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Page 6 of 14 Olla et al. Plast Aesthet Res 2024;11:24 https://dx.doi.org/10.20517/2347-9264.2024.30

incision is made, and the flap is harvested. To increase the volume of the flap, the subcutaneous tissue along
the posterior incision can be beveled to include more tissue. If a second flap is being harvested, dissection
can take place while the first microsurgical anastomosis is being completed.

In the chest, standard microsurgical anastomosis is performed, typically to the antegrade internal mammary
artery (IMA) with a 9-0 nylon suture and appropriately sized venous coupler to the antegrade internal
mammary vein (IMV). In cases where the antegrade IMA and/or IMV are not available or suitable for
anastomosis, or when stacked flaps are being used, the retrograde IMA and IMV, or thoracodorsal vessels,
can be used as alternatives for microvascular anastomosis. Once the anastomosis is completed, SPY-PHY
fluorescence imaging (Stryker Corp., Kalamazoo, MI, USA) is used to evaluate flap perfusion. Anesthesia
administers ICG and the device is positioned, so that the fluorescent angiogram is visualized in real time.
Any areas with little to no fluorescence are considered poor or questionable perfusion and the tissue is
removed to prevent fat necrosis [42,43] . The buried portion of the flap around the monitoring skin paddle is de-
epithelialized and the flap is secured into the breast envelope. The tissue is shaped with care to set adequate
medial pole fullness and ptosis. A closed suction drain is placed and kept far from the anastomosis.

The donor site closure sometimes requires selective posterior skin flap elevation off muscle fascia to help
reduce tension. This undermining is limited to maximize perfusion of the skin edges and minimize dead
space. To decrease seroma formation, a multilayered closure is performed over a closed suction surgical
drain. We inject liposomal bupivacaine subfascially and into the surrounding soft tissues of the donor site to
reduce postoperative pain.

CASE PRESENTATION
The patient is a 48-year-old female with a history of right breast stage IA invasive ductal carcinoma and
morbid obesity status post gastric bypass, for which she lost 79 kilograms [Figure 1]. After her significant
weight loss, she had redundancy and laxity of her skin and tissue in her abdomen and medial thighs. It was
determined that there was a more suitable amount of tissue for PAP flap reconstruction compared to DIEP,
so PAP flaps were chosen. She underwent bilateral mastectomies (wise pattern) and immediate pre-pectoral
tissue expander placement in preparation for autologous PAP flap reconstruction [Figure 2]. Following her
mastectomies and adequate volume expansion, the patient underwent preoperative MRA imaging for the
localization of perforators [Figures 3-5].

On the day of autologous reconstruction, the patient was met in the preoperative area, and the ideal soft
tissue of the posteromedial thighs was marked with her in the standing position [Figure 6]. In the operating
room, the patient was positioned in lithotomy. Preoperative markings clearly outlined the gracilis (G) and
adductor longus (AL) muscles. Flaps had dimensions measured to be 11 × 26 cm. The location of each
perforator was confirmed with a hand-held Doppler ultrasound [Figure 7].

To start, the anterior incision was completed, and dissection was carried down to the gracilis muscle. The
fascia surrounding the gracilis muscle was incised, and the muscle was retracted anteriorly to expose the
adductor magnus muscle. The investing fascia of the adductor magnus was then incised, and a subfascial
dissection was carried out posteriorly to identify the perforators supplying the skin. The perforators were
then dissected retrograde through the adductor magnus muscle, sparing the muscle and the nerves
supplying it [Figure 8]. Once adequate vessel length and caliber were obtained, the vessels were ligated, and
the posterior incisions were completed.