Single Pedicled Profunda Femoral Artery Perforator Flap for Breast Reconstruction

Abstract

For patients who need autologous breast reconstruction after mastectomy, it is a common choice to use the perforator flap of inferior abdominal artery based on abdominal free flap. However, not all patients have sufficient abdominal tissue, either because of low body mass index, scars, inappropriate perforations, or because they have had DIEP or abdominal wall plastic surgery before [1]. An alternative is the transverse crescent-shaped upper gracilis myocutaneous flap (TUG) composed of upper tissue above the thigh [2–4]. However, TUG flap is considered to have some disadvantages. The amount of tissue available in the thigh is scarce, the vascular pedicle is short (6–7 cm in length), and the donor area is prone to wound dehiscence and infection [5–7]. As reported in the successful cases, a number of solutions against these constraints have been described from many aspects, among which the profunda artery perforator flap (PAP) reported by Allen is the most interesting refinement [8]. PAP flap is based on the musculocutaneous or septal perforator of the second or third perforator of profunda femoral artery. They converge behind the gracilis muscle and supply blood to the skin and subcutaneous fat under the gluteal sulcus. According to clinical observation and preoperative imaging studies, about 97% of the thighs have at least one suitable perforating branch with an average diameter of 1.9 mm in this area. The medial perforator is close to the adductor magnus, with an average distance of 3.8 cm from the midline and 5 cm below the gluteal sulcus, and the lateral perforator is close to the biceps femoris and lateral femoral muscle, with an average distance of 1.2 cm from the midline and 5 cm below the gluteal sulcus [9, 10]. When the abdominal tissue is insufficient, the flap can also be used as an alternative to provide soft tissue from the medial thigh donor area with relatively abundant tissue to complete breast reconstruction. It can be regarded as an evolutionary form of TUG flap. According to the evaluation of reconstructed breast and donor area, PAP flap should have more advantages than TUG flap in theory [8].