Profunda Artery Perforator Research Articles

Donor-Site Morbidity and Quality of Life after Autologous Breast Reconstruction with PAP versus TMG Flap

The transverse myocutaneous gracilis (TMG) and the profunda artery perforator (PAP) flap are both safe choices for autologous breast reconstruction originating from the same donor region in the upper thigh. We aimed to compare the post-operative outcome regarding donor-site morbidity and quality of life. We included 18 patients who had undergone autologous breast reconstruction with a PAP flap (n = 27 flaps). Prospective evaluation of donor-site morbidity was performed by applying the same questionnaire that had already been established in a previous study evaluating TMG flap (n = 25 flaps) outcome, and results were compared. Comparison of the two patient groups showed equivalent results concerning patient-reported visibility of the donor-site scar and thigh symmetry. Still, the TMG group was significantly more satisfied with the scar (p = 0.015) and its position (p = 0.001). No difference was found regarding the ability to sit for prolonged periods. Donor-site wound complications were seen more frequently in the PAP group (29.6%) than in the TMG group (4.0%). Both groups expressed rather high satisfaction with their quality of life. Both flaps show minimal functional donor-site morbidity and high patient satisfaction. To minimize wound healing problems in PAP patients, thorough planning of the skin paddle is necessary.

The Superthin Profunda artery perforator flap for Extremity Reconstruction: Clinical Implications

The profunda artery perforator flap has numerous advantages. For coverage of extremity wounds, however, traditional subfascial harvest results in a thick flap, which routinely requires secondary thinning. The author describes his approach and experience with thin and superthin profunda artery perforator flaps for extremity reconstruction. With preoperative perforator localization via computed tomography angiogram, color Doppler, and handheld Doppler, the author used a single dominant perforator for extremity reconstruction in 10 consecutive patients. The mean age of patients who had a thin or superthin profunda artery perforator flap for extremity reconstruction was 41.2 ± 21.3 years. Flaps were used to cover wounds in the upper ( n = 3) and lower ( n = 7) extremities. Mean flap thickness was 0.7 ± 0.2 cm. Mean flap artery diameter was 16 ± 3 mm; mean flap vein diameter was 21 ± 6 mm. Mean pedicle length was 6.8 ± 1.2 cm. The difference between the actual measured intraoperative proximal-distal distance and the preoperative computed tomography angiogram measurement for each patient was calculated, with a mean difference of 1.2 ± 0.6 cm. Advantages of the profunda artery perforator flap include a concealed donor site, large perforator caliber, long pedicle length, and a straightforward perforator dissection. Intraoperative measurement of the proximal-distal distance of the dominant perforator fell within 2 cm of the preoperative computed tomography angiogram measurement in all cases. The thin and superthin profunda artery perforator flaps provide new reconstructive options, particularly suited for use in the extremities. Therapeutic, IV.

Does it Always have to be the Abdomen? Alternative Flaps in Autologous Breast Reconstruction

[English] Deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis muscle (ms-TRAM) flaps remain the gold standard for autologous reconstruction in post-mastectomy patients, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap), trunk (lumbar artery perforator flap), and buttock (superior and inferior gluteal artery perforator flaps). This article will provide insight into the history, relevant anatomy, surgical technique and novel applications (neurotization) for alternative flaps in autologous breast reconstruction.

BREAST-Q and Donor Site Comparison in Bilateral Stacked Autologous Breast Reconstruction.

Background:Patients undergoing bilateral autologous breast reconstruction may benefit from increased flap volume using bilateral stacked deep inferior epigastric perforator (DIEP) and profunda artery perforator (PAP) flaps. Our aim was to characterize the donor site morbidity and patient-reported outcomes in four-flap breast reconstruction.Methods:Retrospective review was performed for all patients undergoing four-flap breast reconstruction by two surgeons between January 2010 and September 2021. Outcome measures including the BREAST-Q reconstructive module, the lower extremity functional scale (LEFS), inpatient surgical site pain scores by numeric pain rating scale (NPRS), and a postoperative subjective survey comparing donor sites were obtained. Four-flap BREAST-Q scores were compared with bilateral DIEP and bilateral PAP patients.Results:A total of 79 patients undergoing four-flap breast reconstruction were identified. Four-flap BREAST-Q scores (n = 56) were similar to bilateral DIEP and bilateral PAP reconstruction patients. Long-term survey outcomes from the LEFS demonstrated improved score trend after 6 months. Mean instances of donor site pain location recorded at the abdomen were significantly higher than the thigh during the postoperative admission. Subjective survey data revealed more long-term donor site pain at the PAP site, a patient preference for the DIEP donor site, and easier postoperative care for the DIEP donor site.Conclusions:This is the largest consecutive series of four-flap breast reconstruction outcomes reported to date. BREAST-Q scores in four-flap patients demonstrate overall patient satisfaction that is similar to both bilateral DIEP and bilateral PAP reconstruction patients. The DIEP donor site appears to be preferred by patients over the PAP donor site.

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction.

Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated. Retrospective analysis. A single-institution review. PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps. A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m2 . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts. PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

Anatomical characteristics of profunda artery perforator flap in the posteromedial femoral region and its application in the reconstruction of oral and maxillofacial defects

Objective: To investigate the anatomical basis for the preparation of the profunda artery perforator flap (PAPF) in the posteromedial femoral region and its application in the reconstruction of oral and maxillofacial defects. Methods: Six lower limbs of Chinese adult cadavers were micro-surgically dissected. CT angiography (CTA) data of bilateral lower limbs of 6 patients was also collected retrospectively. The number, external diameter, pedicle length, and distribution of perforators in the posteromedial femoral region were recorded from the specimens and CTA data. Meanwhile, 10 patients with oral squamous cell carcinoma in the Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Stomatology, Nanjing Medical University from August 2018 to June 2021 were treated with the PAPF. At each follow-up, contour and function of recipient and donor site, as well as swallowing and speech function were evaluated. Results: A total of 19 profunda artery perforator were identified in 6 lower limb specimens. The outer diameter at the beginning of the source artery was (2.34±0.25) mm and the total length of the pedicle was (11.12±1.06) cm. CTA data analysis of 12 legs identified 15 perforators of profunda artery in the posteromedial region. Eleven perforators were septocutaneous, including 2 perforators with a common trunk, while the remaining 4 perforators were musculocutaneous. As for different patterns of perforators (septocutaneous perforators, musculocutaneous perforators and perforators with a common trunk), the longitudinal distance to the pubic tubercle was (19.95±2.43), (21.84±2.54) and (19.48±0.55) cm respectively. The horizontal distance to the posterior edge of gracilis was (3.54±1.10), (3.72±0.30) and (3.85±1.48) cm, respectively. The initial diameters of perforators was (2.4±0.4), (2.6±0.6) and 1.9 mm respectively. Ten cases of the profunda artery perforator flaps survived successfully after operation. The flap sizes ranged from 8 cm×6 cm to 12 cm×7 cm. The patients were evaluated at 1, 3 and 6 months, and with 6 months interval ever since. During the follow-up, the shape of the recipient site was ideal, and the swallowing and language functions were not significantly affected. There was only linear scar in the donor area, and the function of the thigh was basically normal. Conclusions: PAPF possessed a good anatomic stability, suitable vascular pedicle length and diameter, minor influence to the donor area, sufficient amount tissue with good quality. It is an ideal choice for head and neck reconstruction.

Evaluating the accuracy of three-dimensional surface-imaging for circumference analysis of the thigh

Three-dimensional (3D) surface-imaging is an increasingly popular and useful tool in surgical planning and evaluation. These systems are used for anthropometric measurements of the face, breast and upper extremity. Its accuracy has, however, not yet been evaluated for the thigh. This could prove useful in the evaluation of autologous breast reconstructions using fasciocutaneous tissue of the thigh, such as the profunda artery perforator (PAP) flap. Thirty-five patients who underwent PAP flap surgery and 35 healthy controls were included. Thigh circumferences were measured using a flexible measuring tape at pre-defined levels. 3D images of the thigh were taken with the Canfield Vectra XT and fused to create 3D reconstructions. 3D circumferences were measured using the Vectra Analysis Module. Measuring tape and 3D circumferences were compared for mutual agreement. Thigh circumference measurements by measuring tape correlated excellently with 3D measurements (r=0.999). Bland-Altman plots demonstrated good agreement with a mean difference of -1.2 mm between the measuring tape and 3D measurements. The mean relative difference of both methods was -0.24%. Paired t-tests showed no significant statistical differences between the measuring tape and 3D circumference measurements in legs that underwent PAP flap surgery and without. Flexible measuring tape and 3D circumference measurements of the thigh show excellent correlation. Three-dimensional surface imaging can thus be used to measure thigh circumferences in both patients with and without prior surgery of the thigh.

PC2. THREE-DIMENSIONAL TISSUE RENDERING AND VOLUME ANALYSIS OF A NOVEL MEDIAL THIGH FLAP USING CT ANGIOGRAPHY: THE CHIMERIC GRACILIS AND PAP FLAP

PURPOSE: A common arterial pedicle supplying both gracilis and profunda artery perforator (PAP) flap perforasomes is a recently described anatomical variation, favoring the potential harvest of a chimeric gracilis and PAP flap. We sought to characterize this novel flap configuration with three-dimensional (3D) angiography. METHODS: Lower extremity CT angiograms were performed according to standard angiography technique: 5 ml/s contrast injection with bolus tracking. Thin slice (0.6mm) axial reconstructions created multiplanar and volume rendered 3D images. Post-processing (Visage 7.1.15b) consisting of vessel measurements and centerline reconstructions of gracilis and PAP pedicles. Tissues supplied by these vessels were identified by tracing perforator branches, tagging supplied muscle and overlying tissues using semiautomated volume selection. RESULTS: A total of 974 CT angiograms were reviewed, yielding a total of 1,940 lower extremities (RLE= 970, LLE= 970) for evaluation. A chimeric gracilis and PAP flap was found in 51% of patients (N=494/974). Average length of the common arterial pedicle was 31.1 ±16.5 mm (Range = 2.0-95 mm), with an average diameter of 2.8 ±0.7 mm (Range = 1.3-8.8 mm). Average length of downstream gracilis and PAP flap pedicles were 58.0 ±18.7 mm (Range = 9.8-123 mm) and 101.7±27.0 mm (Range = 42.2-183 mm) respectively. 3D rendering yielded an overview of chimeric flap anatomy, allowing for comprehensive volumetric assessment (197.1 ± 29.2 cm3) CONCLUSION: 3D rendering of a chimerically configured gracilis and PAP flap with CT provides an objective assessment of arterial anatomy, flap configuration, and tissue volume for potential use in a clinical setting.

31. THE PEDICLED VPAP FLAP ALLOWS FOR PRESERVATION OF THE ABDOMINAL WALL IN THE RECONSTRUCTION OF APR DEFECTS

PURPOSE: Abdominoperineal resections (APR) often leave large cavitary defects that have historically been reconstructed with vertical rectus abdominus muscle (VRAM) flaps. We present a case series and surgical technique for a novel approach to reconstructing complex defects with a fasciocutaneous flap, the pedicled vertical profunda artery perforator (VPAP) flap, which was first performed for reconstruction of robotic and minimally invasive APR defects in order to preserve the functional abdominal wall. METHODS: A total of 13 patients underwent immediate or delayed reconstruction of APR defects using a pedicled VPAP. Seven patients underwent a minimally invasive APR, with six robotic-assisted and one laparoscopic-assisted procedure, leaving the abdomen completely intact. One patient had a previously failed VRAM, thus the abdomen was unavailable for reconstruction. One patient had bilateral ostomies. Five reconstructions were performed secondarily due to post-operative infection and dehiscence. RESULTS: Of the 13 cases, 2 patients required take back to the operating room for venous congestion. The major complication rate (15.4%) in this series was similar to historically reported rates described for VRAM reconstruction of APR defects. There were no total flap losses or donor site complications. All patients ultimately had successful wound closure. CONCLUSION: The pedicled VPAP presents a viable solution for reconstruction of APR defects while simultaneously preserving the functional abdominal wall in patients who have undergone minimally invasive ablative procedures. Additionally, this technique offers a reconstructive solution in patients that experience post-operative infection and dehiscence, or in whom the abdominal donor site is not available due to bilateral ostomies.

Long-Term Outcome Analysis and Technical Refinements after Autologous Breast Reconstruction with PAP Flap: What We Have Learnt

Introduction: The profunda artery perforator (PAP) flap represents a valuable alternative to the deep inferior epigastric artery perforator flap which, nowadays, is considered the golden standard for autologous breast reconstruction. The goal of this study was to evaluate the long-term satisfaction, functional outcomes of the donor site following PAP flap-based breast reconstruction and to present our personal learning experience along with suggestions for technique refinements. Methods: In this prospective single-center appraisal, 18 patients who underwent PAP flap-based breast reconstruction between January 2016 and November 2019 were enrolled. The Patient and Observer Scar Assessment Scale (POSAS) and the Breast-Q questionnaire were employed to evaluate the results 12 months postoperative. Data were analyzed with the Q-Score program. Complications were recorded in the medical database and classified with the Clavien-Dindo classification. Results: In the questionable time frame, 164 female patients underwent free flap breast reconstruction. Of those, 18 patients that received PAP flaps (9 bilateral) were included in this study. We recorded one flap loss because of venous failure. Most complications concerned the donor site, including hematoma, seroma, and wound healing problems. Patients’ satisfaction was high at 12 months post-surgery, despite critical evaluation of the donor site scar. Conclusion: The PAP flap serves as an excellent option for breast reconstruction in patients who do not have abundant abdominal tissue. The overall clinical outcome was good and patients’ evaluation showed high satisfaction after 12 months despite high complication rates. Modifications in planning and flap harvesting might improve the donor site outcome and the overall complication rate.

Comparing Donor Site Morbidity for Autologous Breast Reconstruction: Thigh vs. Abdomen.

Background:Although abdominally-based free flaps have long been the gold standard, the profunda artery perforator (PAP) flap has emerged as an important alternative option for autologous breast reconstruction. The aim of this study was to directly compare the donor site morbidity of using the PAP versus deep inferior epigastric perforator (DIEP) free flap.Methods:We performed a retrospective review of patients undergoing autologous breast reconstruction using a DIEP and/or PAP flap from January 2017 to December 2020. In total, 30 PAP flap patients were matched with 60 DIEP flap patients. Outcomes included donor site wound dehiscence, length of stay, narcotic consumption, and pain scores. Patient-reported outcomes for the thigh versus abdomen were compared using questions derived from the BREAST-Q.Results:There was no significant difference in length of stay (P = 0.182), reoperation rates (P = 0.999), flap failure rates (P = 0.999), or donor site complications (P = 0.999). Both groups had similar mean pain scores, maximum pain scores, daily and total narcotic requirements. In comparing the thigh or abdomen as a donor site, there was no difference in frequency of negative symptoms (difficulty with daily activities, discomfort, tightness, and negative impact on ability to work) or satisfaction scores as related to their appearance in and out of clothing and the appearance of the scar.Conclusions:The thigh and abdomen are both suitable donor sites for autologous breast reconstruction with similar flap-related and patient-reported outcomes. The ultimate decision regarding whether to use a PAP or DIEP flap for breast reconstruction should be tailored based on patient anatomy and preference.

Suprafascial radiological characteristics of the superthin profunda artery perforator flap

Traditional subfascial harvest of the profunda artery perforator (PAP) flap results in a thick flap, which routinely requires secondary thinning. The aim of this study was to characterize the suprafascial perforator anatomy of PAPs on preoperative computed tomography angiography (CTA) and correlate radiological findings with our clinical experience in extremity reconstruction. Suprafascial PAP anatomy was reviewed in CTAs in 159 thighs. Findings on CTA were correlated with intraoperative findings in a cohort of patients who had a PAP flap for extremity reconstruction. Two main perforator patterns, a "T" (superficial bifurcation) and "Y" (deeper bifurcation) were identified. The ratio between the total skin thickness and the distance from the skin to the perforator bifurcation point and the total skin thickness was higher in the "T" perforator pattern. A dominant "T" perforator (n=97) was more common than "Y" (n=62). A dominant "T" perforator was more common in women and with higher body mass index (BMI). In the clinical study, we found a positive correlation between the skin thickness of the bifurcation point of a dominant "T" perforator and the thickness of the superficial fascia where a thin PAP flap is elevated. A dominant "T" perforator on preoperative CTA accurately predicts thickness of a PAP flap elevated at the level of the superficial fascia.

When staged surgical treatment can solve bilateral axillary and inguinal severe hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic and debilitating disease that primarily affects the axillary, inguinal and anogenital areas. The treatment requires wide surgical excision of the affected tissue with adequate free margins in order to avoid recurrence. However, axillary and inguinal regions reconstruction after HS excision still represents a big challenge; the large defect can be closed using flaps, which allows more rapid rehabilitation and minimizes the risk of later scar contracture. In this report is discussed our experience with reconstruction of severe bilateral hidradenitis lesions of the axillary and inguinal areas in a young woman. Bilateral thoracodorsal artery perforator flaps were used for the axillary reconstruction while profunda artery perforator flap and direct suture were used respectively for left and right inguinal region. (www.actabiomedica.it)

Breast reconstruction using the profunda artery perforator (PAP) flap: Technical refinements and evolution, outcomes, and patient satisfaction based on 116 consecutive flaps

When a deep inferior epigastric artery flap is not suitable, the profunda artery perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction. We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data, and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively. One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72kg/m2 (range 18.9-29.2) and mean flap weight was 251.30g (range 152-455g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%), and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p=0.0016). Breast reconstruction with PAP flap yields a high success, low complications, and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence, it can be considered an excellent option for autologous breast reconstruction.

Inferior gluteal artery perforator (IGAP) flap versus profunda artery perforator (PAP) flap as an alternative option for free autologous breast reconstruction

When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer. In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods. Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p=0.001), principally due to the risk of total flap failure (12% versus 0%, p=0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p<0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p<0.001). PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction.

Bilateral Outpatient Breast Reconstruction with Stacked DIEP and Vertical PAP Flaps.

Background:Stacking free flaps for breast reconstruction is far from novel, even in the case of a deep inferior epigastric perforator (DIEP) plus profunda artery perforator (PAP) configuration, where the latter is always described in the traditional transverse configuration. We present a series of consecutive patients undergoing bilateral breast reconstruction with stacked DIEP and vertical PAP flaps.Methods:Patients with inadequate abdominal donor tissue were offered the possibility of a stacking breast reconstruction. The DIEP flap was harvested via microfascial incisions, whereas the vertical PAP flap was harvested in the lithotomy position, following the course of the gracilis muscle.Results:In total, 28 consecutive patients with a mean BMI of 24.9 underwent bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. The internal mammary artery and vein were used as recipient vessels in all 56 stacked flaps. Fifty-three PAP flaps were anastomosed to the distal portion of the (primary) DIEP flaps utilizing a sequential flap anastomosis technique, and one DIEP flap was anastomosed to the distal portion of the (primary) PAP flap. Hospitalization for the initial eight patients averaged 35 hours, whereas the following 20 patients were discharged within 23 hours. There were no postoperative takebacks or vascular complications.Conclusions:Stacked DIEP/PAP flaps offer an excellent option for patients who require more volume than available from DIEP flaps alone. When compared with transverse PAP flaps, the vertical PAP offers excellent variability of volume and ease of shaping to allow for excellent results, while minimizing donor site tension in the seated position and preserving the gluteal fold.

Anatomic study of the profunda artery perforators by multidetector CT scanner and clinical use of the banana-shaped flap design for breast reconstruction.

The profunda artery perforator (PAP) flap is a well-known free flap for breast reconstruction. However, a reproducible perforator mapping system has yet to be developed. The PAP perforators were localized by CTA using a novel X-Y axis system. Flap dimensions were based on the CTA images and localized PAP-perforators. Perioperative findings and postoperative outcomes were analyzed. A total of 70 lower limbs and 180 PAP perforators were evaluated. An average of 2.78 ± 1.22 and 2.22 ± 0.96 perforators were seen, in the right and left legs, respectively, and were divided in five clusters (PAP1-PAP5) based on their location on the Y-axis. The course of the perforators was noted as well as the average diameter at the origin. The overall average diameter was 1.99 ± 0.86 mm. A banana-shaped PAP-flap was harvested in 10 patients. The mean operative time was 278 min, pedicle length 76 ± 12 mm, and mean flap weight 247 g. No major complications were seen. The PAP flap can be mapped by CTA in a reproducible way. The X and Y axes are based on fixed anatomic landmarks and may form the basis for a banana-shaped flap design of the PAP-flap.

Perineal Reconstruction With the Profunda Artery Perforator Flap.

Abdominoperineal resection is used to treat a variety of colorectal pathologies. Traditionally, the vertical rectus abdominis myocutaneous flap has been most commonly used for reconstruction. Here, we explore the role of the profunda artery perforator (PAP) flap for perineal reconstruction. A prospectively maintained database was retrospectively analyzed to identify patients who had undergone perineal reconstruction with a pedicled PAP flap. Parameters of interest included age, sex, body mass index, primary diagnosis, comorbidities, and history of radiation, and postoperative complications. Fifteen patients (5 men and 10 women) with a median age of 52 years (interquartile range, 48.5-61.5 years) were included in the study. Median body mass index was 26.3 kg/m2 (interquartile range, 24.0-29.3 kg/m2). Patients underwent abdominoperineal resection for treatment of rectal cancer (n = 9, 60.0%), recurrent anal squamous cell carcinoma (n = 3, 20.0%), and Crohn's disease (n = 3, 20.0%). Twelve patients (80.0%) underwent neoadjuvant radiotherapy. Eight patients (53.3%) experienced a total of 10 complications (2 major and 8 minor). The most common complication was donor (n = 3, 20.0%)/recipient (n = 3, 20.0%) site wound dehiscence. Stable soft tissue coverage was achieved in all patients. The PAP flap provides stable soft tissue coverage of perineal defects with a low donor-site morbidity. This flap should be strongly considered in the reconstructive algorithm when approaching perineal defects.

Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction?

Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.

Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study.

While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.