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Page 2 of 14 Olla et al. Plast Aesthet Res 2024;11:24 https://dx.doi.org/10.20517/2347-9264.2024.30

[5]
health-related quality of life compared to patients with implant-based reconstruction .

[4]
The gold standard for autologous breast reconstruction is abdominally based free flaps . The creation of the
conventional pedicled transverse rectus abdominus myocutaneous (TRAM) flaps and the free TRAM set the
[6,7]
stage for autologous breast reconstruction . Since its introduction in 1994, the deep inferior epigastric
perforator (DIEP) free flap has been established as the most widely used operation for autologous breast
reconstruction, offering less donor site morbidity with equally successful results [8-10] .

In patients where there are contraindications to abdominally based flaps, other donor sites for autologous
reconstruction should be considered. Thigh-based flaps have become the second most common option.
These include the gracilis-based flaps (Transverse [TUG], diagonal [DUG], and vertical upper gracilis
[VUG] myocutaneous flaps), the lateral thigh perforator (LTP) flap, and the profunda artery perforator
(PAP) flap. The PAP flap has emerged as a commonly utilized thigh-based flap, given its favorable ability to
be oriented according to the patient’s body habitus and scar preference. Originally, the PAP flap was
[11]
described for posterior thigh V-Y flaps in the 1980s . In 2001, a study with 20 cadaveric dissections and 25
PAP flaps was published describing the anatomy and soft tissue territory for this flap with a reported vessel
diameter of 2 mm and a pedicle length of 7-9 cm . It was not until 2012 that Allen et al. described the use
[12]
and technique of the PAP flap as a reliable option for autologous breast reconstruction. Their initial reports
included a series of 27 flaps detailing the harvest of perforators off the profunda femoris artery to transfer
posterior thigh soft tissue to the breast .
[13]

There are several reasons why the PAP flap has become a more popular option compared to other donor
sites. Compared to gracilis-based flaps mentioned above, the PAP flap is a perforator flap that does not
require muscle sacrifice, potentially reducing donor site pain, functional morbidity, and dead space [14,15] . In a
systematic review, the PAP flap had a longer pedicle length, increased flap weight, decreased occurrence of
donor site wound dehiscence, and similar rates of partial flap necrosis and total flap loss compared to the
[16]
TUG flap . An additional advantage of the PAP flap is that it is located more posteriorly on the thigh,
further away from the major lymphatic drainage of the lower extremity. This location reduces the
devastating risk of postoperative lymphedema that can be seen with the TUG flap [15,17] . Compared to other
alternate options for breast reconstruction (i.e., gluteal artery perforator [IGAP, SGAP] flaps, lumbar artery
perforator [LAP] flaps), the incisions of a transversely-oriented PAP flap can be concealed within the gluteal
crease, providing an inconspicuous scar that does not disrupt the gluteal crease or contour. Upper medial
thigh tissue exhibits greater malleability than gluteal and lumbar tissue, making it easier to shape into a
breast with a natural ptotic appearance . Additionally, sensory nerves in the thigh have been identified as
[4]
suitable for harvesting and neurotization of PAP flaps [18,19] . Dayan and Allen, Jr. successfully performed the
first neurotized PAP flap through end-to-end coaptation of the anterior branch of the obturator nerve to the
lateral branch of the T4 intercostal nerve .
[19]

The main disadvantage of PAP flaps for breast reconstruction remains the relatively limited volume when
larger volume reconstructions are desired [4,20] . It has been reported that the average volume of a hemi
abdominal DIEP flap is approximately 700 g, while volumes for PAP flaps range from 220 to 405 g, with the
possibility of higher volumes through modifications in the flap design [20,21] . Haddock published a review of
his experience of a decade of PAP flaps and reported an average flap weight of 354.3 g across the 405 PAP
flaps he performed . Other disadvantages include the potential for sensory changes to the posterior thigh,
[22]
patient positioning during surgery, and conspicuous scars on the posterior thigh (with transversely or
vertically oriented PAP flaps).