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

The BREAST-Q is a validated metric to assess patient-reported outcomes (PROs) following breast
reconstruction and normative data have been published for comparative purposes. Despite being an
[49]
alternative donor site, PROs following PAP flap reconstruction are comparable to normative values .
Haddock et al. report that patients who underwent PAP flaps had favorable reported outcomes compared to
the normative data in all BREAST-Q segments except the physical well-being of the chest. Following
reconstruction with PAP flaps, they found lower extremity functional scale scores of 75/80 (94%) by 6
months. Patients reported high scores for both satisfaction with breasts and thigh domains, 78.9% and
82.1%, respectively . After stacked autologous reconstruction, the BREAST-Q scores were comparable to
[25]
bilateral DIEP and bilateral PAP flap reconstructions . Such findings further reinforce the use of the PAP
[41]
[50]
flap as an additional donor site for autologous breast reconstruction .
SUMMARY WITH SOME KEY POINTS
● Given its long pedicle, muscle preservation, easy contouring of the soft tissue, and minimal aesthetic
shortcomings of the donor site, the PAP flap is an excellent choice for autologous breast reconstruction.

● Ideal candidates for PAP flaps are those who are pear-shaped, carrying most of their weight in their
thighs, or massive weight loss patients who would benefit from a thigh lift.

● Smaller flaps in patients with limited skin laxity may not completely replace the breast footprint. In these
cases, stacking smaller flaps is a good option to reduce donor site morbidity and add adequate volume.
These are the same patients who have undergone radiation to the chest or those undergoing delayed
reconstruction following a mastectomy without tissue expander placement. In these cases, more skin may
be needed for resurfacing of the chest and/or to recreate the natural ptotic shape of the breast. Frequently,
you can plan a diagonally orientated PAP or stack flaps, or do a combination of both to achieve enough skin
and volume for the reconstruction.

● Dissection in lithotomy maximizes exposure and ergonomics for the surgeon.

● Broadly open the fascia and split the muscle along the entire length of the flap to prevent working in a
hole and enhance the exposure of nerves and perforators during the dissection.

● The vein is always larger than the artery along the course of the perforator. Dissection should continue to
a point where the length is adequate to reach the recipient vessels and to the point where the artery is a good
size match for the recipient artery. This is usually > 8-10 cm.

● Leave the posterior incision intact during dissection of the pedicle. Once the pedicle is completely
dissected, it can then be ligated and divided. Regaining this exposure is difficult to replicate, so we like to
divide the pedicle before the posterior incision is made. The flap remains perfused from posterior
perforators, allowing time for recipient vessels to be prepared and limiting ischemia time.

● Indocyanine green angiography (SPY-PHY) is used after the anastomosis is performed on the chest to
confirm that the flap is adequately perfused and to identify poorly perfused areas of the flap for removal

DECLARATIONS
Acknowledgments
The authors would like to acknowledge Dr. Martin R. Prince, M.D., Ph.D., for providing the MRA images
presented in this manuscript using Weill Cornell Imaging.