The Chimeric Gracilis and Profunda Artery Perforator Flap: Characterizing This Novel Flap Configuration with Angiography and a Cadaveric Model

Abstract

Objective A chimerically configured gracilis and profunda artery perforator (PAP) flap is highly prevalent based on recent computed tomography (CT)-imaging data. The purpose of this study is to further characterize the vascular anatomy of this novel flap configuration and determine the feasibility of flap dissection. Materials and Methods To characterize flap arterial anatomy, lower extremity CT angiograms performed from 2011 to 2018 were retrospectively reviewed. To characterize venous anatomy and determine the feasibility of flap harvest, the lower extremities of cadavers were evaluated. Results A total of 974 lower extremity CT angiograms and 32 cadavers were included for the assessment. Of the 974 CT angiograms, majority (966, 99%) were bilateral studies, yielding a total of 1,940 lower extremities (right-lower-extremity = 970 and left-lower-extremity = 970) for radiographic evaluation. On CT angiography, a chimerically configured gracilis and PAP flap was found in 51% of patients (n = 494/974). By laterality, chimeric anatomy was present in 26% of right lower extremities (n = 254/970) and 25% of left lower extremities (n = 240/970); bilateral chimeric anatomy was found in 12% (n = 112/966) of patients. Average length of the common arterial pedicle feeding both gracilis and PAP flap perforasomes was 31.1 ± 16.5 mm (range = 2.0–95.0 mm) with an average diameter of 2.8 ± 0.7 mm (range = 1.3–8.8 mm).A total of 15 cadavers exhibited chimeric anatomy with intact, conjoined arteries and veins allowing for anatomical tracing from the profunda femoris to the distal branches within the tissues of the medial thigh. Dissection and isolation of the common pedicle and distal vessels was feasible with minimal disruption of adjacent tissues. Chimeric flap venous anatomy was favorable, with vena commitante adjacent to the common pedicle in all specimens. Conclusion Dissection of a chimeric medial thigh flap consisting of both gracilis and PAP flap tissues is feasible in a cadaveric model. The vascular anatomy of this potential flap appears suitable for future utilization in a clinical setting.

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

“…Both radiographic and cadaveric anatomic studies have displayed the presence of clinically viable profunda perforators distally in the posterior-medial thigh. 8 9 15 16 17 18 19 22 23 Based on these findings—as well as our previously reported clinical experience—we believe the vPAP presents an excellent flap configuration to consider in appropriate patients. 3 13 24 Our data suggests that although the dominant perforator exits within 8 cm most of the time, over 25% of the time in our imaging studies and up to 50% of the time in our cadaver dissections the dominant perforator can be missed in the traditional tPAP design.…”

“…22,25,26 These findings lend further anatomic support for the clinical application of the vPAP flap in autologous breast reconstruction, as well as for the use of preoperative imaging for surgical planning. 1,8,15,[17][18][19] Fig. 9 Here is an example of a patient with left breast cancer, who was treated with mastectomy and bilateral stacked deep inferior epigastric perforator-vertical profunda artery perforator (vPAP) flap reconstruction: (A, C) Preoperative and (B, D) postoperative.…”

“…Hammond et al describe the use of a potential chimeric flap consisting of the gracilis and PAP flap for increased volume and contour, but the prevalence of a single arterial pedicle supplying both the gracilis and PAP flap was not 100%. 18 19…”

“…Hammond et al describe the use of a potential chimeric flap consisting of the gracilis and PAP flap for increased volume and contour, but the prevalence of a single arterial pedicle supplying both the gracilis and PAP flap was not 100%. 18,19 Attention must also be paid to potential donor site morbidity. The transverse design was originally employed to hide the scar in the gluteal fold; however, in our experience, we have found this can result in wound healing problems, painful scars or contour deformities while sitting, or unsightly distortion of the buttock fold.…”

“…22 25 26 These findings lend further anatomic support for the clinical application of the vPAP flap in autologous breast reconstruction, as well as for the use of preoperative imaging for surgical planning. 1 8 15 17 18 19…”