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

Abstract

Introduction 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. Methods 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. Results 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. Conclusion 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.

Cadaveric Study for Safe Elevation of a Profunda Artery Perforator Flap: Anatomy of the Perforators and Obturator Nerves

“…Our study evaluated the PAP anatomy through a cadaveric study to determine the detailed anatomic information of the perforators from the profunda femoris artery. The average distance from the origin of perforators to the gluteal sulcus was 71.72 mm, which is similar to the reported average perforator distance by Jourdain et al of 71.6 mm below the gluteal sulcus (20). However, another anatomic study by Allen et al has reported a shorter average distance inferior to the gluteal crease of 3.5 cm (13).…”

“…The PAP flap has become a popular secondary option for autologous breast reconstruction because of its advantages including a hidden scar, and this technique is useful in slim patients who do not have sufficient abdominal volume (15). Previous studies have reported an anatomic analysis of the PAP flap (12,13,(16)(17)(18)(19); however, a detailed anatomic study has not been conducted.…”

“…A PAP flap can be designed in a vertical or transverse direction. Considering the segmental natures of the posterior thigh blood supply, vertically designed flaps have more perforators for maximizing flap perfusion (20). However, in breast reconstruction, the donor site scar should be considered.…”

Comparative Study of DIEP and PAP Flaps in Breast Reconstruction: Reconstructive Outcomes and Fat Necrosis

“…A recent study advocated that the vertical PAP flap with multiple perforators has advantages over the transverse PAP flap, 24 25 including multiple perforators and flexibility in utilizing distal and larger perforators. However, a vertical visible scar could not be avoided.…”

The profunda artery perforator flap for upper limb reconstruction: A case report and literature review on the flap applications in reconstruction

“…Historically, based on proximal musculocutaneous perforators from the adductor magnus (AM) muscle, it was initially referred as “adductor flap” by Angrigiani et al ( 2001 ). Later, further publications have then better elucidated PAP's anatomy and identified clinical applications (Ahmadzadeh et al, 2007 ; Allen et al, 2012 , 2016 ; Artz et al, 2021 ; Haddock et al, 2012 ; Hammond et al, 2021 ; Saad et al, 2012 ; Scaglioni et al, 2015 ; Song et al, 2020 ; Wong et al, 2015 ).…”