PREDICTING PERFORATOR LOCATION ON PREOPERATIVEIMAGING FOR THE PROFUNDA ARTERY PERFORATOR FLAP

NICHOLAS T. HADDOCK, M.D.,* PATRICK GREANEY, M.D., DAVID OTTERBURN, M.D.,

STEVE LEVINE, M.D., and ROBERT J. ALLEN, M.D.

Introduction: The profunda artery perforator (PAP) flap is a new addition to our reconstructive armamentarium. In effort to better under-stand patient candidacy for the PAP flap we characterized the profunda artery perforators on preoperative imaging. Methods: A retrospec-tive review was completed of 40 preoperative posterior thigh computed tomography angiographies and magnetic resonance angiographiesby four plastic surgeons. The positioning of the patient, type of study, number of perforators, and size of perforators were documented.The location was documented on an x–y-axis. Perforator course and surrounding musculature was documented. Results: In 98.8% of pos-terior thighs suitable profunda artery perforators were identified. The average number and size of perforators was 3.3 and 1.9 mm. Themost common perforator was medial (present in 85.6% of thighs); found near the adductor magnus at 3.8 cm from midline and 5.0 cmbelow the gluteal fold. The second most common perforator was lateral (present in 65.4% of thighs); found near the biceps femoris andvastus lateralis at 12.0 cm from midline and 5.0 cm below the gluteal fold. Nearly 48.3% were purely septocutaneous. And 51.7% had anintramuscular course (average length 5.7 cm). Preoperative imaging corresponded to suitable perforators at the time of dissection of allPAP flaps. Thirty five PAP flaps (18 patients) were performed with 100% flap survival. Conclusion: Analysis of preoperative posterior thighimaging confirms our intraoperative findings that a considerable number of suitable posterior thigh profunda perforators are present,emerge from the fascia in a common pattern, and are of sufficient caliber to provide adequate flap perfusion and recipient vessel sizematch. VVC 2012 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2012.

The reliability of perforator flaps is well documented in

the literature. The popularity for perforator flaps is based

on the ability to preserve underlying muscle, provide a

longer pedicle length, and the ability for variability in

design and location. The profunda artery perforator (PAP)

flap was recently introduced as an alternative method of

breast reconstruction with favorable outcomes.1 The PAP

flap provides a sufficient area of posterior thigh skin and

fat for unilateral breast reconstruction based on a single

profunda artery perforator.

The posterior thigh has previously been utilized as

both a myocutaneous2 flap and a perforator flap.3,4

Patients undergoing breast reconstruction are equally con-

cerned about donor site cosmesis. The upper posterior

thigh provides a favorable donor site with a well-hidden

scar in most women. This area of skin and fat is supplied

by the profunda artery via three main perforators; the first

perforator supplies the adductor muscle and gracilis while

the second and third perforators supply the semimembra-

nosus, biceps femoris, and vastus lateralis.5

There are multiple benefits of accurate preoperative

imaging in breast reconstruction with perforator flaps.6

Computed tomography angiography (CTA) allows the

identification of suitable perforators.7 This in turn pro-

vides guidance with flap choice, incision design, and

avoids a potential negative exploration.

Preoperative imaging has been paramount for the

early success of the PAP flap. As experience grows with

this flap there are obvious patterns in perforator location,

which help dictate flap design and operative approach. In

effort to better describe the location of these perforators

and potential patient candidacy for use of the PAP flap

we reviewed the profunda artery perforators in 40 preop-

erative images for transverse upper gracilis (TUG), supe-

rior gluteal artery perforator (SGAP), and PAP flaps. In

doing so we were able to determine which perforators are

appropriate for use as a microvascular free flap, describe

the perforator locations, and how many patients have

suitable perforators for use of the PAP flap.

PATIENTS AND METHODS

A retrospective review was completed of 40 preopera-

tive CTAs and magnetic resonance angiographies

(MRAs) involving the upper posterior thigh. The images

were reviewed by four independent plastic surgeons. All

images were obtained using standard perforator protocols

with the intent of using a PAP flap, SGAP flap, or a

TUG flap for reconstruction of the breast.

The positioning of the patient, the type of study, and

the number of perforators were documented. Patient age

was documented and ranged from 38 to 55. The location

was documented with the gluteal fold set as zero on the

y axis and the midline set as zero on the x axis. The

location in respect to the posterior thigh musculature and

the perforator course was also documented. The size of

all perforators was documented.

New York University Langone Medical Center, Institute of ReconstructivePlastic Surgery, New York, NY

*Correspondence to: Nicholas Haddock, M.D., New York University Lan-gone Medical Center, Institute of Reconstructive Plastic Surgery, New York,NY. E-mail: haddockmd@gmail.com

Received 21 October 2011; Revision accepted 7 February 2012; Accepted8 February 2012

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.21980

VVC 2012 Wiley Periodicals, Inc.

PAP Flap Procedure

Preoperative imaging helped identify skin perforators,

which were confirmed by a handheld Doppler. The supe-

rior border of the flap was marked 1 cm inferior to the

gluteal fold. The inferior border of the flap was marked

�7 cm below the superior marking. An elliptical flap was

designed (average width of 27 cm). The patient can be

positioned prone or supine with legs frog-legged. The

prone position utilizes a lateral approach and maintains

the theoretical possibility of conversion to a TUG flap if

required while the supine position has the obvious benefit

of no position change. The elliptical incision was made

and dissection proceeded to the muscular fascia. Beveling

in the lateral thigh increased flap volume, but should be

limited superiorly to avoid disturbance of buttock contour

and the gluteal fold. Dissection proceeded in a suprafas-

cial plan until near the marked perforator and the fascia

was entered. Subfascial dissection helped with perforator

identification. The perforator was traced to its origin as

in other perforator flaps. The donor site was closed in a

multilayer fashion over a drain.

RESULTS

All images were obtained for preoperative imaging

for breast reconstruction utilizing a buttock or thigh-based

autologous reconstruction. Eighteen of the preoperative

images were for a PAP flap, 21 were for a TUG flap,

and 1 was for a SGAP flap. CTA accounted for 23 and

MRA accounted for 17 of the images. Majority of

patients were imaged in the supine position, 21 compared

to 19 in the prone position.

Posterior thigh perforators originating from the pro-

funda artery were consistently visualized on preoperative

imaging. In 98.8% of the posterior thighs perforators with

sufficient size were identified on preoperative imaging.

The average number of perforators was 3.3 6 1.2 and

the average size was 1.9 6 0.5 mm). The most common

perforator location is in the medial posterior thigh, exit-

ing the fascia in the vicinity of the adductor magnus at

�3.8 cm from midline and 5.0 cm below the gluteal fold

(Fig. 1). These perforators accounted for 49.2% of all

posterior thigh perforators and were on average 1.9 60.4 mm. At least one sizeable medial perforator was pres-

ent in 84.6% of evaluated posterior thighs. The second

most common perforator location is in the vicinity of the

Figure 1. Preoperative MRA of a patient that presented for bilateral breast reconstruction with a paucity of abdominal tissue. This image

shows a medial profunda artery perforator that would supply a medially based PAP flap.

Figure 2. Preoperative MRA of a patient that presented for bilateral

breast reconstruction with a paucity of abdominal tissue. This

image shows a lateral profunda artery perforator that would supply

a laterally based PAP flap.

2 Haddock et al.

Microsurgery DOI 10.1002/micr

biceps femoris and vastus lateralis at �12.0 cm from

midline and 5.0 cm below the gluteal fold (Fig. 2). These

perforators accounted for 32.5% of all posterior thigh

perforators and were on average 1.9 6 0.4 mm. At least

one sizeable lateral perforator was present in 65.4% of

evaluated posterior thighs. The perforators are shown

mapped on an x–y coordinate (Fig. 3) and in table form

(Table 1).

There was one patient that had no suitable profunda

artery perforators on one posterior thigh on preoperative

imaging. This patient was initially scheduled to undergo

a PAP flap, however was preoperatively converted to a

TUG flap based on the imaging. Thirty-five PAP flaps in

18 patients were included in this series. In all cases per-

forators on preoperative imaging corresponded to a perfo-

rator at the time of dissection.

Intraoperatively, the course of these perforators has

been found to be predominantly septocutaneous, but in

some patients there was a small intramuscular compo-

nent. On preoperative imaging 48.3% were purely septo-

cutaneous. For the remaining muscular perforators

(51.7%) the intramuscular course was on average 5.7 62.1 cm in length.

All 35 PAP flaps (18 patients) were performed with

100% flap survival and no flap related complications.

There were two donor site complications (one seroma

and one small wound dehiscence). Postoperative photo-

graphs are shown of both recipient site and donor site

(Figs. 4 and 5). Those patients included in this study that

Figure 3. Image shows the coordinates of all significant profunda artery perforators on an x–y axis. The numbers are in centimeter incre-

ments. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Table 1. Posterior Thigh Profonda Artery Perforators

Medial Central Lateral

Size 1.9 6 0.4 mm 1.8 6 0.4 mm 1.9 6 0.4 mm

Location

X-Axis 3.8 cm 6.5 cm 12 cm

Y-Axis 5 cm 4.1 cm 5 cm

Border Muscles Adductor

Magnus

Semimembranosus Biceps

Femoris

Semitendinosus Vastus

Lateralis

Consistency

Present in Thighs 86.0% 32.7% 65.0%

Average location, size, and consistency of medial, lateral, and central pro-funda artery perforators.

Figure 4. Postoperative result following bilateral breast reconstruc-

tion with the PAP flap. [Color figure can be viewed in the online

issue, which is available at wileyonlinelibrary.com.]

Preoperative Imaging for the PAP Flap 3

Microsurgery DOI 10.1002/micr

underwent a TUG flap or a SGAP flap had similar

results. In this series 25 TUG flaps were performed in 21

patients. Two SGAP flaps were performed in one patient.

There was 100% flap survival in all TUG flaps and all

SGAP flaps. There were no flap-related complications.

There were three donor site complications (seromas).

DISCUSSION

The PAP flap offers an additional reconstructive

option for postmastectomy patients in which no abdomi-

nal-based flap is available. While the posterior thigh pro-

funda artery angiosome and flaps based on this angio-

some have been well described8–11 the use of a transverse

upper posterior thigh flap based off of these perforators is

a new technique for breast reconstruction.1 CTA has been

used to guide identification of perforators off the pro-

funda artery allowing planning in these procedures and

thus avoiding the ‘‘free-style’’ perforator dissection.12

While a preoperatively identified perforator on CTA or

MRA does not always guarantee a suitable perforator at

the time of surgical dissection, in the PAP series

described here a suitable perforator was present corre-

sponding with preoperative imaging in all cases.

The need for this flap came from the dissatisfaction

with other alternative flaps (TUG, SGAP, and IGAP).

Tissue obtained from the gluteal flaps lacks the same

malleable characteristics of abdominal or posterior thigh

tissue, restricting the surgeon’s ability to mold an aes-

thetic breast mound. The harvest of these flaps can also

have a detrimental effect on buttock contour. A variation,

utilizing a lateral septocutaneous perforator,13 has been

described to provide increased pedicle length for gluteal

flaps; however this is not always an option and still

requires prone positioning. The TUG flap provides a

more manageable tissue type similar to that of the PAP

but sacrifices a muscle, has a short pedicle, can affect

lymphatic drainage, and has an anterior scar that is visi-

ble to the patient.

On preoperative imaging for a TUG flap a posterome-

dial perforator off of the profunda artery was identified

giving the inspiration for the first PAP flap. As experi-

ence was gained with this flap preoperative imaging was

paramount to identify perforators to supply this skin pad-

dle. Following preoperative imaging the perforators were

confirmed with handheld Doppler.

To better understand the characteristics of this flap

we sought to define the perforator patterns in relation to

the upper posterior thigh flap. The predictability of the

profunda artery perforators in the PAP flap appears to be

strong on preoperative imaging. In 98.8% of posterior

thighs suitable profunda artery perforators were identified

on preoperative imaging. This compares favorably with

other common methods of breast reconstruction.

In addition, this review provides increased documen-

tation of the pedicle characteristics. Retrospective preop-

erative imaging analysis confirms our intraoperative find-

ings that a considerable number of usable posterior pro-

funda perforators are mainly septal in nature, while the

remaining branches require some degree of muscular dis-

section. This is yet another advantage of this flap as com-

pared to DIEP, SGAP, IGAP, which almost always

require muscular dissection. Thus far, patients undergoing

PAP breast reconstruction have very limited muscle

related donor site morbidity or weakness. More patient

studies are required to more closely examine the donor

site morbidity of this flap.

Clinically, the average artery diameter was 2.2 mm

and the average vein was 2.8 mm.1 Preoperative imaging

often over estimates the diameter of the perforator and

while we report an average diameter of 1.9 mm at the

fascia this has not been found clinically. At the fascia the

perforators tend to be much smaller but when dissected

proximally the diameter is universally an adequate match

with the internal mammary vessels. Future work should

focus on perfusion studies to determine the maximum

capacity of this flap when harvested on one perforator.

It is possible that a zonal classification could be

developed based on specific perforator choice and angio-

some principles.8

Figure 5. Postoperative donor site following bilateral breast recon-

struction with the PAP flap. [Color figure can be viewed in the

online issue, which is available at wileyonlinelibrary.com.]

4 Haddock et al.

Microsurgery DOI 10.1002/micr

CONCLUSION

The PAP flap is a viable nonabdominal flap alterna-

tive for breast reconstruction. There are routinely suitable

perforators for harvest of the PAP flap. These perforators

are present in standards locations; medially in the vicinity

of the adductor magnus and laterally in the vicinity of

the biceps femoris and vastus lateralis. The initial experi-

ence with the PAP flap has been very favorable. Future

work is focused on determining where this flap falls in

the breast reconstruction algorithm.

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Preoperative Imaging for the PAP Flap 5

Microsurgery DOI 10.1002/micr