Neurotized Diagonal Profunda Artery Perforator Flaps for Breast Reconstruction

Abstract

Although the deep inferior epigastric artery perforator flap remains the gold standard for autologous breast reconstruction, many patients are not candidates for this surgery. A variety of thigh-based flaps have been used including the diagonal upper gracilis (DUG) flap, vertical upper gracilis flap, profunda artery perforator (PAP) flap, and lateral thigh perforator flap. However, each of these techniques has a unique set of benefits and drawbacks in terms of wound healing, donor site morbidity, and potential for lymphedema. We describe the first report of a sensate diagonal PAP flap for breast reconstruction: combining the benefits of the DUG (wider skin paddle and reliable wound healing) with the benefits of the PAP (muscle-sparing technique and greater distance from the lymphatic collectors). This was the authors' sentinel case in a woman with paraplegia and chronic leg swelling. Preoperative imaging, markings, and technical details are presented along with postoperative results. In the appropriately selected patient, this flap offers several advantages: a 2-team approach to reconstruction, ample tissue for breast reconstruction, potential neurotization for breast sensibility, wound closure in resting skin tension lines, and avoidance of the lymphatic drainage to the lower extremity. The diagonal PAP flap provides a muscle-sparing alternative to the DUG flap while minimizing the risk of lymphedema. Future studies are needed to assess the donor site morbidity of this flap; however, this case proves the safety and reliability of the diagonal PAP flap in our breast reconstruction population.

Fig. 1.

Preoperative photograph of a patient with recurrent left breast cancer and breast lymphedema following lumpectomy and radiation.

Fig. 2.

MRA demonstrating PAP perforator and viable sartorius muscle with fatty replaced remaining thigh musculature. MRA indicates magnetic resonance angiography; PAP, profunda artery perforator.

Fig. 3.

Markings for the bilateral DPAP. Because of paraplegia-related muscle atrophy, the markings appear more posterior than usual. DPAP indicates diagonal profunda artery perforator.

Fig. 4.

DUG and PAP pedicles fully mobilized. DUG indicates diagonal upper gracilis; PAP, profunda artery perforator.

Fig. 5.

Three-month postoperative result.

Fig. 6.

Postoperative appearance of the donor site.