This natural tissue reconstruction option uses tissue from the inner thigh to create a breast.


The most common type of natural-tissue breast reconstruction involves lower abdominal tissue. However, abdominal flaps are not suitable for people who do not have enough tissue in that area or those who have had prior abdominal surgery. Thigh flaps provide a natural tissue reconstruction option for those patients.

The TUG (transverse upper gracilis) flap or PAP (profunda artery perforator) flap allows surgeons to use tissue from a patient’s inner thighs to create a breast shape. The soft fatty tissue of the inner thigh is transplanted to the chest. Using an operating microscope, the blood supply to the flap is attached to vessels on the chest wall. The tissue is then used to create a natural-looking breast shape.

Once the TUG or PAP flap has been transferred, the incisions on the inner thigh are closed with an effect similar to that of a thigh lift.

Types of TUG/PAP Flap Procedures

TUG Flap

This flap includes a portion of the gracilis to carry the blood supply of the upper inner thigh tissue.

TUG Flap
Ⓒ Image credit
Immediate TUG flap (includes gracilis muscle with the flap – in red) after nipple-sparing mastectomy – incision can frequently be hidden along the lower breast.

PAP Flap

This flap transfers upper inner thigh tissue without removing the gracilis muscle. It is only possible if large enough perforator blood vessels are available.

pap flap
Ⓒ Image credit
Immediate PAP flap after nipple-sparing mastectomy – incision can frequently be hidden along the lower breast.

Stacked TUG/PAP Flap

In unusual cases, a TUG or PAP flap is used in conjunction with another flap to reconstruct a fuller breast. These flaps are most commonly combined with DIEP flaps.

Surgeons determine which type of flap is possible either via CT angiogram or during the procedure itself. The incisions and initial operating procedures for both flaps are the same.

Procedure details:

  • Skin and fat are removed from the inner thigh as a flap.
  • The flap is transferred to the chest. Surgeons connect blood vessels from the flap to blood vessels in the chest using microsurgery techniques.
  • The transplanted tissue is used to create a breast shape.
  • Thigh incisions are closed using techniques similar to a thigh lift.

Risks & Benefits

These flaps are microsurgical free flaps, which means that small blood vessels are connected to transplant tissue from one part of the body to another. This creates a risk of problems with flap blood supply after surgery. Should problems with blood supply arise, you may require additional surgery to complete the breast reconstruction.

When a surgeon is trained and experienced in microsurgery, this risk of issues with blood supply is very small. It is critical to choose a plastic surgeon with experience in microsurgery.

The main benefit of a thigh flap is that it creates a warm, soft breast reconstruction from living tissue. It also avoids the need for a breast implant, and it improves the shape of the thighs in some patients.