Medical Oncologist
Treatment options
SGAP, PAP and TUG flaps: options when the tummy is not suitable
When the tummy cannot be used for reconstruction, tissue from the buttock or inner thigh may rebuild the breast instead. This page explains SGAP, IGAP, PAP and TUG flaps, who they suit, where the scars sit, what recovery involves, and the honest trade-offs to discuss with your surgeon.
MM
Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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On this page
- What are SGAP, PAP and TUG flaps, and when are they used?
- The main alternative flaps
- How the alternative flaps compare
- The vocabulary, in plain language
- Honest realities about alternative flaps
- Recovery from buttock and thigh flaps
- How surgeons and patients decide
- What people assume about alternative flaps
- Common questions about SGAP, PAP and TUG flaps
The short answer
What are SGAP, PAP and TUG flaps, and when are they used?
The lower tummy is the most common source of tissue for rebuilding a breast, but it is not always suitable. Some people are very slim, have had a tummy tuck or major abdominal surgery, have already used their tummy tissue, or hope to have more children. In these situations, surgeons may take tissue from the buttock or the inner thigh instead. The SGAP flap uses skin and fat from the upper buttock, supplied by a small vessel called the superior gluteal artery perforator. A related IGAP flap uses the lower buttock. The PAP flap uses tissue from the back of the upper inner thigh, supplied by the profunda artery perforator. The TUG flap, sometimes called a TMG flap, takes tissue and a thin muscle from the upper inner thigh. All of these are free flaps, which means the tissue is fully detached with its blood vessels and joined to vessels in the chest under a microscope. They can produce a soft, natural-feeling breast. However, they are often smaller than tummy flaps, so they may suit small to medium breasts best, and sometimes tissue from both thighs or both buttocks is combined. The scars sit in the buttock crease or the upper thigh, which clothing usually covers. These operations are technically demanding and are offered mainly by teams with experience in microsurgery, so availability varies between centres.
They are alternatives to the tummy
They are used when abdominal tissue is not suitable or not wanted.
They suit smaller breasts best
The amount of tissue available is often less than from the tummy.
They need specialist teams
These flaps rely on advanced microsurgery skills.
This page gives general information only. Your surgeon can explain which flaps suit your body.The options
The main alternative flaps
Each takes tissue from a different place and leaves a different scar.
SGAP flap
Skin and fat from the upper buttock, with the muscle left in place. The scar usually sits high on the buttock, and the buttock may look slightly flatter afterwards.
IGAP flap
Tissue from the lower buttock, with the scar placed near the buttock crease so it is easier to hide.
Sitting can be uncomfortable for a while afterwards.PAP flap
Skin and fat from the back of the upper inner thigh. The scar runs along the thigh crease, and the tissue is often soft and easy to shape.
TUG or TMG flap
Skin, fat and a thin, less essential muscle from the upper inner thigh, with a scar in the groin crease.
Often considered when
- The tummy is too slim or scarred
- Small to medium breasts are planned
- Both breasts need rebuilding with modest volume
Not sure whether this applies to you?
Ask an oncologistAt a glance
How the alternative flaps compare
Question
General picture
Where is the scar?
Buttock flaps leave a buttock or crease scar; thigh flaps leave an inner thigh or groin crease scar
How much tissue?
Usually less than a tummy flap, with buttock flaps sometimes offering more than thigh flaps
Is muscle taken?
Not in SGAP, IGAP or PAP flaps; a thin thigh muscle is taken in a TUG flap
Change of position in surgery?
Buttock flaps often need you turned during the operation, which can add time
Common donor site issues
Wound opening, fluid collection, numbness and some change in contour of the buttock or thigh
Words you may hear
The vocabulary, in plain language
- SGAP
- Superior gluteal artery perforator flap, taken from the upper buttock.
- IGAP
- Inferior gluteal artery perforator flap, taken from the lower buttock.
- PAP
- Profunda artery perforator flap, taken from the back of the upper inner thigh.
- TUG or TMG
- Transverse upper gracilis flap, taken with a thin muscle from the upper inner thigh.
- Stacked flaps
- Two flaps joined together to build one breast when a single flap is too small.
- Contour change
- A change in the outline or shape of the area where the tissue was taken.
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Being straight with you
Honest realities about alternative flaps
These flaps widen the choices for people who cannot use the tummy, but they come with trade-offs.
Not every centre offers them
They are less commonly performed, and you may need to travel to a team with specific experience.
Volume can be limited
If you want a larger breast, you may need stacked flaps, fat grafting or an adjustment to the other breast.
Sitting and walking can be sore
Buttock and thigh wounds are close to places that move and bear weight, which can make early recovery uncomfortable.
What this page cannot tell you
It cannot say which flap fits your body. Your surgeon needs to examine you and often map your blood vessels.
After surgery
Recovery from buttock and thigh flaps
Recovery follows a similar path to other free flaps, with a few differences linked to where the tissue was taken.
Frequent flap checks
As with any free flap, nurses check the new breast often for the first few days to spot blood flow problems early.
Care with sitting
After a buttock flap you may be advised to limit sitting for a period, or use a cushion, to protect the wound.
Care with leg movement
After a thigh flap you may be asked to avoid wide leg movements and deep squatting while the groin or thigh wound heals. Squatting on the floor and using an Indian-style toilet may be difficult at first.
Returning to activity
Most people return to normal daily activity over around six to eight weeks, with heavier exercise later.
Making a choice
How surgeons and patients decide
The choice between buttock, thigh, back or implant options depends on several things together.
Where you carry spare tissue
Some people have more tissue on the thighs, others on the buttocks. The surgeon pinches and measures each area.
Where you prefer the scar
Some people prefer a scar hidden in a crease; others worry about thigh scars showing in certain clothes.
The breast size you want
A small breast may be built from one thigh or buttock flap; a larger one may need more.
Commonly believed
What people assume about alternative flaps
If your tummy is unsuitable, you cannot use your own tissue.
Buttock, thigh and back tissue can all be used to rebuild a breast.
A thigh flap will make it hard to walk permanently.
Walking is uncomfortable at first but usually returns to normal as the wound heals.
These flaps look very different from a tummy flap.
The breast can look and feel natural, though it may be smaller.
Every hospital offers these flaps.
They are specialist operations and are available mainly in experienced units.
Questions we are asked
Common questions about SGAP, PAP and TUG flaps
Why would my surgeon suggest a thigh or buttock flap?
Usually because the tummy is not suitable. You may be very slim, have had a tummy tuck, liposuction or major abdominal surgery, or have already used tummy tissue. Some people also prefer to keep the tummy intact because they hope to have more children.
Which is better, PAP or TUG?
Neither is better for everyone. A PAP flap keeps the muscle and places the scar further back on the thigh, while a TUG flap takes a thin muscle and sits in the groin crease. Your tissue, vessels and scar preferences guide the choice.
Will my buttock or thigh look uneven afterwards?
There may be some flattening or a change in outline where tissue was taken. When both breasts are rebuilt, tissue is often taken from both sides, which keeps things balanced. Fat grafting or minor adjustments can sometimes improve the contour later.
Can I sit normally after a buttock flap?
Sitting is usually uncomfortable for a few weeks, and some teams advise limiting it at first or using a soft cushion. Long car or train journeys may be hard early on. Ask your team for advice before planning travel home.
Are these flaps riskier than a DIEP flap?
All free flaps carry a small risk of flap loss and donor site problems. Buttock and thigh flaps can have wound issues because of their location near creases and moving areas. The experience of the team matters a great deal, so ask about theirs.
Can these flaps be used for both breasts?
Yes. Tissue from both thighs or both buttocks can rebuild both breasts. It is a long operation, and the resulting breasts are usually small to medium in size, so your expectations about volume should be discussed clearly beforehand.
Will I lose feeling in my thigh or buttock?
Some numbness near the scar is common because small skin nerves are cut. It often improves over months, though some may remain. Occasionally a nearby nerve is irritated, causing tingling down the thigh, which usually settles with time.
What if these flaps are not available near me?
You could ask for a referral to a team experienced in these flaps, consider a back flap with or without an implant, choose an implant alone, or delay reconstruction. Staying flat is also an option. Discuss what matters most with your surgeon.
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Sources
- American Cancer Society — Breast reconstruction using your own tissue
- Breast Cancer Now — Breast reconstruction
- Cancer Research UK — Breast reconstruction
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.