Profunda artery perforator free flaps for breast reconstruction

Abstract

The gold standard for post-mastectomy autologous breast reconstruction is abdominally based free flaps. For patients with contraindications to abdominal free flap reconstruction, utilization of other donor sites should be considered. The profunda artery perforator flap has become a popular option for autologous reconstruction as it offers many advantages, including a long pedicle, muscle preservation, and easy soft tissue contouring. This review will provide an extensive outline of the history, anatomy, clinical indications, surgical techniques, and outcomes of the profunda artery perforator flap. It will also discuss appropriate preoperative imaging (CTA, MRA) and present a case of a patient who received a profunda artery perforator flap at our institution.

Keywords

Autologous breast reconstruction / profunda artery perforator (PAP) flap / microsurgery

References

[1] Giaquinto AN,Miller KD.Breast cancer statistics, 2022.CA Cancer J Clin2022;72:524-41

[2] Panchal H.Current trends in postmastectomy breast reconstruction.Plast Reconstr Surg2017;140:7S-13S PMCID:PMC5722225

[3] Sung H,Siegel RL.Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin2021;71:209-49

[4] Allen RJ. Breast reconstruction. Plastic Surgery - Principles and Practice. Elsevier; 2022. pp. 535-64.

[5] Nelson JA,Polanco T.Long-term patient-reported outcomes following postmastectomy breast reconstruction: an 8-year examination of 3268 patients.Ann Surg2019;270:473-83

[6] Hartrampf CR.The transverse abdominal island flap for breast reconstruction. A 7-year experience.Clin Plast Surg1988;15:703-16.

[7] Grotting JC,Maddox WA.Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction.Plast Reconstr Surg1989;83:828-41; discussion 842

[8] Allen RJ.Deep inferior epigastric perforator flap for breast reconstruction.Ann Plast Surg1994;32:32-8

[9] Healy C.The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap.J Reconstr Microsurg2014;30:121-5

[10] He WY,Yesantharao P.Complications and patient-reported outcomes after TRAM and DIEP flaps: a systematic review and meta-analysis.Plast Reconstr Surg Glob Open2020;8:e3120 PMCID:PMC7647662

[11] Hurteau JE,Nahai F,Jurkiewicz MJ.V-Y advancement of hamstring musculocuataneous flap for coverage of ischial pressure sores.Plast Reconstr Surg1981;68:539-42

[12] Angrigiani C,Thorne CH.The adductor flap: a new method for transferring posterior and medial thigh skin.Plast Reconstr Surg2001;107:1725-31

[13] Allen RJ,Ahn CY.Breast reconstruction with the profunda artery perforator flap.Plast Reconstr Surg2012;129:16e-23e

[14] Park JE,Song DH.TUGs into VUGs and friendly BUGs: transforming the gracilis territory into the best secondary breast reconstructive option.Plast Reconstr Surg2015;136:447-54

[15] Dayan JH.Lower extremity free flaps for breast reconstruction.Plast Reconstr Surg2017;140:77S-86S

[16] Jo T,Eom JS.Comparison of transverse upper gracilis and profunda femoris artery perforator flaps for breast reconstruction: a systematic review.Microsurgery2020;40:916-28

[17] Hunter JE,Dower DR.Evolution from the TUG to PAP flap for breast reconstruction: comparison and refinements of technique.J Plast Reconstr Aesthet Surg2015;68:960-5

[18] Yano T,Yoshimatsu H.The feasibility of harvesting an innervated profunda artery perforator flap for breast reconstruction.Plast Reconstr Surg Glob Open2020;8:e3160 PMCID:PMC7647641

[19] Dayan JH.Neurotized diagonal profunda artery perforator flaps for breast reconstruction.Plast Reconstr Surg Glob Open2019;7:e2463 PMCID:PMC6846295

[20] Hunsinger V,Haddad K.Medium- and large-sized autologous breast reconstruction using a fleur-de-lys profunda femoris artery perforator flap design: a report comparing results with the horizontal profunda femoris artery perforator flap.J Reconstr Microsurg2019;35:8-14

[21] Eder V,Drumm M,Baulieu F.Three-dimensional analysis of left ventricle regional wall motion by using gated blood pool tomography.Nucl Med Commun2004;25:971-8

[22] Haddock NT,Teotia SS."Categorizing patient selection, outcomes, and indications in a decade of 405 PAP flaps".Plast Reconstr Surg2023;

[23] Saad A,Allen RJ.The anatomic basis of the profunda femoris artery perforator flap: a new option for autologous breast reconstruction--a cadaveric and computer tomography angiogram study.J Reconstr Microsurg2012;28:381-6

[24] Haddock NT,Cho MJ.101 Consecutive profunda artery perforator flaps in breast reconstruction: lessons learned with our early experience.Plast Reconstr Surg2017;140:229-39

[25] Haddock NT.Consecutive 265 profunda artery perforator flaps: refinements, satisfaction, and functional outcomes.Plast Reconstr Surg Glob Open2020;8:e2682 PMCID:PMC7209884

[26] Allen RJ Jr,Mayo JL,Ahn C.The profunda artery perforator flap experience for breast reconstruction.Plast Reconstr Surg2016;138:968-75

[27] Haddock NT,Teotia SS.Consecutive bilateral breast reconstruction using stacked abdominally based and posterior thigh free flaps.Plast Reconstr Surg2021;147:294-303

[28] Haddock NT,Teotia SS.Comparative analysis of single versus stacked free flap breast reconstruction: a single-center experience.Plast Reconstr Surg2019;144:369e-77e

[29] Fischer JP,Sieber B.Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions.Plast Reconstr Surg2013;131:681e-92e

[30] Lee KT.Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flap: a systematic review and meta-analysis.Ann Plast Surg2016;76:576-84

[31] Cho MJ,Haddock NT.Classification and management of donor-site wound complications in the profunda artery perforator flap for breast reconstruction.J Reconstr Microsurg2020;36:110-5

[32] Haddock NT,Otterburn D,Allen RJ.Predicting perforator location on preoperative imaging for the profunda artery perforator flap.Microsurgery2012;32:507-11

[33] Thimmappa N,Bishop K,Prince MR.Preoperative cross-sectional mapping for deep inferior epigastric and profunda artery perforator flaps.Cardiovasc Diagn Ther2019;9:S131-42 PMCID:PMC6732116

[34] Ahmadzadeh R,Tang M,Morris SF.The posterior thigh perforator flap or profunda femoris artery perforator flap.Plast Reconstr Surg2007;119:194-200

[35] Rubin JA,Stevenson TR.The posterior thigh fasciocutaneous flap: vascular anatomy and clinical application.Plast Reconstr Surg1995;95:1228-39

[36] DeLong MR,Bond JE,Boll DT.A detailed evaluation of the anatomical variations of the profunda artery perforator flap using computed tomographic angiograms.Plast Reconstr Surg2014;134:186e-92e

[37] Rivera-Serrano CM,Wu J.Vertical PAP flap: simultaneous longitudinal profunda artery perforator flaps for bilateral breast reconstructions.Plast Reconstr Surg Glob Open2017;5:e1189 PMCID:PMC5340472

[38] Scaglioni MF,Lindenblatt N.The vertical posteromedial thigh (vPMT) flap for autologous breast reconstruction: a novel flap design.Microsurgery2017;37:371-6

[39] Bourn L,Stalder MW.Mosaic fleur-de-profunda artery perforator flap for autologous breast reconstruction.Plast Reconstr Surg Glob Open2019;7:e2166 PMCID:PMC6467610

[40] Haddock NT,Gassman A.Stacked profunda artery perforator flap for breast reconstruction in failed or unavailable deep inferior epigastric perforator flap.Plast Reconstr Surg2019;143:488e-94e

[41] Haddock NT,Perez K,Liu Y.BREAST-Q and donor site comparison in bilateral stacked autologous breast reconstruction.Plast Reconstr Surg Glob Open2022;10:e4413 PMCID:PMC9324622

[42] Zenn MR.Fluorescent angiography.Clin Plast Surg2011;38:293-300

[43] Lauritzen E.Use of indocyanine green angiography decreases the risk of complications in autologous- and implant-based breast reconstruction: a systematic review and meta-analysis.J Plast Reconstr Aesthet Surg2021;74:1703-17

[44] Cho MJ,Teotia SS.Utility of ERAS pathway in nonabdominal-based microsurgical breast reconstruction: efficacy in PAP flap reconstruction?.J Reconstr Microsurg2022;38:371-7

[45] Lee ZH,Asaad M.Comparing donor site morbidity for autologous breast reconstruction: thigh vs. abdomen.Plast Reconstr Surg Glob Open2022;10:e4215 PMCID:PMC8947678

[46] Atzeni M,Haywood R,Figus A.Breast reconstruction using the profunda artery perforator (PAP) flap: technical refinements and evolution, outcomes, and patient satisfaction based on 116 consecutive flaps.J Plast Reconstr Aesthet Surg2022;75:1617-24

[47] Mayo JL,Sadeghi A.Four-flap breast reconstruction: bilateral stacked DIEP and PAP flaps.Plast Reconstr Surg Glob Open2015;3:e383 PMCID:PMC4457246

[48] Martinez CA,Secchi-Del Rio R.Bilateral outpatient breast reconstruction with stacked DIEP and vertical PAP flaps.Plast Reconstr Surg Glob Open2021;9:e3878 PMCID:PMC8522876

[49] Mundy LR,Klassen AF,Kerrigan CL.Breast cancer and reconstruction: normative data for interpreting the BREAST-Q.Plast Reconstr Surg2017;139:1046e-55e PMCID:PMC5713639

[50] Lu J,Graziano FD,Allen RJ Jr.Alternative donor sites in autologous breast reconstruction: a clinical practice review of the PAP flap.Gland Surg2023;12:516-26 PMCID:PMC10186161