.
        Plastic and reconstructive breast surgery. 1990; vol II: 593