Long-Term Outcome Analysis and Technical Refinements after Autologous Breast Reconstruction with PAP Flap: What We Have Learnt

Abstract

Introduction: The profunda artery perforator (PAP) flap represents a valuable alternative to the deep inferior epigastric artery perforator flap which, nowadays, is considered the golden standard for autologous breast reconstruction. The goal of this study was to evaluate the long-term satisfaction, functional outcomes of the donor site following PAP flap-based breast reconstruction and to present our personal learning experience along with suggestions for technique refinements.

Methods: In this prospective single-center appraisal, 18 patients who underwent PAP flap-based breast reconstruction between January 2016 and November 2019 were enrolled. The Patient and Observer Scar Assessment Scale (POSAS) and the Breast-Q questionnaire were employed to evaluate the results 12 months postoperative. Data were analyzed with the Q-Score program. Complications were recorded in the medical database and classified with the Clavien-Dindo classification.

Results: In the questionable time frame, 164 female patients underwent free flap breast reconstruction. Of those, 18 patients that received PAP flaps (9 bilateral) were included in this study. We recorded one flap loss because of venous failure. Most complications concerned the donor site, including hematoma, seroma, and wound healing problems. Patients' satisfaction was high at 12 months post-surgery, despite critical evaluation of the donor site scar.

Conclusion: The PAP flap serves as an excellent option for breast reconstruction in patients who do not have abundant abdominal tissue. The overall clinical outcome was good and patients' evaluation showed high satisfaction after 12 months despite high complication rates. Modifications in planning and flap harvesting might improve the donor site outcome and the overall complication rate.

Keywords: Breast; Breast cancer; Breast reconstruction; Breast-Q; Flap surgery; Free flap; Long-term outcome; PAP flap; POSAS; Profunda artery perforator flap; Vertical PAP flap.

Fig. 1

Preoperative (a, b) and postoperative (c, d) pictures of a 29-year-old patient requiring bilateral skin sparing mastectomy. Subsequent autologous breast reconstruction was done with profundal artery perforator flaps. The resected areolae were reconstructed using the flap skin paddles and NAC reconstruction was completed after 6 months with local C-V-flaps.

Fig. 2

Preoperative (a, b) and postoperative (c, d) pictures of a 51-year-old patient requiring unilateral autologous breast reconstruction of the right breast with profundal artery perforator flap after nipple-sparing mastectomy due to recurrent mastitis. The donor site is found in the left thigh. Vertical breast reduction following Lejour's technique was performed on the left side.

Fig. 3

The postoperative photographs show a patient after unilateral reconstruction with a primary healed donor site in the right thigh (a–c) and a patient after bilateral PAP flap-based breast reconstruction (d–f) that encountered donor site wound healing disturbance in both thighs. The complications were managed conservatively and resulted in well-concealed scars without a requirement for correction.