7 Profunda Artery Perforator Flap for Breast Reconstruction
Robert J. Allen, Maria M. LoTempio, and Constance M. Chen
Since its introduction by Allen1 in 1992, the deep inferior epigastric artery perforator flap has become the gold standard for breast reconstruction. However, the lower abdomen is not an option in 25% of women. Absolute contraindications include previous abdominoplasty, and relative contraindications include previous liposuction, certain abdominal operations, and a paucity of subcutaneous fat. The profunda artery perforator (PAP) flap described by Allen2,3 in 2010 is our first consideration if the abdomen is not a viable option. Other choices include the superior or inferior gluteal artery flaps3,4 the thigh gluteal artery perforator (GAP) flap, and the lateral thigh flap.
The blood supply to the muscles surrounding the profunda artery perforators, specifically the adductor, has been described by Angrigiani et al.5 The dominant blood supply to the posterior thigh is from the profunda artery perforators. The PAP flap has been used for breast reconstruction in over 200 cases over the past 4 years.
Indications
The ideal candidates for the PAP flap have breasts of small to moderate size, with excess body fat below the waist. A woman with a pear-shaped figure is a better candidate than one with an apple-shaped figure. Many of our patients have had previous abdominal surgery such as abdominoplasty, but a significant percentage of PAP patients have a paucity of abdominal fat, with more fat in the posterior thigh. Preoperative imaging with magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is recommended on all patients to facilitate perforator mapping and dissection, and to reduce the operative time ( Fig. 7.1 ).
Vascular Anatomy
The profunda femoris artery arises from the common femoral artery ~3.5 cm distal to the inguinal ligament. Initially lateral to the femoral artery, it spirals posterior to the ligament to reach the medial side of the femur. The profunda femoris artery enters the posterior compartment of the thigh and gives off three main perforators. The first perforator is preferred as the pedicle to the PAP flap due to its more medial location and more ideal perfusion pattern.
Preoperative Planning
Preoperative markings are applied in the office the day prior to surgery. The patient starts in the standing position, and the inferior gluteal fold is marked for the superior extent of the incision. The second marking is 6 to 7 cm below this line, which is the lower extent of the skin flap. The lateral marking extends to the end of the infragluteal crease or slightly lateral to it. The patient is then moved to the supine position with the thigh in abduction, and the medial marking begins just posterior to the lymphatic-rich inguinal area posterior to the adductor longus muscle. The transverse crescent pattern is typically 26 cm x 7 cm. Then with the patient in the prone position, the key perforator6 is marked based on the preoperative imaging. The key perforator is usually 3 to 6 cm below the infragluteal crease and within 4 cm of the posterior border of the gracilis muscle. The handheld Doppler confirms the location of the perforator(s). Most patients have adequate perforators through the adductor magnus muscle for the PAP flap, but sometimes the best perforator may be inferior to the skin island. In this case a perforator off the descending branch of the inferior gluteal artery (thigh gluteal artery flap) or more lateral profunda femoris perforator may be used. Another option with an inferiorly located perforator is to lower the skin pattern in a “boomerang” fashion to capture the key perforator.
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