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Olla et al. Plast Aesthet Res 2024;11:24 https://dx.doi.org/10.20517/2347-9264.2024.30 Page 3 of 14

Given its long pedicle, muscle preservation, easy contouring of the soft tissue, and minimal aesthetic
shortcomings of the donor site, PAP flaps are an excellent second choice for autologous breast
reconstruction. This review will summarize the indications, vascular anatomy, preoperative planning,
operative technique, and postoperative care when utilizing a PAP flap in breast reconstruction.

CLINICAL CONSIDERATIONS
Ideal patients for PAP flaps require small to moderate breast volume and have excess tissue in the posterior
thigh region. Ideal candidates are pear-shaped, carrying most of their weight in their thighs, or massive
weight loss patients that would benefit from a thigh lift. PAP flap patients often have a contraindication to
abdominally based flaps. This includes patients with prior abdominal surgeries that have affected the blood
supply to the lower abdomen (i.e., liposuction, abdominoplasty, laparotomy) or those patients who have
already had a DIEP flap . If there is concern about the integrity of the vascularity when evaluating a patient
[23]
for potential abdominally based free tissue transfer, imaging with CTA or MRA can provide additional
information to determine candidacy.

Other patients may not have enough abdominal tissue to provide adequate volume flaps. Multiple studies
have found that individuals with low body mass index (BMI) and without adequate abdominal tissue can
harvest enough soft tissue for breast reconstruction with PAP flaps. The average BMI of patients across
studies ranges from roughly 22 to 26, with PAP flap weights averaging 300 to 400 g [24-26] . In situations where
additional soft tissue is needed for breast reconstruction, the PAP flaps can be stacked together for unilateral
reconstructions or with other donor sites for bilateral reconstructions [27,28] .

PAP flaps are contraindicated in patients with prior surgery to the donor site, venous insufficiency of the
lower extremity, history of deep vein thrombosis of the legs, lower extremity lymphedema, and body mass
2
index > 35 kg/m .

Abdominal-based flaps are generally considered safe for the obese population. However, a higher BMI is
linked to an increased risk of wound healing issues, infection, and flap failure [29,30] . These findings have
translated to similar results in the PAP population, showing that increased BMI also raises the risk of donor
site complications . The decision to limit PAP flap reconstruction to patients with a BMI less than 35 is a
[31]
relative contraindication. Typically, these patients have limited laxity in their thigh region and are prone to
complications such as seroma formation and wound dehiscence. Furthermore, patients with a higher BMI
face an increased risk of deep vein thrombosis, which is further compounded by the meticulous
manipulation of the soft tissues in the thighs required for this procedure. Nevertheless, each patient is
unique, and an individualized assessment should be undertaken to evaluate the risks and benefits of the
procedure thoroughly.

PREOPERATIVE PLANNING
Successful microsurgery requires meticulous preoperative planning and routinely includes preoperative
imaging. As imaging has become more accurate in predicting perforator anatomy, computed tomography
angiography (CTA) and magnetic resonance angiography (MRA) are being more commonly utilized to
[32]
assess perforator location, size, and anatomic variations preoperatively . Thin slice CTA has been
commonly used in preoperative imaging as it is widely available, fast, familiar to most surgeons, and
provides accurate anatomic localization of the perforators. Limitations of CTA include the requirement for
radiation, complexity in the timing of contrast bolus, and poor opacification of veins. Additionally, the
images obtained through CTA may not be of the highest quality if radiation dosage constraints are imposed.
As an alternative, MRA has lower spatial resolution but makes up for it with superior contrast resolution.