Autologous breast reconstruction with the profunda artery perforator (PAP) flap

Introduction

Perforator flap breast reconstruction has evolved into a reconstructive modality touting the ability to provide “natural-like” tissue for breast reconstruction with a low morbidity profile. The deep inferior epigastric perforator (DIEP) flap first described for breast reconstruction by Allen in 1992 remains the gold standard. Tissue from the abdomen is harvested based on perforator(s) from the deep inferior epigastric artery sparing the surrounding rectus abdominis muscle leaving the patient with a slimmer midline. Outcome studies have shown this flap to be aesthetically pleasing while providing limited donor site morbidity. Algorithms and techniques have evolved from an extensive background of experience and time aimed at perfecting DIEP free flap breast reconstruction.

While the application of the DIEP flap for breast reconstruction has spread with aims of further reducing complications and perfecting aesthetics, not uncommonly does a reconstructive surgeon find the abdomen to be either insufficient in volume or contraindicated due to previous surgery. In a review of 20+ years performing microsurgical breast reconstruction, the senior author, Dr. Allen, has performed DIEP flaps in 66% of his reconstructions, leaving one-third of patients in need of a secondary donor site. The ideal donor site would offer an adequate volume of pliable fat and skin with limited morbidity and a fairly well-hidden scar.

The search for the optimal “secondary” flap for microsurgical breast reconstruction has been extensive. Reported flaps have included the superior and inferior gluteal artery perforator (GAP) flaps, transverse upper gracilis (TUG) flaps, lumbar artery perforator flaps and profunda artery perforator (PAP) flaps. After early experience with gluteal flaps, a search for the next flap option was directed to the thighs. The gluteal flaps were successful and remain a viable option for breast reconstruction. However, a difficult dissection and suboptimal efficiency with patient repositioning seen in the SGAP flap can be burdensome. Additionally, both GAP flaps occasionally led to donor site contour deformities requiring secondary procedures.

The PAP flap offers adequate volume, pliable tissue, and a donor site well hidden within the upper thigh and buttock crease ( Fig. 36.1 ). Beginning in 2010, the senior author, Dr. Allen, has utilized the PAP flap as his second option for perforator-based breast reconstruction performing over 200 PAP flaps for breast reconstruction. This chapter discusses the evolution and history of the PAP flap, reviews pertinent anatomy, and details operative technique, followed by outlining outcomes and complications.

Historical perspective

The profunda artery perforator (PAP) flap shares a common origin with both the posterior thigh flap and the adductor perforator flap. The posterior thigh flap began as a pedicled myocutaneous flap first described by Hurwitz in 1981 for local reconstruction. At the time, this flap was based mainly on a descending branch of the inferior gluteal artery. Song et al . described various thigh septocutaneous perforators, including the posterior thigh flap based on profunda perforators between the vastus lateralis and biceps femoris muscles. Expanding on the use of profunda artery perforators, Angrigiani et al . described utilizing perforator flaps based on the adductor magnus perforators, which originate from the profunda artery. These flaps were described as large rectangular flaps for burn and pressure sore reconstruction with donor site closure via skin graft.

Focusing on donor site location and availability of volume for breast reconstruction, Dr. Allen designed a flap similar to the tissue resection for an upper medial thigh lift. First performed in Mexico City in 2010, this perforator flap spanned from an anterior point at the origin of the adductor longus posteriorly to the end of the inferior gluteal crease (transverse PAP). Originally, the flap was designed based on the first or second perforator off the profunda traveling through the adductor magnus muscle. Quickly, the benefits of an average flap volume of over 350 g and a hidden donor site were recognized and a new next-in-line option to the DIEP flap for breast reconstruction was realized.

Dr. Allen’s continued experience has found that the first profunda perforator is not always dominant. Additionally, there is incidence of wound healing complications associated with the often tight closure and awkward location of the transverse donor site. Thus, flap designs have evolved to include vertical (most commonly performed), diagonal, and fleur-de-lis variations in an attempt to both increase the probability of capturing the dominant vascular pedicle, and also to reduce tissue tension with closure and mitigate donor site complications.