Page 14 - Read Online

Olla et al. Plast Aesthet Res 2024;11:24 https://dx.doi.org/10.20517/2347-9264.2024.30 Page 9 of 14

Figure 7. Preoperative markings in the lithotomy position. Flaps measured 11 × 26 cm. Perforators are confirmed with Doppler (blue
dots). (AL = adductor longus muscle; G = gracilis muscle).

Figure 8. The anterior incision is made first. Dissection is carried down through the fascia surrounding the gracilis muscle, which is then
retracted anteriorly. The investing fascia of the adductor magnus is incised behind the gracilis muscle, and a subfascial dissection
continues posteriorly until perforators are identified. (A) The perforators are dissected retrograde through the adductor magnus
muscle, sparing the muscle and muscular nerves supplying it. This continues until adequate length and caliber vessels are obtained (B).
Two perforators that joined quickly in the muscle were chosen for perfusion for this left-sided diagonal PAP flap. (PAP = profunda
artery perforator).

antegrade internal mammary vessels bilaterally. The flaps were de-epithelialized and inset with absorbable
sutures.

The patient's postoperative course was uncomplicated, and she was discharged on postoperative day 2 with
drains and compression garments for her lower extremity donor sites. Her most recent follow-up was 4
months post operation. Her breast and posterior thigh incisions are well healed [Figure 9].

POSTOPERATIVE CONSIDERATIONS
In the postoperative period, flaps are typically monitored with clinical examination and pencil Doppler
assessments by nursing and house staff. The foley is removed and patients are mobilized out of bed on
postoperative day 0. Using enhanced recovery after surgery (ERAS) protocol, patients are generally ready
for discharge from the hospital on postoperative day 1 for unilateral flaps and day 2 for bilateral flaps.
Before discharge, patients receive education on incision and drain care and are advised on clinical flap
monitoring. ERAS protocols have been commonly used in abdominally based flaps and more recently have
been found to be beneficial after PAP flaps, decreasing length of stay and minimizing opioid use .
[44]