TUG Breast Reconstruction

The TUG gives a permanent, warm, soft and shapely breast reconstruction with a good cosmetic result however the volume is limited and you may require additional procedures to achieve a desired volume.

Transverse Upper Gracilis (TUG) flap

The Transverse Upper Gracilis (TUG) flap is the transfer of autologous (own tissue) muscle, fat and skin to create a breast mound. Part of the gracilis muscle with overlying crescent-shaped flap of skin and fat are isolated on a blood vessel and detached in the groin. The tissue which is moved is called a flap. The TUG flap has the same distribution as cosmetic thigh lift, and closure of the donor site creates a slender and attractive inner thigh donor site. The flap replaces the breast tissue with soft, warm, living tissue that in the long-term feels just like a natural breast.

The flap is re-attached to blood vessels in the chest (internal mammary) or armpit (thoracodosal) using micro-vascular surgery. The TUG can be performed at the time of mastectomy (immediate reconstruction) or a period of months or years after your mastectomy (delayed).

You have a gracilis muscle in the inner part of both upper thighs. The muscle works as part of a group of muscles that move the hip to bring the legs together. When the muscle is removed your leg movements should not be affected in the longer term as the remaining muscles strengthen and compensate. If you have any particular hobbies or sports that you participate in please inform your surgeon and they will discuss whether removal of the muscle would impact on these.

The TUG gives a permanent, warm, soft and shapely breast reconstruction with a good cosmetic result however the volume is limited and you may require additional procedures to achieve a desired volume. If appropriate additional options available to further contour or augment the TUG flap in the future will have been discussed with you prior to your operation. The TUG flap also enables immediate nipple and areola reconstruction, which is a unique advantage of this reconstructive option.

Dr Rachel Holt conducting surgery.

Immediate Breast Reconstruction

In theatre the breast surgeon removes the breast tissue, usually with the nipple and areola, through an opening around the nipple (skin sparing mastectomy). An island of skin attached to the tissue from the thigh will replace the breast skin when the operation is complete. The nipple can usually be reconstructed at the same time. After a few months the colour of the nipple can be tattooed as an outpatient procedure.

Delayed Breast Reconstruction

Delayed breast reconstruction gives a slightly different appearance as the skin is required to replace the skin that was removed during the mastectomy operation. The nipple can be reconstructed at a later date under local anaesthetic followed by a tattoo as an outpatient procedure.

Who is a Good Candidate?

The TUG flap is used for breast reconstruction in ladies with small to moderate sized breasts who would like reconstruction using their own tissue and have enough tissue on their inner thighs.

Who is not a Good Candidate?

Ladies with significant health issues or those with soft tissue disease will not be appropriate for microvascular reconstruction. In some cases the biology of your cancer makes it inappropriate to consider immediate breast reconstruction however, a delayed breast reconstruction can be discussed once you have completed treatment.

Which Flap Free will be selected for my Breast Reconstruction?

The DIEP flap is usually my first choice for Microsurgical breast reconstruction as the quality of the fat of the tummy tissue is superior to other sites. However, if abdominal tissue is unavailable due to previous abdominal flap or tummy tuck or an extremely thin tummy area, a TUG flap is an excellent alternative for breast reconstruction. Some women have little abdominal fat but significantly more inner thigh fat. In these women, the TUG flap is in fact their best reconstructive option based on their body shape and fat distribution.

What to Expect at Your Consultation

At your initial consultation I will take a full medical history including all the details of your cancer diagnosis, treatments so far and any intended additional treatments. I will also ask about lifestyle and family support. I will examine you and assess your chest wall, breast size, and tissue to assess which reconstructive options are available to you.

I spend a great deal of time with my patients at this stage to get to know you personally and identify with your expectations of reconstructive surgery. Once I have completed a comprehensive assessment I will discuss all reconstructive options with you even if you are already strongly considering TUG reconstruction.

Following our consultation you will have the opportunity to spend sometime with the breast care nurse. You will be able to discuss your proposed surgery helping you to understand and consider the options open to you, learn what the surgery entails and what support is available to you. You will be able to see photos of results of the different options available to you. Some patients, for whom the surgery is urgent, have only a short period of time in which to decide on what is the best procedure for them. Although I will explain everything to you it can be difficult to absorb all the relevant information at one visit therefore you may have more questions for your breast care nurse.

Before booking surgery you will be brought back for a second consultation giving you an opportunity to ask any additional questions and to go through the consent process in the clinic.

Before Your Operation

Following your consultation and the decision for surgery you will be seen in the pre-operative assessment clinic. A team of nurses and anaesthetists will review your medical history and assess whether there are any clinical tests that need to be carried out to check your fitness for surgery.

It will assist if you stop taking any herbal remedies, homeopathic or complementary medicine not prescribed by your GP. Some of these tablets can cause excessive bleeding during surgery. They should be stopped at least 3 weeks before surgery but can be resumed when you are discharged. You must also tell me if you are taking aspirin, warfarin or other blood thinning medication. Smoking is detrimental to this type of surgery therefore you are advised to stop smoking prior to embarking on surgery.

What to Expect During Admission

You should expect to be in hospital for 4-7 days.

On the day of surgery you will need to come into hospital starved in preparation for a General Anaesthetic. I will draw some markings on you to be used as a guide for surgery. You will also see the anaethetist who will discuss the anaesthetic and post-operative pain management plan.

Items you should bring to hospital:

  • Slippers
  • Dressing Gown
  • Nightclothes
  • Post-op bra
  • Compression Garment (see below)
  • Toiletries

Your bra will need to be supportive and without wires, ideally with a front fastening. If you need guidance this can be discussed with your breast care nurse. The bra is worn from the day of surgery, day and night for 6 weeks. This gives your reconstructed breast support.

Please do not bring in any jewellery and remove rings from the operated side because your hand is prone to swelling after the operation.

After your operation you will be closely monitored for the first 48 hours. The operation will take 4 to 8 hours depending on whether you are having one or two TUG flaps. You will probably feel drowsy until the next day so it is advisable for your next of kin to telephone the ward before visiting.

When you wake up you will have a urinary catheter, a drain in each reconstructed breast and a drain in each donor site (thigh area).

After your operation you will stay in bed for the first night. On the first day after the operation you will stand out of bed, even if it is only for a short period of time. This helps to open your airways up following the long anaesthetic. At this stage many ladies feel it is too uncomfortable to sit on the wounds at the back of the thigh therefore we encourage you to do a few short episodes of standing with a few steps at this stage.

You will have some tape dressings on the wounds and will put the bra on before getting out of bed to support the reconstruction. You will have a warming blanket (bair hugger) on for the first 24-48 hours after the operation. It is important to keep the area warm to maintain a good blood supply to the

Your thigh wound may feel tight following surgery. To improve comfort and aid healing your legs should be kept gently apart whilst in bed and slightly elevated.

The nursing staff will make regular observations including blood pressure, temperature, flap observations, drip monitoring and oxygen monitoring. The flap is closely observed during the first 48 hours to ensure that any problems with the blood flow are picked up early and dealt with in a timely fashion. If any problems with blood flow to the flap or other problems such as bleeding occur it would be necessary to return you to theatre to investigate the cause.

Please bring into hospital a pair of tight-fitting cycling shorts or Spanx type pants that fit from waist to knee. On the day following surgery the nurses will help you put on your “compression garment”. This should be worn continuously until your 6-week post-op review, only removing for showering or dressing changes.

During your hospital stay our physiotherapists will see you on several occasions. The aims of physiotherapy following breast reconstruction are to prevent you developing breathing problems such as chest infections, to help get you mobile again, to help you regain strength and movement in your shoulder and arm and to advise you on returning to your normal daily activities.

On the first post-operative day you will be helped to stand up next to your bed, you may even do a few steps. On the second post-operative day you will start walking short distances. When moving you should keep your legs hip distance apart and be careful not to have your knees to far apart. As you start moving there will be a little soreness and pulling at the wounds but do not worry they will not split. You may find it difficult to sit initially due to pressure on your donor site but you can stand and walk then return to bed until this area is comfortable which is usually day 3. You will increase this distance you walk on day 3 and aim to do stairs on day 4 before discharge the same day.

What to Expect on Discharge

You will have all your dressings changed on the day of discharge, which is usually 4-7 days after surgery. At this stage you will still not be using the arm on the operated side for any lifting or carrying and you may still feel a little weak. You should have another adult at home with you for the first week after discharge. You will be seen again in the dressings clinic one week following discharge.

Once you are at home it is important to continue to get yourself going. Build up your stamina by going for a walk everyday, increasing the distance you walk each day. It is normal to feel tired after major surgery. You may find simple tasks such as getting washed and dressed leave you feeling tired. Try to get plenty of rest and always balance periods of activity with periods of rest.

Continue to do the shoulder exercises that you have been given in hospital and at two weeks you will have additional exercises, which you will have been shown. You should continue the exercises until twelve weeks after your operation.

There are no strict rules for when you return to work, driving or sports and this will depend upon you as an individual, how you heal and the nature of your work or hobbies. The team will give you guidance in the clinic.

Two weeks after your operation you can use the arm on the affected side for light activities eg lifting a full kettle or brushing your hair. Over the next 4 weeks you can build up the use of this arm by doing light household activities such as dusting and preparing light meals. At 6 weeks after the operation you should have returned to most normal daily activities such as carrying shopping and hovering.

Return to Work

It will depend on the type of work you do. For office jobs or other non- physical work you can probably return at 6 weeks although you may find you tire easily and therefore it may be appropriate to negotiate reduced hours for the first couple of weeks. If your work is physical and involves heavy lifting you could return on light duties if possible at 8 weeks post- operatively but you should not do any heavy lifting until 12 weeks post-operatively. When you return to work you will need to gradually build up your strength so may benefit from a phased return.

Return to Driving

You should avoid driving for 4 weeks after surgery. You should not return to driving until you feel 100% alert and able to react in an emergency. You must have regained full shoulder movement before attempting to drive. You must always wear your seatbelt when in the car.

Return to Sport

Provided you have healed you can return to sports at 6 weeks but you should start with less vigorous activities and gradually build up your level of activity. You will be unfit and will need to build slowly. You should not participate in contact sports or raquet sports until 3 months after your surgery.

Listen to your body is the rule I recommend, if it feels like you are straining even after six or twelve weeks, be sure to avoid activities or movements that are creating discomfort. It takes many months for your body to fully recover after any form of surgery. Breast reconstruction is no exception. Your body will let you know when it is ready to resume your normal activities.

Scar Management

Scar tissue is vital to the healing process however scars can tighten, limit movements and become uncomfortable. Massage helps to encourage the scar tissue to form in the correct lines and make a more functional rather than restrictive scar. Massage also makes the scar less sensitive and prevents adhesions.

To massage apply a small amount of simple un-perfumed moisturizing cream to the scar. Use the thumb or index finger to massage in small circular motion along the scar. Use a firm pressure and massage several times a day. Only start the massage once the wounds are fully healed (dressings clinic will provide you with guidance on this).

Psychological Support

We know that this may be a difficult time for you. It often helps to talk to family and friends about how you are feeing. All of the team are here to offer support. If you feel that you need some additional support after discharge your breast care nurse will be your first point of contact. If it is felt necessary you will be offered referral to a psychotherapist for additional support. You are also welcome to request this if you feel in need of additional support.

Outpatient Clinics

You will be given a dressing clinic appointment one week after you go home. At this appointment a nurse will clean the wounds, re-dress them if required and organise additional appointments as required. You will be seen in the dressing clinic on a weekly basis until you are fully healed.

Consultant Clinic

I will see you 6 weeks after your operation. I will check the reconstructed breast and make sure all is going well.

If you have had an immediate reconstruction you will be seen by the Breast Surgery team 2-3 weeks after surgery to discuss your results and additional treatments that you may be offered. You may be referred to see an oncologist to discuss radiotherapy or chemotherapy.

Your breast care nurse will be able to offer advise on wound care management and general support either face-to-face or by telephone.

Potential Risks and Complications of TUG reconstruction

Like all Microsurgical breast reconstructions, the TUG flap requires a specially trained and skilled Plastic Surgeon with Microsurgical expertise with a specialist theatre team and anaethetist. In the vast majority of cases, Microsurgery is a success. There is a 1-2% risk of failure of the flap. Remember that the procedure involves reconnecting a 2 mm diameter artery and vein under the microscope and there is a small chance of a clot forming at the site of this join. If the flap circulation becomes blocked for some reason, the flap could fail and require removal. This is most likely in the first 24 – 48 hours, which is why we monitor you most closely during this period. Around 5% of patients may require return to theatre to have the vessels inspected and possible re-joined.

Potential complications include those related to having a general anaesthetic such as cardiac or respiratory compromise, blood clots in the leg (DVT) or the lung (PE).

In addition to the risk of flap loss other early complications include bleeding or haematoma that may require return to theatre, infection, delayed wound healing, seroma (a collection of tissue fluid) and post-operative pain.

You will feel swollen and bruised for the first few weeks in both the breast and the thighs, this settles down over a period of a few weeks. You will experience numbness at both sites which will recover slowly over many months but is unlikely to fully recover. The scars will be red/pink initially but should fade over time. In rare cases patients develop abnormal thickened scars, which may require additional treatment.

Occasionally some areas of the flap do not quite have enough blood supply and small areas of fat become necrotic forming a firm hard lump in the reconstructed breast. This usually settles with time but can take 1-2 years. In very rare cases fat necrosis requires excision.

It is not unusual for the whole TUG flap to feel quite firm for a number of weeks post-operatively. This usually softens over the first few months to ultimately feel like a normal soft breast.

In the long-term there may be a degree of asymmetry requiring “touch-up” surgery or contralateral symmetrizing surgery (see following section). In a few cases the may be a mild contour defect in the upper thigh which is usually amenable to liposuction to improve the contour.

Additional Procedures

The entire process of breast reconstruction may take many months and you will often require additional procedures to achieve the final result. Other procedures that may be offered to you are;

Nipple-Areolar Reconstruction & Tattoo

If you have not had nipple reconstruction as part of your first operation, it is typically offered at least 3 months after your reconstruction. It is a local anaesthetic, day-case procedure that takes around 30 minutes. It involves lifting an area of skin on the flap and suturing it to create a prominence. It does not give any colour to the nipple / areola and to achieve this you will
require a tattoo.

Nipple tattooing can be done once the scars in the area to be tattooed are mature (no longer pink). It is a simple outpatient procedure that takes around 40 minutes. A coloured semi-permanent pigment is applied using a small needle. The area is then covered with a dressing and you will be advised when to remove it. It can fade with time and may need a top-up from time to time.

Lipofilling / Autofat Injection

This involves taking fat from other areas of the body (by liposuction) and injecting it into the reconstructed breast to fill out and contours / dips in the reconstructed breast or to give additional volume. Usually 50% of the fat is absorbed so the procedure may need repeating.


Occasionally to reconstruction is too large or has fullness in one area. You may be offered liposuction to correct this.

Excess Skin (Dog Ear) Excision

Occasionally at the end of a scar excess skin can form a prominence which has the appearance of a dog’s ear. Often these settle with time but if appropriate they can be removed under local anaesthetic.

Reduction Mammaplasty

After reconstruction there may be a difference in the size of the breasts as the natural breast is larger. If this is the case it can be reduced to match the reconstructed side. This is usually a day-case procedure but you may require one night in hospital.

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