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Page 10 of 14 Olla et al. Plast Aesthet Res 2024;11:24 https://dx.doi.org/10.20517/2347-9264.2024.30

Figure 9. The patient in Figure 1 shown here 4 months following bilateral dPAP flap breast reconstruction. Her breast (A) and posterior
thigh incisions (B) are well healed. (dPAP = diagonal profunda artery perforator).

Compression garments are utilized in the immediate postoperative period and patients are instructed to use
them for a month following surgery. This compression decreases fluid production to help decrease seroma
risk and allow drains to be removed earlier. If no compression is used, drains may remain for an extended
period. The compression may also improve postoperative contour and minimize scar hypertrophy or
widening. There are no activity restrictions on postoperative movement other than avoiding strenuous
activity for 6 weeks.

CLINICAL OUTCOMES AND COMPLICATIONS
The overall success rate of PAP flaps is consistently high, with published flap success rates ranging from
97% to 100% [25,26,45,46] . Donor and recipient site complications following PAP flaps are low and acceptable,
with comparable rates to abdominally-based reconstruction . Typical complications at the donor site
[45]
include seroma, hematoma, infection, and/or dehiscence. Similar rates have been reported across three of
the most extensive single-center series. Of 265 PAP flaps, Haddock et al. revealed the following rates of
complications of the donor site: wound infection (4.9%), seroma (4.5%), hematoma (2.6%), and dehiscence
(2.6%) . Similarly, Allen et al. illustrated the following complication rates: seroma (6%), hematoma (1.9%),
[25]
[26]
and wound dehiscence 3.6% . Of the 116 PAP flaps reported by Atzeni et al., complications at the donor
site consisted of seroma (2.6%), wound dehiscence (2.6%), hematoma (1.7%), and fat necrosis (1.7%) .
[46]
These complications are generally managed non-operatively. The overall success rates were comparable
among all three investigators. Total flap loss was low, 0%-3%, with a similar OR take-back rate [25,26,46] .

The complication profile remains low in situations requiring stacked DIEP/PAP flaps. Mayo et al. reported
on 20 patients who underwent stacked flaps. There was only 1 donor-site hematoma, 1 donor-site
dehiscence, 1 arterial and venous thrombosis treated with anastomotic revision, and 3 episodes of minor
[47]
mastectomy skin flap necrosis . A similar study by Martinez et al. reported no postoperative tack-backs or
vascular complications following stacked DIEP/PAP flaps in 28 consecutive patients . Haddock et al.
[48]
reported that of 200 flaps in 50 patients undergoing stacked DIEP/PAP flaps, only 5 flaps were lost (2.5
percent). Due to flap-related concerns, 7 patients required take-backs resulting in 2 negative explorations
and 1 flap salvage. Thigh wounds of the PAP flap donor site were the common non-flap-related
complication .
[27]