Free Profunda Artery Perforator Flap Breast Reconstruction

Introduction

Breast reconstruction is a common challenge faced by many surgeons working in the plastic and reconstructive arenas. There are various options for autologous breast reconstruction. The more commonly performed procedures include the deep inferior epigastric perforator flap (DIEP) and the superior and inferior gluteal artery perforator flaps (SGAP, IGAP). Despite the refinements in the latter donor sites, specific reconstructive needs and body habitus sometimes call for an alternate donor site. This has led to the development of the medial thigh as a donor site, more specifically based on the profunda artery system.

The senior author first introduced the PAP flap for breast reconstruction at the 13th International Course on Perforator Flaps in 2010. The patient was a 52-year-old woman with previous failed attempts at breast reconstruction using implants and then a transverse rectus abdominis muscle flap. As the patient had been noted to have excess posterior thigh tissue, Dr. Allen decided to proceed with the first posterior thigh profunda artery perforator (PAP) flap for microsurgical breast reconstruction. This idea was supported by the background work of other surgeons and anatomists, who had previously described the profunda artery anatomy as responsible for the regional blood supply of the posterior upper thigh. The PAP flap had become an innovative addition to the breast reconstructive armamentarium.

The PAP flap has proven to have consistent anatomy and blood supply, with adequate perforator size for anastomosis to the internal mammary or thoracodorsal vessels. Additionally, due to its elliptical pattern used for flap design, it has proven to have excellent aesthetic results, either coned to accommodate the natural contour of the breast, or stacked to create a full-shaped breast.

The donor-site incision is concealed in the gluteal crease in the transverse pattern, or in the transition between the medial and posterior thigh in the vertical pattern. Like all of the various options for microsurgical free tissue transfer, the PAP flap is not without its disadvantages; however, the reported complication rate has overall been quite low and acceptable as compared to the alternative options for autologous tissue breast reconstruction.

In this chapter, we will focus on providing guidelines for using the PAP flap by discussing the indications and contraindications for choosing this flap for breast reconstruction, how to properly evaluate a patient who appears to be a good candidate for this procedure, our surgical technique, and the postoperative care. Additionally, we will provide some case examples of the various uses of the PAP flap, and some variations to this technique. These include the use of a transverse incision, vertical incision, and its use as stacked flap, “four flap” autologous breast reconstruction with use of DIEP flaps along with PAP flaps. Finally, we will discuss some possible complications, how to avoid them, and appropriate short- and long-term management of patients having this surgical procedure, including the need for secondary procedures for improved aesthetic outcomes.

Indications and Contraindications

Although the DIEP flap has been the workhorse for microsurgical breast reconstruction, there are some circumstances that make the PAP flap a more valuable option. Some indications that favor the use of the PAP flap include patients with previous abdominal surgery and/or thin patients with a paucity of abdominal tissue. There is also a subset of patients who do not wish to use their abdominal tissue for reconstruction, or are trying to avoid an anterior abdominal scar, thus making the PAP flap an ideal option, especially with its inconspicuous donor site scar. The PAP flap has been harvested on patients with various body mass indexes; the ideal patient has small to moderate-sized breasts and excess body fat below the waist. The PAP flap has also been used in different reconstructive scenarios such as lower extremity and head and neck reconstruction. The PAP flap has no major contraindications; however, we see a limitation in those patients who have limited hip abduction or previous surgery to the inferior gluteal crease region.

Preoperative Evaluation and Special Considerations

The PAP flap has proven to have consistent anatomy; however, preoperative imaging is paramount in surgical planning. Current imaging modalities such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have demonstrated great utility in the identification of perforator vessels needed for flap harvesting. Saad et al. demonstrated the consistent anatomy for the PAP based on cadaveric dissection and CT scanning, which showed the perforator supplying the medial and posterior thigh skin and subcutaneous tissue just below the buttocks crease. Identification of these perforators has become the standard of care for the surgical planning of the PAP flap ( Fig. 6.1 ).

The CTA technique should be performed in a high-resolution scanner with thin cuts. With the patient in prone position, a marker should be placed in the gluteal crease, which will help provide accurate measurements relating to the perforator position for flap design. The perforators will be identified posterior to the gracilis muscle as septocutaneous or musculocutaneous perforators through the adductor magnus.

Surgical Techniques