Profunda Artery Perforator Research Articles

Color differences of skin paddles using the free flap for autologous breast reconstruction in Asian patients.

In this study, we aimed to evaluate color differences of the skin paddle in autologous breast reconstruction performed using the deep inferior epigastric artery perforator (DIEP) flap and the profunda artery perforator (PAP) flap. The primary focus was to compare the color match between the reconstructed breast skin and the donor-site skin, to achieve optimal esthetic results. A retrospective analysis was performed on patients who had undergone unilateral breast reconstruction with a DIEP flap or a PAP flap between January 2020 and December 2022. The colors were captured using a digital camera and analyzed using Adobe Photoshop 2024 software. The L*, a*, and b* coordinates were used. The International Commission on Illumination Delta E 2000 (CIEDE2000) score was used to quantify color differences, comparing skin tones of the unaffected breast, DIEP flap, PAP flap, abdomen, and medial thigh. A total of 125 patients were analyzed. The DIEP flap demonstrated a closer color match to the native breast skin compared with the PAP flap (CIEDE2000 scores, 5.29 vs. 8.69, p < 0.01). No significant difference in color deformity with time was found between the DIEP flap and the PAP flap (CIEDE2000 scores, 5.61 vs. 8.25, p = 0.17). Our findings suggest that the DIEP flap results in a more favorable color match for breast reconstruction than the PAP flap, enhancing esthetic outcomes. These results underscore the importance of considering skin color matching in flap selection for breast reconstruction surgery.

“Comparison of DIEP and PAP free flaps for breast reconstruction in the context of breast cancer: A retrospective study of 677 patients over 10 years”

BackgroundPAP (Profunda Artery Perforator) flap following cancer surgery has emerged as a relevant alternative for breast reconstruction but remains mainly used in cases where the DIEP (Deep Inferior Epigastric Perforator) flap cannot be performed. The aim of this work is to compare PAP and DIEP flaps’ surgical and aesthetics outcomes in breast reconstruction. MethodsWomen who underwent breast reconstruction by DIEP or PAP flap at the Plastic Surgery Department of Georges Pompidou European University Hospital, Paris, France, between January 2012 and December 2020 were included. Patient’s demographic characteristics were recorded as well as type, laterality and timing of reconstruction. Operative times, length of hospital stay, general and surgical complications were compared. The number of late surgical reoperations, their timing relative to the initial reconstructive procedure, and their purpose were also compared. ResultsA total of 677 patients were included, 559 of whom received a DIEP flap and 118 a PAP flap. PAP flap patients were significantly younger, thinner, and had a smaller initial bra cup size than those who received a DIEP (p<0.001) Operative time was similar for both groups (p=0.074). There was no difference in the number of early postoperative reoperations (p>0.554) or of late revisions (p>0.403) between DIEP or PAP. ConclusionProvided that the technical and human resources are available, PAP flap is a valid technique, with no increased risk of surgical complications and reoperations, nor lengthening of operative time. The PAP flap should be considered a primary therapeutic option and not only an alternative to the DIEP flap.

Considering factors for breast reconstruction using stacked profunda artery perforator flaps in an Asian patient: a case report

In cases where there is insufficient abdominal tissue or a history of previous abdominal surgery, thigh tissue may be considered as an alternative for reconstruction. This report discusses a case involving a 49-year-old Asian woman with thin abdominal fat and thick thigh fat, who underwent a right nipple-sparing mastectomy followed by bilateral profunda artery perforator flap breast reconstruction. The discussion will address specific considerations relevant to Asian patients preoperatively.

Clinical Outcomes Following Profunda Artery Perforator Flap Breast Reconstruction: A Systematic Review and Meta-Analysis.

There is a lack of reliable evidence on the surgical outcomes of profunda artery perforator (PAP) flap breast reconstruction. We conducted a meta-analysis to evaluate its safety and compare it with deep inferior epigastric perforator (DIEP) flap, aiming to offer more information on whether the PAP flap was an ideal alternative for autologous breast reconstruction. PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The postoperative complication rates following PAP reconstruction were pooled. Mean differences of patients' age, BMI, mastectomy weight and flap weight between PAP and DIEP group were calculated, and relative risk was estimated to compare their incidence of complications. Twenty-four articles reporting 1612 PAP flap breast reconstructions were included. The surgical success rate was 99.6%; the incidence of total and partial flap loss was 0.4% and 0.0%; the incidence of infection, hematoma, seroma, fat necrosis and wound dehiscence in recipient sites was 0.3%, 1.4%, 1.0%, 3.3% and 0.3%, respectively; the incidence of infection, hematoma, seroma, wound dehiscence and sensory disturbance in donor sites was 2.0%, 0.9%, 3.5%, 9.2% and 0.6%, respectively. Compared to the DIEP group, the average age, BMI, mastectomy weight and final flap weight were significantly lower in the PAP group. No significant difference was observed in terms of flap failure, breast fat necrosis and donor site wound dehiscence. This systematic review demonstrates similar levels of postoperative morbidities for the PAP and DIEP flaps with some subtle differences and verifies the PAP flap as a second-line treatment for patients when the DIEP is unavailable or undesirable. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Effect of Leg Dominance in Patients on Perforator-Based Flaps Elevated From the Lower Extremities.

The lower extremities are the largest donor sites in the body for perforator flap reconstruction. Multislice row computed tomography angiography allows for a multiplanar assessment of perforators using a large number of three-dimensional images with high resolution. In this study, the effect of leg dominance on perforator flap donor site preference was investigated radiologically to increase preoperative perforator mapping precision and surgical success. The study included 40 patients. Superior gluteal artery perforator (SGAP) flap, inferior gluteal artery perforator (IGAP) flap, superficial circumflex iliac artery perforator flap, anterolateral thigh (ALT) flap, profunda artery perforator (PAP) flap, medial sural artery perforator (MSAP) flap, peroneal artery perforator (PP) flap, and posterior tibial artery perforator (PTAP) flap were analyzed according to their number of perforators (> 0.8-mm perforators counted, number of larger perforators [nLP]), dominant perforator diameter (DPD), related muscle thickness (RMT), and related subcutaneous tissue thickness (RSTT) in each leg. Of these 40 patients, 35 (87.5%) were right-leg dominant and 5 (12.5%) were left-leg dominant. The dominant leg had higher DPD for MSAP, PTAP, and PP than the nondominant leg (p = 0.08, p = 0.06, and p = 0.06, respectively). The dominant leg had a significantly higher nLP (> 0.8 mm) in MSAP, PTAP, and PP flaps than the nondominant leg (p < 0.05). Except for the PAP flap (adductor magnus muscle; p > 0.05), RMT of all other perforator flaps (SGAP, IGAP, ALT, MSAP, PTAP, and PP) was statistically higher in the dominant leg (p < 0.05). There was no statistically significant difference in RSTT between any of the two groups (p > 0.05). According to findings, the dominant leg could be considered a donor site preference to improve surgical outcomes and reduce microsurgical complications due to an increased nLP, perforator diameter, and RMT.

Systematic Review of the Profunda Artery Perforator Free Flap for Head and Neck Reconstruction.

The profunda artery perforator (PAP) flap has gained popularity in head and neck reconstruction with a favorable donor site providing a relatively hidden scar and the ability to harvest a large amount of pliable tissue with consistent vascular anatomy. The primary aim of this study is to evaluate the safety and efficacy of this PAP flap in head and neck reconstruction. PUBMED, EMBASE, Web of Science, Google Scholar (January 1948-February 2022). A systematic review of the English language literature was conducted for studies with at least 3 patients 18 years or older undergoing head and neck reconstruction utilizing the PAP. Study quality and risk of bias were evaluated using the MINORS scoring system. Main analysis endpoints were flap failure rate, donor site morbidity, and complication rate. Nine articles and 206 total PAP flaps were included. The rate of flap-related and medical complications was 33%, with only 2 (0.97%) instances of complete flap failure. Other complications included partial flap failure (10, 4.86%) and donor site wound complications (12, 5.83%). A total of 16 flaps (7.77%) required subsequent revision in the operating room. Average MINORS score of the studies suggested a moderate to high risk of bias. Based on limited quality evidence, this review suggests that the PAP flap is a safe and feasible tool for head and neck reconstruction, with comparable complication and success rates as other free flaps. Further large-scale studies are warranted.

Advances in Microsurgical Treatment Options to Optimize Autologous Free Flap Breast Reconstruction

Introduction: Reconstructive plastic surgeons have made great strides in the field of breast reconstruction to achieve the best results for patients undergoing treatment for breast cancer. As microsurgical techniques have evolved, these patients can benefit from additional treatment modalities to optimize the results of the reconstruction. Free tissue transfer from alternative donor sites for breast reconstruction is routinely performed, which was not possible in the past. Neurotization is now possible to address the numbness and lack of sensation to the reconstructed breast. For those patients who develop lymphedema of the upper extremity as a result of their breast cancer care, supermicrosurgical options are now available to treat and even to prevent the development of lymphedema. This study presents a narrative review regarding the latest microsurgical advancements in autologous free flap breast reconstruction. Methods: A literature review was performed on PubMed with the key words “autologous free flap breast reconstruction”, “deep inferior epigastric perforator flap”, “transverse upper gracilis flap”, “profunda artery perforator flap”, “superior gluteal artery perforator flap”, “inferior gluteal artery perforator flap”, “lumbar artery perforator flap”, “breast neurotization”, “lymphovenous bypass and anastomosis”, and “vascularized lymph node transfer”. Articles that specifically focused on free flap breast reconstruction, breast neurotization, and lymphedema surgery in the setting of breast cancer were evaluated and included in this literature review. Results: The literature search yielded a total of 4948 articles which were screened. After the initial screening, 413 articles were reviewed to assess the relevance and applicability to the current study. Conclusions: Breast reconstruction has evolved tremendously in recent years to provide the most natural and cosmetically pleasing results for those patients undergoing treatment for breast cancer. As technology and surgical techniques have progressed, breast cancer patients now have many more options, particularly if they are interested in autologous reconstruction. These advancements also provide the possibility of restoring sensibility to the reconstructed breast as well as treating the sequela of lymphedema due to their cancer treatment.

DIEP Flap versus PAP Flap versus LAP Flap: A Propensity-Matched Analysis of Aesthetic Outcomes, Complications, and Satisfaction.

As free breast reconstruction options evolve, a patient- and body-centric approach can distinguish refined aesthetic outcomes. Although deep inferior epigastric perforator (DIEP), profunda artery perforator (PAP), and lumbar artery perforator (LAP) flaps are all safe and effective options for breast reconstruction, a head-to-head analysis of these 3 flaps has not been performed. The authors aim to compare these 3 flaps based on outcomes, BREAST-Q scores, and aesthetic results. After institutional review board approval, a retrospective review in a Research Electronic Data Capture database-guided analysis was conducted of patients who underwent simultaneous bilateral DIEP, PAP, or LAP flaps at a single academic institution. Propensity matching was performed to match 50 patients (100 flaps) in each group. Postoperative complications and BREAST-Q satisfaction survey scores were documented, and crowdsourcing was carried out to determine aesthetic preference in the general population. Overall patient postoperative breast satisfaction was insignificantly different across the 3 flap groups ( P > 0.05). Associations were seen with LAP flap donor-site seromas, PAP flap donor-site infections and wounds, and DIEP flap breast wounds and flap necrosis ( P < 0.05). DIEP flaps had a higher raw score average on crowdsourcing survey, although LAP flaps were rated significantly higher aesthetically than DIEP and PAP flaps when undergoing a matched head-to-head analysis ( P < 0.05). DIEP, PAP, and LAP flaps all have favorable outcomes with insignificantly different long-term satisfaction, with comparable complication profiles. Although DIEP flaps may initially score higher, LAP flaps score higher frequently when analyzed in a head-to-head analysis. For these reasons, tailoring breast reconstruction to the patient's anatomy and morphology provides optimal outcomes. Therapeutic, III.

Multi-Flap Microsurgical Autologous Breast Reconstruction.

Microsurgical autologous breast reconstruction (MABR) remains the gold standard technique of breast reconstruction, providing a durable, natural, and aesthetically pleasing result. However, some patients may not be candidates for a traditional deep inferior epigastric perforator (DIEP) flap, either due to abdominal tissue paucity, the need for higher-volume reconstruction, or prior surgical procedures. In these patients, alternative flaps must be considered to achieve the optimal result. Such configurations include the conjoined (or double pedicle) DIEP flap, and alternative flaps such as the lumbar artery perforator (LAP) and profunda artery perforator (PAP) flaps, which can be combined in a stacked fashion. By combining multiple flaps in a conjoined or stacked fashion, breast reconstruction can be optimized to fulfill the three critical components of breast reconstruction in restoring the skin envelope, breast footprint, and conus shape. When harvesting multiple flaps, the surgical sequence of events must be meticulously planned to ensure an efficient and successful operation. Preoperative imaging can aid the surgeon in identifying the ideal perforator, assess for side branches for possible intra-flap anastomoses, expedite the operative time, and decrease intraoperative complications. Reconstructive surgeons should be familiar with the variety of configurations with conjoined and/or stacked flaps to address patient-specific reconstructive needs.

Anatomical Analysis of the Superior Gluteal Artery in 100 Women for Superior Gluteal Artery Perforator Flap Breast Reconstruction.

The superior gluteal artery (SGA) perforator (SGAP) flap is used more rarely for breast reconstruction with autologous tissue than other flaps because the SGA is often narrow, and the SGAP can be short. However, it provides ample fat, including in lean women. To improve its safety and utility, the preoperative SGA course in women who underwent autologous breast reconstruction was determined with three-dimensional computed tomography angiography. Consecutive deep inferior epigastric perforator, profunda artery perforator, and SGAP flap cases in 2019-2023 were identified. Frequencies of the following favorable preoperative SGA-anatomy variables were determined: branching of the main-SGA trunk on top/posterior of the greater sciatic foramen (designated M1/2), which allows access to a sufficiently wide SGA artery; superolateral perforating location of the superficial-SGA branch (SP3), which means the perforator is sufficiently long for uncomplicated flap placement; and nonbranching of the deep-SGA branch (D1/D2), which means this branch can used a venous and an arterial graft to extend an insufficiently long perforator. A total of 100 cases of deep inferior epigastric perforator (n = 80), profunda artery perforator (n = 13), and SGAP flap-based breast reconstructions (n = 7) were identified. Out of 200 buttocks, 89%, 91.5%, and 62% had the favorable M1/2, SP3, and D1/D2 variables, respectively. An atypical descending branch feeding the lower buttocks (DES1/2) was observed in 34%. The branching position of the main-SGA trunk, perforating location of the SGAP, and the shape of the deep branch were classified in detail in 100 patients. By creating a surgical plan that understands the anatomy taking preoperative three-dimensional computed tomography angiography, the SGAP flap can accommodate many patterns, increasing the possibility of safe execution.

Microsurgical breast reconstruction in the United States: a narrative review of the current state.

Breast reconstruction with microsurgical techniques allows for autologous reconstruction after mastectomy without the complications associated with alloplastic reconstruction. Autologous reconstruction has undergone significant improvement and now offers patients a variety of options depending on patient specific factors and aesthetic outcomes. This review aims to focus on the history of autologous reconstruction, operative considerations, general surgical techniques for flaps, and indications for choosing the ideal free tissue transfer for all medical specialties and not only plastic surgeons. A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to history of microsurgical options, surgical techniques, patient considerations, and contraindications were utilized for this review with the objective to simplify data for all non-plastic surgeon readers. In this study, we find that patient selection is critical in successful outcomes for microsurgical breast reconstruction. We find that abdominal free flaps are now considered gold standard for autologous reconstruction. However, reliable alternatives exist for patients who are not considered ideal candidates for this reconstruction. These include thigh-based flaps such as gracilis myocutaneous flaps, profunda artery perforator flaps, lateral thigh perforator flaps and trunk-based flaps such as lumbar artery perforator flap. Postoperative considerations involve clinical monitoring and enhanced recovery after surgery. The rate of reconstructive success and flap viability is greater that 95%, even in high-risk populations, and therefore risk stratification should be performed based on an individual basis. While there are no absolute contraindications to autologous reconstruction, relative contraindications do exist including obesity and elderly populations due to the increased surgical and medical complications. While implant-based reconstruction remains the predominant method of breast reconstruction in the United States, there have been many exciting advancements in autologous reconstruction that offers high aesthetic outcomes and patient satisfaction.

Characterization of the Posterior Femoral Cutaneous Nerve and Its Clinical Application for Autologous Breast Reconstruction

IntroductionAutologous breast reconstruction (ABR) uses a harvested tissue flap from the abdomen, posterior thigh, or buttocks to rebuild the breast postmastectomy. Identification of nerves for use in autologous sensate breast reconstruction flaps is an important surgical consideration as loss of breast sensation is a common risk of ABR. The posterior femoral cutaneous nerve (PFCN) and its branches supply sensory innervation to skin of the posterior thigh, leg, perineum, and buttocks, creating a feasible candidate for sensate profunda artery perforator (PAP) flaps for reestablishing breast sensation through ABR. This study characterized PFCN perforating branches located within the PAP flap region as compared to an anatomical landmark intersection (ALI). Twenty-three posterior thigh regions from 15 formalin-embalmed donors were dissected to the level of deep fascia to identify PFCN branches. PFCN branch diameter (mean, 1.34 ± 0.35 mm) and length (mean, 8.82 ± 5.78 mm) piercing the deep fascia were measured; branches were retro-dissected proximally to the PFCN trunk and the distance recorded (mean, 92.55 ± 38.00 mm). The distance to branch emergence from ALI (mean, 113.55 ± 19.80 mm) and from the midline of the posterior thigh (mean, 18.90 ± 11.17 mm) were calculated. Two-Tailed T-tests comparing the left and right limb of 7 donors determined bilateral, statistically significant difference between the length of branch emergence back to the main trunk of PFCN (P = .00). These findings illustrate the presence of adequate yet variable PFCN branches within the PAP flap region in regards to diameter, length, and location for use in sensate ABR.

The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction.

Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable. After receiving local institutional review board approval, a single center, retrospective cohort study from January 2020 to December 2021 was performed assessing pedicled vPAP flap reconstruction of APR defects. Age, sex, body mass index, primary diagnosis, comorbidities, concomitant oncologic procedures, radiation, timing, incorporation of gracilis flaps, follow-up, and complications were compared. Ten patients (70% male) with an average age of 56.2 years and BMI of 27.6 were included in the study. Rectal adenocarcinoma (50%) was the most common indication for APR, followed by rectal squamous cell carcinoma (30%), vulvar squamous cell carcinoma (10%), and Crohn disease (10%). Eighty percent of the patients received radiation, and 70% of reconstructions were delayed after the initial resection. The average length of clinical follow-up was 26.1 months. Concerning major complications, 2 patients were required to return to the operating room due to venous congestion (20%), and 2 patients suffered partial flap failure (20%). Minor complications were perineal dehiscence (50%), abscess requiring percutaneous drainage by interventional radiology (30%), and infection requiring antibiotics (20%). Twenty percent of patients developed fistulas requiring surgical excision. There were no instances of donor site dehiscence, and there was no complete flap loss, indicating successful reconstruction in all included cases. vPAP flaps are a reliable method to reconstruct perineal defects with less donor-site morbidity than previous reconstructive options. vPAP flaps should be considered in the setting of delayed reconstruction, minimally invasive APRs, and when the abdominal donor site is unavailable.

Surgical outcomes of profunda artery perforator flap in head and neck reconstruction: A systematic review and meta-analysis.

This study aims to evaluate the efficacy of the profunda artery perforator (PAP) flap in head and neck reconstruction. A single arm meta-analysis was performed for flap survival rate (primary outcome), reoperation for major complication, and overall complication rates (secondary outcomes). The search strategy yielded a total of 295 potentially relevant publications, of which 13 were included. A total of 305 patients (males: 80.8%, n = 232/281), with a median age of 56.1 years (n = 305/305; 95% CI 53.9-63), who underwent a total of 307 PAP flap reconstructions for head and neck defects were included. Flap survival rate was 100% (n = 306/307; 95% CI 99.6%-100%), with a reoperation rate for major complications of 3.7% (n = 15/307; 95% CI 1.85%-6.1%) and an overall complication rate of 26.5% (n = 92/307; 95% CI 15.7%-38.9%). Notable postoperative complications included wound dehiscence (n = 15/307, 4.9%), delayed healing (n = 14/307, 4.6%), and wound infection (n = 12/307, 3.9%). Partial flap necrosis and hematoma occurred in 2.6% of cases (n = 8/307), while arterial and venous thrombosis were documented in 0.7% (n = 2/307) and 1.3%, respectively (n = 4/307). The application of the PAP flap in head and neck reconstructions showed several favorable aspects, such as an exceptionally low flap failure rate, versatility in achieving variable dimensions, and a relatively low incidence of complications. PAP flap might be considered as a compelling alternative to the traditionally employed soft tissue free flaps in head and neck reconstruction.

Profunda artery perforator free flaps for breast reconstruction

Profunda artery perforator free flaps for breast reconstruction

Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction.

Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is the current gold-standard autologous option. The profunda artery perforator (PAP) and lumbar artery perforator (LAP) flaps have more recently been described as alternatives for patients who are not candidates for a DIEP flap. The aim of this study was to review the survival and complication rates of PAP and LAP flaps, using the DIEP flap as a benchmark. A literature search was conducted using PubMed, MEDLINE, Embase, BIOSIS, Web of Science, and Cochrane databases. Papers were screened by title and abstract, and full texts reviewed by three independent blinded reviewers. Quality was assessed using MINORS criteria. Sixty-three studies were included, for a total of 745 PAP, 62 stacked PAP, 187 LAP, and 23,748 DIEP flap breast reconstructions. The PAP (98.3%) had comparable success rate to DIEP (98.4%), and the stacked PAP (88.7%) and LAP (92.5%) success rate was significantly lower (P < 0.0001). The PAP and LAP groups both had a low incidence of fat necrosis. However, the revision rate for the LAP group was 16.1% whereas the PAP group was 3.3%. Donor site wound dehiscence rate was 2.9 in the LAP group and 9.1% in the PAP group. Profunda artery perforator and DIEP flaps demonstrate very high rates of overall survival. The LAP flap has a lower survival rate. This review highlights the survival and complication rates of these alternative flaps, which may help clinicians in guiding autologous reconstruction technique when a DIEP flap is unavailable.

Volumetric Analysis of a Novel Chimeric Gracilis and Profunda Artery Perforator Flap.

The presence of a chimeric gracilis and profunda artery perforator (PAP) flap with a common arterial pedicle has been demonstrated on computed tomography angiography in up to 59% of patients and confirmed in a cadaveric model. Already utilized for head and neck reconstruction by Heredero et al, this novel flap could provide more volume than either flap alone which is advantageous, particularly in patients with sizable defects. The purpose of this study was to determine the average tissue volume that can be utilized from this chimeric flap. CT Angiogram imaging studies exhibiting chimeric flap anatomy were reviewed over a 7-year period at a single institution utilizing Visage Version 7.1, a radiology picture archiving and communication system. This software was used to trace the flap pedicles and to capture estimated soft tissue volumes of each respective flap. A total of 31 patients, consisting of 52 lower extremity gracilis and PAP chimeric flaps, underwent tissue volume analysis. The average total volume of soft tissue supplied by the gracilis flap was found to be 70.21 cm3 (standard deviation [SD] = 26.99). The average volume of the PAP flap was 31.73 cm3 (SD = 26.12). The average total volume captured by the chimeric gracilis and PAP flap was 101.94 cm3 (SD = 62.40). The potential soft tissue volume that can be harvested from a chimeric gracilis and PAP flap is significantly greater than solitary gracilis or PAP flaps. This chimeric flap may serve as a viable and advantageous reconstructive option for patients requiring large volume soft tissue coverage, particularly if other sizable options are not available.

Neurotized profunda artery perforator flap for subtotal tongue reconstruction – Prospective case series

BackgroundTotal or subtotal glossectomy defects cause significant functional deficits in swallowing and speech and subsequently impair patients’ quality of life. Recently, the profunda artery perforator (PAP) flap has emerged as a potential alternative for reconstructing extensive glossectomy defects. While previous studies assessing recovery of neurotized ALT flaps in head and neck reconstruction reported superior sensory recovery, improved swallow function, and improved overall patient satisfaction in patients with neurotized flaps vs. non-neurotized ALT flap reconstruction, PAP flap neurotization has not been described and systematically assessed in head and neck patients. MethodsSix patients underwent subtotal tongue reconstruction with neurotized PAP flaps at the authors’ institution from May 2022 until August 2023. A branch of the posterior femoral cutaneous nerve of the PAP flap was coaptated to the lingual nerve. Two-point discrimination, Semmes-Weinstein monofilament, pain, and temperature assessments were conducted at 3, 6, and 12 months postoperatively on the neo-tongue. The MD Anderson speech and deglutition scales and the EORTC-QLQ-H&N35 were used to record functional outcomes and QOL. ResultsMean age was 69±4 years and mean BMI was 25±7kg/m2. Neo-tongue median two-point discrimination at the tip improved from >10mm at 3 months to 6mm at 12 months. All patients had protective pain and temperature perception at the neo-tongue tip at 6-month follow-up. Speech and swallowing function were similar at 12 month follow-up compared with data on neurotized ALT flaps from literature. No neuropathic pain was reported at the donor site at 6-month follow-up. ConclusionsThis is the first case series of PAP flap neurotization in head and neck patients, suggesting potential functional advantages with minimal donor site morbidity. Level of evidenceV Case Series

Donor site scar preference in head and neck free flap reconstruction: The patient point of view

BackgroundSeveral free flaps are nowadays available for functional reconstruction after hemi-glossectomy in head and neck oncologic surgery. Radial forearm free flap (RFFF) and anterolateral thigh (ALT) have been played a workhorse role until recent years, when other valuable options such as Medial Sural Artery Perforator (MSAP) flap and Profunda Artery Perforator (PAP) flap demonstrated to be suitable contenders and are increasingly taken into account. This study aims to investigate the preference of the donor site in the light of esthetical and functional outcomes. MethodsThe participants attended a one-to-one interview with a surgeon explaining a standardized head and neck oncological procedure requiring a soft tissue reconstruction. The donor site preference in terms of esthetical, functional and overall outcomes among these four flap options was investigated. ResultsUnivariable and multivariable analysis were performed comparing the donor site preference between the two most widespread free flap RFFF vs ALT. Subsequently, the analysis was performed comparing RFFF, ALT, MSAP and PAP. ConclusionsThe study illustrated that a diverse group of patients exhibits similarly diverse preferences and expectations. As we observe a shift in the age distribution of patients with OSCC from the fifth-sixth decade towards the two extremes, and an increased incidence in the female population, it becomes essential to enhance reconstructive options provided to patients. This ensures that, while maintaining an equivalent functional outcome, we maximize patient satisfaction to the fullest extent possible.

One versus two vein anastomoses in breast reconstruction with a profunda artery perforator flap-does it make a difference.

The profunda artery perforator (PAP) flap has gained popularity as a reliable alternative in breast reconstruction. Extensive research has focused on its vascular supply, dissection techniques, and broader applications beyond breast reconstruction. This study aims to investigate the correlation between the number of veins anastomosed for the PAP flap and postoperative complications. A retrospective study was conducted to evaluate the outcomes of breast reconstructions with PAP flaps at our institution between 2018 and 2022. A total of 103 PAP flaps in 88 patients were included. Statistical analysis was performed to compare outcomes between flaps with one vein anastomosis and those with two vein anastomoses. Patient characteristics, intra and postoperative parameters were analysed. One vein anastomosis was used in 36 flaps (35.0%), whereas two vein anastomoses were used in 67 flaps (65.0%). No significant differences were found in patient characteristics between the one vein and two vein groups. The comparison of ischemia times between flaps with one versus two veins revealed no statistically significant difference, with mean ischemia times of 56.2 ± 36.8 min and 58.7 ± 33.0 min, respectively. Regarding outcomes, there were no statistically significant differences in secondary lipofilling, revision of vein anastomosis, or total flap loss between the two groups. Fat necrosis was observed in 5 (13.9%) one vein flaps and 5 (7.5%) two vein flaps, indicating no statistically significant difference between the two groups (p = .313). In the one vein group, the most frequently employed coupler ring had a diameter of 2.5 mm. In the two vein group, the most prevalent combination consisted of a 2.0 mm diameter with a 2.5 mm diameter. Based on our study results, both one vein anastomosis and two vein anastomoses are viable options for breast reconstruction with PAP flap. The utilization of either one or two veins did not significantly affect ischemia time or flap loss. Fat necrosis exhibited a higher incidence in the single-vein group; however, this difference was also not statistically significant. These findings underscore the effectiveness of both approaches, providing surgeons with flexibility in tailoring their surgical techniques based on patient-specific considerations and anatomical factors.