What is the LUG flap and how does it differ from the TUG?

The L-shaped Upper Gracilis (LUG) flap is a technique pioneered and published by Mr Blackburn. Both the TUG and LUG scars begin just below the groin crease. The TUG scar then continues transversely into the buttock crease — the area patients sit on. The LUG scar instead turns vertically downward along the inner thigh, staying just behind the midline. It does not enter the buttock crease and is not visible from the front. When sitting in a bathing suit with knees together, the vertical component is difficult to see. This means patients do not sit on it, significantly easing recovery. The LUG also provides more tissue volume for a larger breast mound, causes less numbness in the upper thigh, and produces a better thigh contour — reducing thigh rubbing and improving the thigh gap. Mr Blackburn will discuss which technique best suits each patient at consultation.

What is the recovery from TUG / LUG reconstruction?

Recovery typically involves a hospital stay of one to two days followed by gradual return to normal activity. Most patients return to desk-based work within six to eight weeks and to full activity within three to four months. There are two areas of recovery to consider: the chest (where the breast is reconstructed) and the inner thigh (the donor site). Mr Blackburn will provide detailed recovery guidance tailored to the specific procedure performed.

Where is the donor scar placed, and is the LUG scar visible?

Both scars begin just below the groin crease. The TUG scar then continues transversely into the buttock crease — which is the area you sit on, making recovery uncomfortable. The LUG scar instead turns vertically downward along the inner thigh, staying just behind the midline, and does not enter the buttock crease. This means patients do not sit on the scar. The vertical component is not visible from the front and, when sitting with knees together in a bathing suit, is difficult to see. The LUG scar is longer overall than the TUG scar, but its position is generally considered better tolerated during recovery.

TUG & LUG Flap Breast Reconstruction | Mr Adam Blackburn FRCS (Plast)

Name: TUG and LUG Flap Breast Reconstruction
Creator: Mr Adam Blackburn FRCS (Plast)

About the Procedure

TUG & LUG Flap Reconstruction

The Transverse Upper Gracilis (TUG) and L-shaped Upper Gracilis (LUG) flaps are microsurgical techniques for breast reconstruction that use skin, fat and a small amount of the gracilis muscle from the inner thigh. Like all free flap procedures, the tissue is completely detached from its donor site and reattached to the chest using microsurgical anastomosis of the blood vessels under a microscope.

These techniques are used primarily for patients who are not suitable for DIEP flap reconstruction — for example, those with insufficient abdominal tissue or fat, significant previous abdominal surgery, or who prefer an alternative donor site. They are also an option for patients with smaller breast size, where the volume available from the inner thigh is sufficient for a good reconstructive result.

The LUG Flap: Pioneered by Mr Blackburn

The standard TUG flap uses a transverse skin ellipse from the upper inner thigh. Mr Blackburn developed and published the L-shaped Upper Gracilis (LUG) flap modification, which uses an L-shaped skin design. This provides several advantages over the standard TUG:

Both the TUG and LUG scars begin just below the groin crease. From that point the designs diverge: the TUG scar continues transversely into the buttock crease — the area a patient sits on — which is why TUG recovery can be uncomfortable. The LUG scar instead turns vertically downward along the inner thigh. The vertical limb runs just behind the midline of the thigh, so it is not visible from the front and is difficult to see when sitting with knees together in a bathing suit. Critically, it does not extend into the buttock crease, so patients do not sit on it.

Beyond scar placement, the L-shaped design harvests a greater volume of tissue, allowing reconstruction of a larger and better-shaped breast mound. It also causes less numbness in the upper inner thigh — a notable limitation of the standard TUG — and produces a better overall thigh contour, reducing thigh rubbing and creating a more natural thigh gap. The LUG scar is longer overall than the TUG scar, and Mr Blackburn discusses the full picture with each patient at consultation to determine the most appropriate technique.

Mr Blackburn has published his results in the peer-reviewed literature and is one of very few surgeons in the UK with extensive operative experience in both the TUG and LUG techniques. He will discuss which design is most appropriate for each individual patient at consultation.

📄 Read the published paper on the LUG flap technique →

The Procedure

TUG and LUG flap reconstruction is performed under general anaesthesia with two consultant surgeons operating simultaneously — one team harvesting the flap from the inner thigh while the other prepares the recipient vessels in the chest. This two-team approach, established by Mr Blackburn, reduces operative time and is associated with excellent outcomes in his published audit.

The procedure typically takes 5–7 hours. After surgery, patients are nursed in a high-dependency or specialist ward where the blood supply to the flap is monitored closely overnight. Hospital stay is usually one to two days.

Recovery

Recovery from TUG and LUG flap reconstruction involves two areas: the chest, where the breast is reconstructed, and the inner thigh donor site. Most patients return to light activity within a few weeks and to desk-based work within six to eight weeks. Full recovery, including return to exercise, is typically achieved at three to four months.

Mr Blackburn's team provide detailed written aftercare guidance and close follow-up throughout recovery. Reconstruction is typically a staged process: the flap procedure creates the breast mound, followed later by symmetrising surgery (if required) and nipple reconstruction.

Inner thigh donor site — suitable when abdominal tissue is unavailable
LUG flap pioneered by Mr Blackburn: greater volume, easier recovery, less numbness, better thigh contour
Two-consultant operating approach for safety and efficiency
100% free flap success rate across Mr Blackburn's career
Published results in peer-reviewed literature
McIndoe Centre East Grinstead & Benenden Hospital

LUG Flap Photos TUG Flap Photos

TUG / LUG Flap — At a Glance

Tissue sourceInner thigh

AnaestheticGeneral

Duration5–7 hours

Hospital stay1–2 days

Return to work6–8 weeks

Full recovery3–4 months

Book a Consultation

Self-referrals welcome.
NHS and insured patients also seen.

Common Questions

Frequently Asked Questions

What is the TUG / LUG flap?

The Transverse Upper Gracilis (TUG) and L-shaped Upper Gracilis (LUG) flaps are microsurgical techniques for breast reconstruction that use skin, fat and a small amount of muscle from the inner thigh to create a new breast mound. They are used primarily when patients are not suitable for DIEP flap reconstruction — for example, those with insufficient abdominal tissue, previous abdominal surgery, or who prefer a different donor site.

What is the LUG flap, and how is it different from the TUG?

The L-shaped Upper Gracilis (LUG) flap is a technique pioneered and published by Mr Blackburn. Both scars start just below the groin crease. The TUG scar then continues transversely into the buttock crease — the area you sit on. The LUG scar instead turns vertically downward along the inner thigh, just behind the midline, and does not enter the buttock crease. It is not visible from the front and, when sitting with knees together in a bathing suit, is difficult to see. Because patients do not sit on it, recovery is significantly easier. The LUG also provides more tissue volume for a larger breast mound, causes less numbness in the upper thigh, and improves thigh contour — reducing thigh rubbing and creating a better thigh gap. Mr Blackburn is one of very few surgeons in the UK with extensive published experience in both techniques.

Who is a good candidate for TUG / LUG reconstruction?

TUG and LUG flap reconstruction is most suitable for patients who are not candidates for DIEP flap reconstruction — due to insufficient abdominal tissue, previous abdominal surgery, or personal preference. Patients with a smaller to medium breast size tend to achieve the best results, as the volume of tissue available from the inner thigh is smaller than from the abdomen. Mr Blackburn will assess each patient's anatomy and goals carefully at consultation and will recommend the most appropriate technique.

What is the recovery like?

Recovery involves two areas: the chest (where the breast is reconstructed) and the inner thigh (the donor site). Hospital stay is typically one to two days. Most patients return to light activity within a few weeks and to desk-based work within six to eight weeks. Full recovery, including return to all exercise, is typically achieved at three to four months. Mr Blackburn's team provide detailed written aftercare guidance and close follow-up throughout recovery.

Where is the donor scar placed?

Both scars begin just below the groin crease. The TUG scar then runs transversely into the buttock crease — the area you sit on, which is why TUG recovery can be uncomfortable. The LUG scar instead turns vertically downward along the inner thigh. This vertical limb sits just behind the midline of the thigh, making it not visible from the front and difficult to see when sitting with knees together in a bathing suit. Because it does not extend into the buttock crease, patients do not sit on the LUG scar. The LUG scar is longer overall than the TUG scar, and Mr Blackburn discusses scar placement and all the relevant trade-offs at consultation.

Where is TUG / LUG reconstruction performed?

Mr Blackburn performs TUG and LUG flap reconstruction at the McIndoe Centre, Queen Victoria Hospital, East Grinstead, West Sussex and at Benenden Hospital, Cranbrook, Kent. Consultation appointments are available at New Victoria Hospital Kingston, Mount Alvernia Hospital Guildford, McIndoe Centre East Grinstead, and Benenden Hospital.

TUG & LUG FlapBreast Reconstruction