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Olla et al. Plast Aesthet Res 2024;11:24 https://dx.doi.org/10.20517/2347-9264.2024.30 Page 5 of 14

the thigh.

Another modification of the PAP flap is the diagonal PAP (dPAP) flap, where the skin paddle is placed
diagonally along the resting skin tension lines. This orientation allows for a larger skin paddle that can be
[19]
closed with minimal tension, decreasing the risk of complications at the donor site . This design also
avoids scars over bony prominences where there is increased pressure when sitting. Due to these
advantages, the dPAP has become the ideal skin paddle design.

While the ipsilateral thigh is generally preferred for breast reconstruction, contralateral reconstruction is
also possible since most PAP flaps have a single perforator in a central location. If a unilateral
reconstruction is being done, both PAP flaps can be stacked or combined to achieve additional volume. In a
bilateral reconstruction, PAP flaps can be combined safely with other flaps for additional volume [22,40,41] .

Markings
The classic skin paddle orientation for the PAP flap is the diagonal modification. The patient is first marked
standing in the preoperative area. The IGC is marked, as well as the location and distribution of the ideal fat
to be included in the flap design. Once in the operating room, the gracilis and adductor longus muscles are
marked and identified with the patient in the frog-legged position. Next, the patient is transitioned to the
lithotomy position. The anticipated locations of the dominant perforators identified on MRA are marked
and confirmed using a hand-held Doppler ultrasound. The anterior incision is marked starting from the
posterior edge of the gracilis and gradually curves posteriorly starting approximately 8 cm inferior to the
IGC. To determine the location of the posterior incision, a pinch test is performed along Langer's lines to
assess the area that can be closed with minimal tension. Subsequently, the posterior incision is marked out,
creating an ellipse, making sure to include the PAP perforator which runs through the adductor magnus
muscle. Dissection in lithotomy maximizes exposure and ergonomics for the surgeon. Positioning the
patient on a split-leg bed or leaving the patient in the frog-legged position are also options, but both are less
ideal for maximizing exposure during surgery. The case is run as a 2-team approach where preparation of
the breast pocket and vessels is performed at the same time as the flap harvest.

OPERATIVE STEPS
To begin, the anterior incision is made, and dissection is continued down through the subcutaneous tissue
with electrocautery to the gracilis muscle. The fascia of the gracilis is incised and dissection is carried out
posteriorly while retracting the gracilis muscle anteriorly, exposing the adductor magnus muscle. The
investing fascia of the adductor magnus muscle is incised throughout the length of the incision. This step is
key to prevent working in a narrow tunnel which limits visualization of the surgical field and increases the
risk of injuring or potentially avulsing perforators. At this point, dissection proceeds subfascially and
posteriorly along the adductor magnus until perforators arising through the muscle into the skin island are
identified. The perforators are then dissected retrograde using bipolar cautery along their course through
the adductor magnus muscle. Dissection is continued until adequate pedicle length and vessel size for
anastomosis in the chest are obtained. If we are not satisfied with either the pedicle length or caliber of the
vessels, dissection can continue proximally to the profunda femoral vessel. (The vein is usually larger than
the artery, so surgeons should continue dissection to a point where the artery is an appropriate size match,
which is usually 8-10 cm.). The entire perforator and pedicle dissection is performed while leaving the
posterior incision intact. Once the pedicle is completely dissected, we then ligate and divide the main
pedicle. Regaining this exposure is difficult to replicate, so the pedicle is divided before the posterior
incision is made. The flap remains perfused from posterior perforators, allowing time for recipient vessel
preparation and limiting the ischemia time of the flap. Once the vessels are ready on the chest, the posterior