In post-mastectomy breast reconstruction, different types of flaps have been described, being the gold standard the abdominal autologous tissue with microsurgical technique; but sometimes this is not the one of choice, taking into account the characteristics of the native breast shape and the proportion with the thorax, so it is described the gracilis muscle flap with cutaneous island, which by its anatomy, as well as the volume it generates, usually gives a favourable aesthetic results, especially taking into account patients with slender morphology and / or athletic. In the case we present, breast reconstruction was performed with gracilis flap and subsequent reconstruction of the per areolar area and neo formation of the nipple areola complex (CAP) with skate flap and tattooing for pigmentation, with adequate aesthetic results.
Keywords: Gracilis muscle flap; Microsurgery; Breast reconstruction
Currently the gold standard for breast reconstruction is the abdominal autologous tissue with microsurgical technique , a common challenge in the daily practice of the plastic surgeon, but in case of contraindications to use an abdominal flap or if the patient does not want surgery in this area or is not a candidate for this procedure, there is an arsenal of possibilities for reconstruction, which forces to question what is the best option and increase the arsenal of flaps. Among the options available for breast reconstruction is the transverse my cutaneous gracilis muscle flap, curiously celebrating its 30th anniversary, described by Yousif et al. In 1991, presenting multiple modifications in the last 30 years  and the possibility to transfer lymph nodes for lymphedema treatment. This is a versatile flap that historically offers us a first choice for functional reconstruction due to its single motor nerve, the anterior obturator branch (L2-L4), with a type II vascular pattern in the Mathes and Nahai classification, a dominant vascular pedicle located approximately 8 cm from its insertion on the inferior branch of the symphysis pubis, in most cases 2 minor pedicles, coming from the superficial and deep femoral, respectively, with a muscular or cutaneous muscle component, which can vary in size, making it a flap with a relatively constant anatomy, which facilitates its harvesting and dissection, decreasing surgical time and the risk of complications, compared to the abdominal autologous tissue . The transverse musculocutaneous gracilis flap is the workhorse for breast reconstruction, indicated when we are faced with a contralateral breast of smaller volume, in case of contraindications to use a deep inferior epigastric perforator flap (DIEP) or a transverse abdominal my cutaneous flap (TRAM), if we have failed flaps, we can use it as a rescue flap or simply by the same choice of the patient . In our experience we can affirm that besides offering us a very good option for breast reconstruction, due to all the advantages it has, it gives us a safe reconstructive possibility, because once the flap is made we have a result with low risk of complications; aesthetically satisfactory for the patient, and once the nipple-areola complex is reconstructed, the final result is similar to the contralateral breast.
36-year-old female with a history of smoking for more than 15 years, right breast cancer (carcinoma in situ) during pregnancy, operated for modified radical mastectomy and node resection. She was sent to our service after referral for reconstructive treatment.
At the initial physical examination she presented sequelae of right mastectomy with horizontal scar of approximately 10 cm and absence of ipsilateral mammary gland, left breast with an approximate volume of 290 cc HCAP 22 cm CAP 6 cm (Figure 1); she was scheduled for breast reconstruction with gracilis free flap; After 6 months contralateral breast symmetrisation is performed with per areolar mastopexy and neo formation of CAP (Figure 2), with skate flap technique and later, tattooing to match pigments of the CAP (Figure 3); currently the patient is satisfied with the result of the total breast reconstruction (Figure 4).\
Figure 1: Post mastectomy images, prior to reconstruction with gracilis muscle flap.
Figure 2: Surgical marking and planning of the reconstruction using the gracilis muscle flap.