The PAP Flap Breast Reconstruction: A Practical Option for Slim Patients

Abstract

Background The posterior thigh-based profunda artery perforator (PAP) flap has been an emerging option as a secondary choice in breast reconstructions. However, whether a PAP flap could consistently serve as the secondary option in slim patients has not been investigated.

Methods Records of immediate unilateral breast reconstructions performed from May 2017 to June 2019 were reviewed. PAP flap breast reconstructions were compared with standard deep inferior epigastric perforator (DIEP) flap breast reconstructions, and were grouped into single or stacked PAP flaps for further analysis.

Results Overall, 43 PAP flaps were performed to reconstruct 32 breasts. Eleven patients underwent stacked PAP flap reconstruction, while 17 patients underwent 21 single PAP flap reconstruction. The average body mass index (BMI) of the patients was 22.2 ± 0.5 kg/m². The results were as follows: no total loss, one case of venous congestion (2.3%), two donor site wound dehiscence cases (4.7%), and one case of fat necrosis from partial flap loss (2.3%). When compared with 192 DIEP flap reconstructions, the final DIEP flap supplied 98.1 ± 1.7% of mastectomy weight, while the final PAP flap supplied 114.1 ± 6.2% of mastectomy weight (p < 0.005), demonstrating that PAP flaps can successfully supply final reconstruction volume. In a separate analysis, single PAP flaps successfully supplied 104.2% (84.2-144.4%) of mastectomy weights, while stacked PAP flaps supplied 103.7% (98.8-115.2%) of mastectomy weights.

Conclusion In our series of PAP flap reconstructions performed in low-to-normal BMI patients, we found that PAP flaps, as single or stacked flaps, provide sufficient volume to reconstruct mastectomy defects.

Keywords

profunda artery perforator - deep inferior epigastric perforator - flap

The deep inferior epigastric perforator (DIEP) flap is currently appreciated as the gold standard in autologous breast reconstructions.[1] The DIEP flap mostly provides sufficient amount of tissue, is easy to harvest, and is usually not a contraindication in the majority of patients. Nevertheless, for some patients, the DIEP flap may not be the best choice, especially when a patient has moderately large to large breasts, but has low body mass index (BMI) and very thin abdominal tissues. In such instances, plastic surgeons typically opt for the secondary choice—the lower extremity-based flaps.[2]

The lower extremity-based flaps include the buttock-based superior and inferior gluteal artery perforator flaps,[3] [4] [5] [6] the lateral thigh-based lateral thigh perforator flap, the medial thigh-based transverse upper gracilis (TUG) flap, and the posterior thigh-based profunda femoris artery perforator (PAP) flap. Among these, the TUG flap has been preferred by many plastic surgeons for breast reconstruction[7] [8] [9] [10] as it is reliable, has consistent anatomy, and therefore, provides quick flap harvest. However, the TUG flap has well-established drawbacks, which include short pedicle length, lack of volume, and high donor site morbidity. On the other hand, the more recently introduced PAP flap has been described to have longer pedicle length and a larger flap.[8] [11] Recent studies have demonstrated that the PAP flap is sufficient for breast reconstruction in appropriately selected patients, both in a single and in a stacked manner.[12] [13] [14] [15] However, as the patients included in these earlier studies were overweight in terms of the average BMI, we were uncertain as to whether a PAP flap could serve as a consistent secondary choice for slim patients with low BMI.[14] Therefore, in this study, we analyzed PAP flap breast reconstructions performed in our center to determine whether a PAP flap, as a single or as a stacked flap, could supply enough volume for slim patients.

Methods

After institutional review board approval, we reviewed all unilateral immediate breast reconstructions (from May 2017 to December 2019) performed in our center. We included 192 patients who underwent conventional unilateral DIEP flap breast reconstructions, and 28 consecutive patients who underwent PAP flap breast reconstructions. All patients included in our study were Koreans, and the average BMI was under 24.9 kg/m².

Selection Criteria for PAP Flap Breast Reconstruction

Our center's primary choice for breast reconstruction is the DIEP flap. The PAP flap was mostly considered as a secondary choice when a patient had insufficient soft tissue volume in the abdomen. Moreover, we recommended the PAP flap reconstruction for patients with severe abdominal scars from prior abdominal surgery, who preferred to avoid an abdominal scar, or who had a short-term plan of pregnancy.

Operative Procedures

First, we checked the perforators with a computed tomography (CT) scan and confirmed the location with a handheld Doppler and duplex ultrasonography ([Fig. 1]). With the patient in a standing position, the upper margin of the elliptical flap design was drawn at 1 cm below the gluteal fold, and the lower margin was drawn 7 to 8 cm below the upper margin. This design most likely hides the closure line with the gluteal fold. In the operation theater, the patients were laid in the supine frog leg position. The flaps were dissected in an anterior to posterior direction and beveled appropriately to minimize contour deformities and to obtain enough volume. During the early stage of dissection, we preserved the branches of the greater saphenous vein ([Fig. 2]). After opening the fascia, the gracilis muscle was tugged away from the underlying muscles to acquire a clear and wide view of the field.[14] Then, the profunda artery perforator was located, and intramuscular dissection was performed. After isolating the pedicle from the adductor magnus and adductor longus muscle, the artery and veins were cut for microanastomosis. When the flap weight was well below the weight of the mastectomy specimen, which in most of the times we could anticipate before the surgery, we harvested the opposite PAP flap to make a stacked flap reconstruction.

Fig. 1 Localization of profunda femoris artery perforators by computed tomographic angiography.

Fig. 2 Preservation of greater saphenous vein branches in early stage of dissection of profunda artery perforator flaps.

For single PAP flaps, the flaps were manipulated into the shape of a cone ([Fig. 3]). However, for stacked flaps, two flaps were placed in cephalic and caudal directions. The fourth rib was generally excised for complete exposure of the internal mammary system, and the vessels were anastomosed in an X-shaped fashion, where the caudal flap was connected with antegrade vessels and the cephalic flap connected in retrograde direction ([Fig. 4]).

Fig. 3 Conical manipulation of single profunda artery perforator flap breast reconstruction.

Fig. 4 Cephalic and caudal flap placement of stacked profunda artery perforator flap breast reconstruction.

For donor sites, a negative drain was inserted, and closure was done in a multilayered fashion. Most importantly, the lower skin flaps were fixed to the Colles' fascia of the medial thigh to prevent caudal migration of donor site scars. The cosmetic outcomes of these procedures were acceptable, as in a thigh lift.[16] A compressive dressing was performed to reduce hematoma or seroma formation.

Postoperative Care

Postoperative care was mainly focused on preventing donor-site suture dehiscence. A supine position was maintained at postoperative day 1, and patients started ambulation from postoperative day 2. To accommodate easy adaptation to sitting, the back of the patient's bed was raised gradually by ∼20 degrees in a day. To prevent deep vein thrombosis due to prolonged bed rest, patients wore sequential compression devices. Compression stockings were recommended when the patients started ambulation.

Statistical Analysis

The values were expressed as mean ± standard error of the mean or median with interquartile range, as appropriate. Statistical analyses were performed using IBM SPSS version 21.0 (IBM Corp., Armonk, NY). An independent sample t-test was used to compare patient characteristics and surgical details between the conventional DIEP flap and PAP flap breast reconstructions. A comparison was also performed between the single PAP flap and stacked PAP flap; p < 0.05 was considered statistically significant.

Results

Overall, 43 PAP flaps were performed to reconstruct 32 breasts. Eleven patients underwent stacked PAP flap reconstruction (34.4%), while 17 patients underwent 21 single PAP flap reconstruction (65.6%), with 4 patients being bilateral. Sixteen left (50%) and 16 right breasts (50%) were reconstructed. The average age of patients was 39.9 ± 1.5 years, and the average BMI was 22.2 ± 0.5 kg/m². The average mastectomy weight was 298.1 ± 25.8 g, and the average final flap weight was 308.9 ± 19.8 g. The average operation time was 309.5 ± 16.7 minute. The results were as follows: no total loss, one case of venous congestion (2.3%), two donor-site wound dehiscence cases (4.7%), and one case of fat necrosis from partial flap loss (2.3%).

Then, we compared the 28 patients with PAP flap breast reconstructions with the 192 patients with conventional DIEP flap reconstructions. The average age and BMI were lower in the PAP flap group. As expected, the mastectomy weight, initial flap weight, and final flap weight were significantly lower in the PAP flap group. The final flap/initial flap ratio appeared to be lower in the DIEP flap group, suggestive of more abundant flap volumes in the DIEP flaps. Most importantly, the final DIEP flap supplied 98.1 ± 1.7% of mastectomy weight, while the final PAP flap supplied 114.1 ± 6.2% of mastectomy weight (p < 0.005), demonstrating that PAP flaps can adequately replace mastectomy volumes. The mean operation time was longer in the PAP flap group, but the difference was not statistically significant ([Table 1]).

Table 1 Comparison of patient and surgical details between the conventional DIEP flap and the PAP flap

Variables (mean ± SEM)	Conventional DIEP flap	PAP flap	p-Value
Number of patients	192	28
Age, years	47.9 ± 0.6	39.9 ± 1.5	< 0.005
BMI, kg/m2	24.1 ± 0.3	22.2 ± 0.5	< 0.005
Operation time	292.1 ± 4.3	309.5 ± 16.7	0.0903
Number of breasts	192	32
Left sided reconstructions (%)	98 (51%)	16 (50%)
Mastectomy weight, g	441.7 ± 14.8	298.1 ± 25.8	< 0.005
Initial flap weight, g	781.9 ± 27.1	375.8 ± 36.8	< 0.005
Initial flap weight/mastectomy weight, %	190.3 ± 5.7	132.2 ± 7.2	< 0.005
Final flap weight, g	410.9 ± 11.3	308.9 ± 19.8	< 0.005
Final flap/Initial flap, %	56.0 ± 1.1	88.4 ± 2.7	< 0.005
Final flap weight/mastectomy weight, %	98.1 ± 1.7	114.1 ± 6.2	< 0.005

Abbreviations: DIEP, deep inferior epigastric perforator; PAP, profunda artery perforator.

Lastly, we compared the single PAP flap reconstructions with stacked PAP flaps ([Figs. 5] and [6], [Table 2]). The median age and BMI were not significantly different for these two groups. The mastectomy weight was higher in the stacked PAP flap group, and the initial flap weight was much higher in the stacked PAP group, in which two flaps were stacked. Most importantly, however, the median final flap weight/mastectomy weight ratio exceeded 100% for both groups. This suggests that both stacked and single PAP flaps can supply sufficient volume in appropriately selected patients.

Table 2 Comparison of surgical details between the single PAP flap and the stacked PAP flap

Variable	Single PAP flap	Stacked PAP flap	p-Value
Number of patients	17	11
Age, years	37.0 (32.0–45.0)	41.0 (37.5–46.5)	0.1499
BMI, kg/m2	22.6 (20.7–22.9)	21.2 (20.5–25.5)	0.1785
Number of breasts	21	11
Unilateral	13	11
Bilateral	4	0
Mastectomy weight, g	220.0 (159.0–317.0)	318.0 (286.5–423.0)	0.0312
Initial flap weight, g	258.0 (236.0–313.0)	472.0 (403.5–534.0)	< 0.005
Initial flap weight/mastectomy weight, %	115.9 (84.2–167.0)	140.7 (131.6–154.1)	0.2219
Final flap weight, g	275.0 (236.0–298.0)	351.0 (281.5–462.0)	0.0086
Final flap weight /mastectomy weight, %	104.2 (84.2–144.4)	103.7 (98.8–115.2)	0.1311
Operation time, min
Unilateral	294.0 (202.0–367.0)	308.0 (293.0–342.5)	0.0820
Bilateral	293.0 (288.3–324.5)

Abbreviations: BMI, body mass index; PAP, profunda artery perforator.

Fig. 5 Breast reconstruction with single profunda artery perforator flap. Preoperative (upper left) and postoperative (upper right) photographs are shown. Because a single large flap was harvested, the donor site scar (lower) location was not perfectly covered by the gluteal fold.

Fig. 6 Breast reconstruction with stacked profunda artery perforator flaps. Preoperative (upper left) and postoperative (upper right) photographs are shown. Preoperative flap design (lower left) and postoperative donor site scar (lower right) in the posterior thigh. When compared with a single profunda artery perforator flap, the patient had a superior donor site scar, as the smaller flap volume harvested made it possible to keep the scar well hidden by the gluteal fold.

Discussion

Although the market for implant-based reconstructions continues to grow, autologous breast reconstructions have their own advantages.[1] They provide natural touches and shapes as well as lifelong reliability once the reconstruction is complete. Currently, the DIEP flap is the gold standard among autologous reconstructions. DIEP flaps provide sufficient volume and are associated with fine aesthetic outcomes and quick recovery.[17] [18] However, when a DIEP flap is insufficient, plastic surgeons typically turn to the secondary option—the lower extremity-based flaps.[2] [3] [4] Among various lower extremity-based flaps used in breast reconstruction, the medial thigh-based TUG flaps have been preferred by many surgeons. Most importantly, a TUG flap is easy to harvest, and a position change is not required during the surgery because the flap harvest is possible in a supine position. However, a TUG flap has a short pedicle, which is a great disadvantage in breast reconstructions. Moreover, a TUG flap usually fails to supply enough volume to moderately large to large breasts.

The posterior thigh-based PAP flap is a more recently introduced option for breast reconstructions.[12] In addition to the advantage of performing a flap harvest in a supine position, the PAP flap is better than the TUG flap in terms of pedicle length and flap volume.[14] [19] [20] A PAP flap has much longer pedicle length, which is important in ptotic breast reconstruction for reducing thrombosis formation caused by inappropriate flap placement. Another big advantage of a PAP flap is the flap volume. The posteriorly located flap provides larger flaps that can be harvested safely, and more importantly, a PAP occupies a larger perforasome than a TUG perforator.[21]

However, earlier PAP flap breast reconstructions were mainly performed in high BMI populations in whom thigh tissues are generally expected to be abundant.[14] In a recent report of 265 PAP flap breast reconstructions, the mean patient BMI was 26.5 kg/m² (range: 18–43).[15] In our series of PAP flaps, all patients were Koreans, and the average BMI was 22.2 kg/m². Such low-to-normal BMI populations are expected to have not only less abdominal tissue, but also less abundant thigh tissue. The primary goal of our study was to determine whether a PAP flap could serve as a consistent secondary option for breast reconstruction in such low-to-normal BMI patients. In our series, 192 DIEP flap patients were compared with 28 PAP flap patients. The PAP flap group was younger and had lower BMI and mastectomy weight. We found that the DIEP flap was preferred in higher BMI patients with larger breasts. However, the younger age of the PAP flap group implies that younger patients, especially when the BMI is low, may also prefer PAP flaps for breast reconstruction. Hiding the scar on their buttock, instead of a long and prominent scar on the abdomen, might have seemed like a better option for young and slim patients. In terms of flap parameters, the initial and flap weights were higher in the DIEP group. Most importantly, however, the average final flap weight to the average mastectomy weight ratio was 98.1% in the DIEP flap group and 114.1% in the PAP flap group. This indicates that lower PAP flap volumes did not act as a significant handicap in determining final reconstruction volumes.

In our comparison of single and stacked PAP flaps, we found that stacked PAP flaps could easily cover even greater mastectomy defects. We chose to perform a single PAP flap reconstruction when the breast projection at the nipple level was similar to the thigh thickness. When the projection was higher than the thigh thickness, we chose to perform a stacked PAP flap. However, more delicate and objective volumetric planning has been described in recent literature.[22] The median mastectomy weight of 11 stacked PAP flap reconstruction cases was 318.0 g, and the total sum of the initial PAP flap weight was 472.0 g, greatly exceeding the mastectomy weight. The total sum of the PAP flap weight was also greater than the average mastectomy weight in the conventional DIEP flap group. This suggests that PAP flaps can also serve as an appropriate option for the same cohort of DIEP flap patients in terms of reconstruction volumes. Stacking PAP flaps helped us retain the horizontal flap design in situations wherein thigh tissue volume was low. However, it is imperative to note that the vertical fleur-de-lys design can also be used to increase flap volumes.[23] [24] Moreover, chimeric TUG extension is now a valid option for patients with a single-arterial pedicle to both the gracilis and PAP flap, which can be found with lower-extremity CT angiography.[25]

Donor-site wound dehiscence remains the most bothersome complication in PAP flap breast reconstructions. We had two cases of donor-site wound dehiscence (4.7%), a number that was markedly lower than the 13% of cases reported by a previous study.[26] The lower number of wound dehiscence cases may be the result of the very small number of bilateral breast reconstructions in our study cohort. Another reason may be the lower patient BMI, which was reported to be a significant factor for reducing the development of postoperative wound dehiscence.[26]

For slim patients, we typically choose latissimus dorsi (LD) flaps for breast reconstruction in our center. However, due to the innately low volume of LD flaps, we typically employed breast implants under the flap for patients with large breasts. The loss of the merits of autologous reconstructions was a great disadvantage of this hybrid reconstruction. Thus, introducing the PAP flap as an appropriate secondary option for slim patients could provide surgeons with a better option when they want to avoid the hybrid LD flap reconstruction.

One of the disadvantages of PAP flaps, especially in stacked cases, is prolonged operation time. An average stacked PAP flap breast reconstruction took an hour longer than conventional DIEP flaps. Although the operation times for single PAP flap reconstructions were generally shorter, single flap reconstructions demonstrated worse donor site scars. As shown in our case presentation, our attempt to harvest as much volume as possible caused the scar to be pulled downward away from the gluteal fold. In contrast, the stacked PAP flap had a definite advantage in donor site scars because less burdening for flap volumes made it possible to harvest smaller and narrower flaps, focusing more on donor site scar locations.

Another important point to note is the PAP flap perforasome. Although we did not present this in our data, we found that intraoperative indocyanine green angiography tests frequently showed that a standard PAP fails to perfuse medial thighs. This is in accordance with the findings of previous reports of cadaveric and CT angiography studies.[21] [27] [28] Based on our experience, we frequently chose to remove less perfused medial thigh areas or at least prepared for possible fat necrosis by adjusting the medial part toward the breast upper pole. Moreover, we preoperatively checked the saphenous veins and tried to save them for flap supercharge, because they are likely to have a connection with the main PAPs. However, further study is warranted to determine the exact anatomic correlation between the saphenous veins and PAPs, and to determine whether a saphenous vein supercharge could affect flap perfusion.

Our center primarily chooses DIEP flap for breast reconstructions because it is versatile, with a lower number of PAP flaps. However, with our primary PAP flap data, we gained confidence and started to expand the applications for PAP flap reconstructions. In addition, the comparison of PAP flaps with DIEP flap lacks objective outcome scoring, especially from the perspective of patient satisfaction. Therefore, we have started to collect BREAST-Q questionnaire data, which would make it possible to objectively compare PAP flaps to DIEP flaps. These data will be reported in the near future.

Conclusion

The PAP flap is an emerging secondary option for breast reconstruction. However, whether PAP flaps could consistently serve as a secondary option in slim patients has not been investigated. In our series of low-to-normal BMI patients, we have shown that PAP flaps, in a single or in stacked manner, could supply sufficient volume for successful breast reconstructions.

Conflict of Interest

None declared.

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Publication History

Received: 21 October 2020

Accepted: 16 February 2021

Article published online:
14 April 2021