Breast Reconstruction Pathways

The Transverse Upper Gracilis (TUG) flap is a type of natural tissue breast reconstruction that uses skin, fat, and a small portion of muscle from the upper inner thigh to rebuild the breast.

Unlike the PAP flap (which takes only skin and fat from the same area), the TUG flap includes the gracilis muscle, a thin muscle from the inner thigh that is not essential for leg strength. This technique can provide slightly more tissue and shape than the PAP flap while still preserving most thigh function.

How It Works

• A flap of skin, fat, blood vessels, and a small segment of gracilis muscle is taken from the upper inner thigh.

• The flap is carefully shaped into a new breast mound.

• Using microsurgery, the blood vessels from the flap are reconnected to vessels in the chest.

• The donor site is closed, leaving a scar along the crease of the inner thigh, where it can be hidden by underwear or swimwear.

Who May Be a Candidate

The TUG flap may be a good choice if:

• You prefer natural tissue reconstruction instead of implants.

• You do not have enough abdominal tissue for DIEP or TRAM flap reconstruction.

• You’ve had prior abdominal surgery that rules out abdominal flaps.

• You have sufficient tissue in your upper inner thighs.

• You are comfortable with including a small portion of muscle in the reconstruction.

Benefits of the TUG Flap

• Natural look and feel: Uses your own tissue for soft, warm, lasting results.

• Good option for smaller breasts: Can create beautiful results when less tissue is needed.

• Hidden scar: Scar is placed along the inner thigh crease.

• Adds volume compared to PAP: Muscle inclusion can help with projection and shaping.

• Alternative donor site: Provides another option when abdominal or buttock flaps aren’t possible.

Things to Keep in Mind

• Muscle sacrifice: Unlike the PAP flap, a small thigh muscle is taken. Most women do not notice long-term weakness, but there may be subtle changes.

• Volume limitations: May not provide enough tissue for larger breast sizes without additional fat grafting.

• Recovery: Healing takes 4–6 weeks, with early soreness in the chest and inner thighs.

• Scarring: Leaves a scar along the upper inner thigh, which may be tender at first but typically fades with time.

• Specialized surgery: Requires microsurgical expertise and longer surgery time.

Emotional Considerations

Some women feel reassured knowing that the gracilis muscle is not essential and that this flap can provide reliable tissue for reconstruction. Others may feel uneasy about losing any muscle, even if the functional impact is small. Both responses are completely valid. Talking openly with your surgeon about activity level, lifestyle, and long-term goals can help guide the decision.

A Personal Choice

The TUG flap uses tissue and a small, nonessential muscle from the inner thigh to create a natural, lasting breast reconstruction. It is a valuable option for women who want natural tissue reconstruction but cannot use the abdomen or prefer an alternative donor site. While it involves taking a small muscle, it can provide beautiful results with a discreet scar and lasting durability.