PAP FLAP

The Profunda Artery Perforator (PAP) flap is an advanced microsurgical technique that removes excess skin and fat from the upper inner and posterior thigh to reconstruct the breast. These flaps are usually used when the abdomen is not available for use as a donor site. Most commonly, the upper thigh is used for breast restoration in the following situations:

• Very thin women who lack enough abdominal fat to create new breasts
• Previous tummy tuck that has already severed the abdominal vessels
• Failed TRAM flap
• Preference for non-abdominal donor site due to "pear-shaped" body habitus

In the PAP flap, the scar is located in the groin and lower buttock crease. The tissue of the upper thigh is particularly soft, and it is sculpted into a conical shape to create a beautiful breast. An older type of flap to reconstruct the breast is the Transverse Upper Gracilis (TUG) flap. The difference between the TUG and the PAP flap is the choice of blood vessels that nourish the flap tissue. The TUG flap is nourished by the medial circumflex femoral artery and vein that runs through the gracilis muscle to supply blood to the fat and skin in the upper inner thigh. Most importantly, the TUG flap usually takes a small amount of the gracilis muscle with the flap, while the PAP flap does not take any muscle at all with the flap. Since the PAP flap preserves the muscle, there is less pain and postoperative morbidity. For this reason, in our practice we no longer perform the TUG flap and now exclusively use the PAP flap when the upper thigh is indicated as the donor site for breast reconstruction.

The PAP flap uses the profunda artery perforators that run through or beside the adductor magnus muscle to supply blood to the fat and skin in the upper inner and posterior thigh. Since the PAP flap vessels are larger than the TUG flap vessels, the PAP flap is always harvested as a perforator flap that preserves the muscle. Since no muscle is sacrificed in the PAP flap, the postoperative pain is often less than expected. Many patients are surprised that they may not even need narcotic pain medication after surgery. In addition, the perforator vessels of the PAP flap are located close to the groin, which makes it possible to camouflage the donor site scar so that it is well hidden within groin and lower buttock crease. The PAP flap is designed so that the scar is not visible from the front, and it is usually well-concealed from the back. Furthermore, it is located well away from the lymph nodes of the groin, which minimizes any postoperative risk of lower extremity lymphedema. In our practice, patients who have used their upper thigh for breast reconstruction have gone on to run marathons and win road races after surgery.

For some women, an added benefit of the PAP flap is that it removes excess upper thigh tissue. Similar to a cosmetic thigh or buttock lift, the scar is hidden within the groin and lower buttock crease, and the result is a slimmer upper thigh. Since the flap is taken from the back of the thigh and not the buttock, there is no disturbance of the padding of the buttock so that the buttock usually appears rounder and more well-defined after surgery. 

What is special about the UPPER inner thigh flap?

The PAP flap is a microsurgical flap that requires specialized expertise when used for breast reconstruction. Tiny 2 mm blood vessels need to be carefully isolated and dissected from the muscles in the upper thigh, and then sewn back together to matching 2 mm blood vessels in the chest to restore blood flow to the tissue. The soft upper thigh tissue is then coned to create a new breast, and a small skin patch from the upper thigh skin can be left to reconstruct a new nipple later. While the initial investment of surgical time and effort is greater than with traditional procedures, the reward of using the upper thigh to reconstruct the breast is an outstanding aesthetic result with a natural, permanent new breast that is can be difficult to distinguish from the original. In fact, the quality of the tissue in the PAP flap often create a particularly soft, youthful appearance to the breast.

We believe it is very important to have a tight, cohesive team that works together safely and efficiently. In our practice, breast restoration with the PAP flap is always performed by two experienced board-certified microsurgeons with specialized expertise. We always obtain preoperative imaging of the upper thigh blood vessels to identify which perforators are the best ones to use. Using an MRA, we choose the best blood vessels to map out the surgical plan before the operation, which shortens time under general anesthesia. In our hands, the average PAP flap breast reconstruction takes about 3-5 hours for a unilateral reconstruction and 6-8 hours for a bilateral reconstruction.

Postoperatively, the flaps are monitored very carefully while the patient is in the hospital. After the first night, patients are allowed to get out of bed, walk, and eat anything they want. Most patients stay in the hospital 3 days. Drains are placed in the reconstructed breast(s) and the upper thigh donor site. At home, daily drain output needs to be measured, and most drains are removed in 1-2 weeks. Patients should take at least 2 weeks off of work, and avoid heavy lifting and strenuous activities for 4-6 weeks. A compression girdle should be worn postoperatively for 6-8 weeks. Most patients are fully recovered without any physical limitations in 6-8 weeks.