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Reconstructive: Head and Neck: Original Articles

Perforator Mapping of the Profunda Artery Perforator Flap: Anatomy and Clinical Experience

Largo, Rene D. M.D.; Chu, Carrie K. M.D., M.S.; Chang, Edward I. M.D.; Liu, Jessie Ph.D.; Abu-Ghname, Amjed M.D.; Wang, Hui M.D.; Schaverien, Mark V. M.B.Ch.B., M.Sc., M.D.; Mericli, Alex F. M.D.; Hanasono, Matthew M. M.D.; Yu, Peirong M.D.

Author Information
Plastic and Reconstructive Surgery: November 2020 - Volume 146 - Issue 5 - p 1135-1145
doi: 10.1097/PRS.0000000000007262
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Abstract

Numerous donor sites for soft-tissue flaps, each with distinct advantages and disadvantages, are available to the reconstructive surgeon. Over the years, a handful of workhorse flaps from different body regions have emerged and gained popularity because of their reliability and functionality in a variety of soft-tissue reconstructions. However, with advances in microsurgical techniques, the emphasis in the field has shifted from flap survival to flap refinement. Alternatives to the workhorse flaps not only meet the aesthetic and functional requirements of the reconstruction but also minimize donor-site morbidity. Examples include the ulnar artery perforator flap, the superficial circumflex iliac artery perforator flap, the extended lateral arm flap, the medial sural artery perforator flap, and the profunda artery perforator flap.1–6

Angrigiani et al. first described the profunda artery perforator, or “adductor,” flap in 2001 as both a pedicled flap for ischial or perineal wounds and a free flap for resurfacing burn scar contractures on the neck.6 The profunda artery perforator flap was then largely neglected, other than for its use in extremity reconstruction and regional surgical management of pressure sores, until 2012, when Allen et al. popularized the free profunda artery perforator flap in their search for alternative flap options for breast reconstruction.7–9 Although best known for its applications in breast reconstruction, of late, the profunda artery perforator flap has gained popularity for reconstruction of a variety of defects over the entire body.7,10–14

We have previously investigated the characteristics and optimal designs and applications of the anterolateral thigh flap, ulnar artery perforator flap, and lateral arm flap.15–17 The present study aims to describe our clinical experience using the profunda artery perforator flap for reconstruction of several diverse oncologic defects and to provide a simplified approach to the design and harvesting of the profunda artery perforator flap based on reliable anatomical landmarks.

PATIENTS AND METHODS

We performed a retrospective review of all consecutive patients undergoing free profunda artery perforator flap reconstruction at our institution from January of 2016 to December of 2018 following institutional review board approval. Primary endpoints were the intraoperative location and course of the profunda artery perforators in relation to the x axis (axis along the adductor longus muscle between the pubic tubercle and the medial epicondyle of the femur) and y axis (axis perpendicular and posterior to the x axis) with the patient in the supine frog-leg position (Fig. 1). Similar to the classification previously described by Yu in 2004, perforators were designated as A, B, or C on the basis of their distance from the pubic tubercle.15 The perforators were also categorized as large (>1 mm), medium (0.5 to 1 mm), or small (<0.5 mm) on the basis of vessel diameter at the level of fascial penetration.15 Merging of the perforators was analyzed, as this provides helpful information if a chimeric flap harvest is desired. Flap dimensions, thickness, tissue components (skin, fat, and muscle), and orientation (transverse or vertical); size of posteromedial and anterolateral thigh pinch; pedicle length; vessel diameter; and duration of flap harvest procedure were also recorded.

Fig. 1.
Fig. 1.:
Location of profunda artery perforators A, B, and C piercing through the fascia in relation to the x axis and y axis. The x axis displays the distance of perforators A, B, and C from the pubic tubercle along the axis between the pubic tubercle and the medial epicondyle of the femur. Thereby, perforator A is the most proximal perforator, perforator B is the second perforator, and perforator C the third perforator along the x axis. The y axis is posterior and perpendicular to the x axis.

Secondary endpoints consisted of patient characteristics (sex, age, body mass index, comorbidities), clinicopathologic features (tumor pathology, anatomical region of the defect, defect dimensions), intraoperative and postoperative outcomes, and complications (minor and major). Major complications were defined as complications requiring hospital readmission and/or unplanned surgical intervention.

Flap Harvest

Harvest of the profunda artery perforator flap harvest is demonstrated. [See Video (online), which demonstrates the harvest of the profunda artery perforator flap.] Early in the authors’ experience with profunda artery perforator flaps, a handheld Doppler probe or computed tomographic angiogram was used preoperatively to determine the location of a suitable perforator. With better understanding of the profunda artery perforator anatomy as a result of the present study, localization of perforators has more recently been based on surface anatomy measurements.

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Flap Harvest with Vertical Skin Paddle Orientation

A vertically oriented ellipse incorporating the profunda artery perforators is marked on the posteromedial thigh (Fig. 2). When designing the flap, accurate marking of the anterior border is crucial. An incision that is excessively anterior relative to the perforator location will result in a flap width that jeopardizes primary closure of the donor site. This situation arises more frequently in patients with minimal skin laxity, such as in young and/or obese patients. In general, we do not recommend skin grafting for the profunda artery perforator donor site, and if a skin graft is anticipated, an alternative flap should be selected to reconstruct the defect.

Fig. 2.
Fig. 2.:
Vertically oriented profunda artery perforator flap design. The anterior marking of the profunda artery perforator flap is longitudinal, with the flap axis parallel to the gracilis muscle. AL, adductor longus muscle; G, gracilis muscle.

Next, the flap is harvested with the patient in the supine frog-leg or lithotomy position, which often allows for an efficient two-team surgical approach in head and neck, upper extremity, or anterior trunk reconstruction. First, an anterior incision is made longitudinally, with the flap axis parallel to the gracilis muscle, according to the marked flap design. The dissection is performed through the gracilis muscle fascia into the subfascial plane until the adductor magnus fascia is reached. This fascia is then incised, and the harvest continues from anterior to posterior, detecting the multiple profunda artery perforators (Fig. 3). The most robust perforator is selected on the basis of its location and size. One such perforator is usually sufficient for adequate flap perfusion. The perforator is typically dissected intramuscularly through the adductor magnus muscle all the way to its origin from the profunda artery (Fig. 4). Branches from the perforator supplying the adductor magnus muscle provide the opportunity to include a muscular component with the flap if needed (Fig. 5). If the pedicle dives deep into a voluminous adductor magnus muscle, final dissection of the pedicle can be conducted through an exposed window between the adductor longus and vastus medialis muscles. Following harvest, the flap is brought into the recipient site in a standard fashion (Fig. 6). The donor site is closed primarily in multiple layers over a closed suction drain.

Fig. 3.
Fig. 3.:
The fascia over the adductor magnus muscle is incised, and the harvest continues from anterior to posterior, detecting the multiple profunda artery perforators. The most robust perforator is selected on the basis of its location and size.
Fig. 4.
Fig. 4.:
The profunda artery perforator is typically dissected intramuscularly through the adductor magnus muscle all the way to its origin from the profunda artery. AL, adductor longus muscle; G, gracilis muscle.
Fig. 5.
Fig. 5.:
Branches from the perforator supplying the adductor magnus muscle provide the opportunity to include a muscular component with the profunda artery perforator flap if needed. AL, adductor longus muscle; G, gracilis muscle.
Fig. 6.
Fig. 6.:
Profunda artery perforator flap harvest with transverse skin paddle orientation. The harvest can be performed with the patient in the lithotomy or supine frog-leg position. AL, adductor longus muscle; G, gracilis muscle.

Flap Harvest with Transverse Skin Paddle Orientation

A transversely oriented elliptical flap design is marked with the patient in the standing position. The superior border is marked approximately 1 cm above the inferior gluteal crease. A pinch test is used to define the maximum flap width allowing for primary closure of the donor site. The flap design should not extend across the lateral border of the inferior gluteal crease posteriorly and should not extend beyond the gracilis muscle anteriorly. The harvest can be performed with the patient in the lithotomy or supine frog-leg position (Fig. 7). The dissection can be carried out from posterior to anterior, but we prefer to harvest the flap in an anterior to posterior fashion so that the descending branch of the inferior gluteal artery can be used to supply an alternative flap in the case of perforator injury during dissection.

Fig. 7.
Fig. 7.:
Intraoperative and postoperative photographs of a patient undergoing subtotal glossectomy and reconstruction with a vertical profunda artery perforator free flap.

Postoperative Care

All patients undergoing profunda artery perforator flap harvest (horizontal and vertical flaps) are allowed to mobilize from postoperative day 1 but should avoid strenuous activity for 4 weeks. Patients undergoing transversely oriented profunda artery perforator flaps are also asked to avoid hip flexion of more than 90 degrees for 4 weeks.

Statistical Analysis

Frequencies and proportions were used to summarize the categorical variables. Means and standard deviations were calculated to summarize continuous variables. A contingency table summarized the association between merged and selected perforators. The correlation between body mass index and flap thickness was evaluated with Pearson product moment correlation, Spearman rank correlation (ρ), and Kendall τ rank correlation tests. Correlation size and strength were assessed on the basis of the Evans classification.18 A histogram was used to illustrate the location of the perforators on the x and y axes. All tests were two-sided. A value of p < 0.05 was considered significant. All analyses were performed using SAS 9.4 (SAS Institute, Inc., Cary, N.C.) by a senior staff statistician (J.L.).

RESULTS

A total of 83 profunda artery perforator flap reconstructions were performed in 70 consecutive patients with a mean age of 59.4 years and mean body mass index of 24.8 kg/m2 (Table 1). Seventeen patients underwent two concurrent profunda artery perforator flap reconstructions: 12 bilateral breast reconstructions and five bilateral stacked profunda artery perforator flaps for unilateral breast reconstruction. Two-thirds (n = 46) of the patients received profunda artery perforator flaps for head and neck reconstruction and almost one-third (n = 21) received profunda artery perforator flaps for breast reconstruction. Eight of the bilateral breast reconstructions with profunda artery perforator flaps were combined with deep inferior epigastric artery perforator (DIEP) flaps. The most prevalent defect cause was oncologic (78.6 percent of patients).

Table 1. - Patient Baseline Characteristics
Value (%)
No. of patients 70
No. of flaps 83
Age, yr
 Mean 59.4
 Range 18–90
Sex
 Female 38 (54.3)
 Male 32 (45.7)
BMI, kg/m2*
 Mean 24.8
 Range 16.9–38
Diagnosis
 Oncologic 55 (78.6)
 Prophylactic 12 (17.1)
 Prior failed flap 2 (2.9)
 Osteoradionecrosis 1 (1.4)
Defect site*
 Head and neck 44 (53.0)
 Breast 36 (43.4)
 Chest wall 2 (2.4)
 Pelvis 1 (1.2)
BMI, body mass index
*Results are reported per flap.

Flap Characteristics

Table 2 summarizes the flap characteristics. Flap orientation was vertical in 57 flaps (68.7 percent), transverse in 25 flaps (30.1 percent), and oblique in one flap (1.2 percent). Pedicle length averaged 11.6 cm, with artery and vein having a diameter of 2.1 and 3.0 mm. Part of the adductor magnus muscle was harvested with the profunda artery perforator flap in 15 flaps (18.1 percent). The average profunda artery perforator flap thickness was 2.6 cm. Flap thickness significantly correlated with patient body mass index (p = 0.013), although the correlation size according to the Evans classification was only 0.2 to 0.4.

Table 2. - Flap Characteristics
Variable Value (%)
Flap length, cm
 Mean 15.2
 Range 5–26
Flap width, cm
 Mean 7.5
 Range 4–14
Flap thickness, cm
 Mean 2.6
 Range 0.5–5.5
Flap size, cm3
 Mean 343.3
 Range 10–1250
Flap orientation
 Vertical 57 (68.7)
 Transverse 25 (30.1)
 Oblique 1 (1.2)
Pinch ALT flap, cm
 Mean 3.3
 Range 1–9
Pinch PAP flap, cm
 Mean 4.6
 Range 1–15
Pedicle length, cm
 Mean 11.6
 Range 9–16
Artery diameter, mm
 Mean 2.1
 Range 1.0–3.0
Vein diameter, mm
 Mean 3.0
 Range 2.0–4.0
Atherosclerosis 9 (10.8)
Muscular component 15 (18.1)
Flap harvest time, minutes 59 (35–90)
ALT, anterolateral thigh; PAP, profunda artery perforator.

Profunda Artery Perforator Anatomy

Table 3 shows the locations, sizes, and courses of the profunda artery perforators. The A, B, and C perforators were located at mean distances of 7.5 cm (range, 4 to 11.5 cm), 12.7 cm (range, 8 to 18 cm), and 17.6 cm (range, 14 to 20.5 cm) from the pubic tubercle along the x axis and 7.9 cm (range, 6 to 12 cm), 7.3 cm (range, 5 to 12 cm), and 6.1 cm (range, 3.5 to 11.5 cm) posterior and perpendicular to the x axis, respectively (Figs. 8 and 9). The majority of the A and B perforators were of large caliber, whereas the majority of the C perforators were of medium caliber. The perforator course was most commonly musculocutaneous in all three perforators (84.6 to 97.8 percent). Flaps were most commonly based on perforator A [28 of 83 (33.7 percent)] or perforator B [28 of 83 (33.7 percent)], followed by perforators B and C combined [15 of 83 (18.1 percent)], perforators A and B combined [six of 83 (7.2 percent)], perforator C [three of 83 (3.6 percent)], and perforators A, B, and C combined [one of 87 (1.2 percent)]. Two separate pedicles were used to supply the same flap in two profunda artery perforator flap reconstructions [two of 83 (2.4 percent)]. The A perforator originated from the medial circumflex femoral artery and not from the profunda femoral artery in four flaps [four of 65 (6.1 percent)].

Table 3. - Perforator Variables and Patterns
Variables Perforator A (%) Perforator B (%) Perforator C (%)
No. 65 51 45
x axis, cm
 Mean ± SD 7.5 ± 1.5 12.7 ± 2 17.6 ± 1.5
 Range 4–11.5 8–18 14–20.5
Relative x
 Mean ± SD 0.2 ± 0.1 0.3 ± 0.1 0.4 ± 0.1
y axis, cm
 Mean ± SD 7.9 ± 1.4 7.3 ± 1.5 6.1 ± 1.8
 Range 6–12 5–12 3.5–11.5
Perforator caliber
 Unknown 1 (1.5) 0 (0) 2 (4.4)
 Large 40 (61.5) 37 (72.5) 8 (17.8)
 Medium 19 (29.3) 13 (25.5) 29 (64.4)
 Small 5 (7.7) 1 (2.0) 6 (13.3)
Perforator course
 Musculocutaneous 55 (84.6) 50 (98.0) 44 (97.8)
 Septocutaneous 10 (15.4) 1 (2.0) 1 (2.2)
Pedicle length, cm
 Mean ± SD 10.3 ± 1.6 11.3 ± 1.9 9.5 ± 2

Fig. 8.
Fig. 8.:
Histogram of location of perforators A, B, and C on the x axis. The x axis displays the distance of perforators A, B, and C from the pubic tubercle along the axis between the pubic tubercle and the medial epicondyle of the femur.
Fig. 9.
Fig. 9.:
Histogram of location of perforators A, B, and C on the y axis. The y axis is posterior and perpendicular to the x axis.

In 51 vertical profunda artery perforator flap procedures, we mapped the courses of all three perforators. Thirty perforators [30 of 51 flaps (58.8 percent)] merged at some point during their courses (Table 4). Merging most commonly occurred between the B and C perforators [19 of 51 flaps (37.3 percent)] followed by the A and B perforators [nine of 51 flaps (17.6 percent)]. There was no merging between perforators in 21 flaps [21 of 51 (41.2 percent)]. We identified perforators A and B in all 51 vertical flaps, but six flaps (11.8 percent) did not have a sizable perforator C.

Table 4. - Merging Pattern of Selected Perforators in the Profunda Artery Perforator Flaps with Full Exploration of Perforators A, B, and C*
Perforator Selected (%)
Perforators Merged A A + B A + B + C A, B + C B B + C C Total
A + B 0 (0) 3 (33.33) 0 (0) 0 (0) 6 (66.7) 0 (0) 0 (0) 9 (17.6)
A + B + C 0 (0) 0 (0) 0 (0) 0 (0) 2 (100) 0 (0) 0 (0) 2 (3.9)
B + C 0 (0) 0 (0) 1 (5.3) 1 (5.3) 3 (15.8) 13 (68.4) 1 (5.3) 19 (37.3)
None 6 (28.6) 0 (0) 0 (0) 0 (0) 13 (61.9) 0 (0) 2 (9.5) 21 (41.2)
Total 6 (11.8) 3 (5.9) 1 (2.0) 1 (2.0) 24 (47.1) 13 (25.5) 3 (5.9) 51 (100)
*n = 51.

Postoperative Outcomes and Complications

Postoperative outcomes and complications are detailed in Table 5. There was no partial or total flap loss. One patient who underwent reconstruction for a maxillectomy defect experienced a loss of Doppler signal on the profunda artery perforator flap on the first postoperative day and required urgent reoperation. Intraoperative exploration of the profunda artery perforator flap pedicle showed thrombosis of the pedicle artery because of a technical mistake at the arterial anastomotic site. The flap was successfully salvaged without any further complications following thrombectomy, revision of the arterial anastomosis, or thrombolytic injection.

Table 5. - Postoperative Complications
Complications No. (%)
Recipient-site complications 1 (1.4)
 Flap loss
  Partial 0 (0)
  Total 0 (0)
 Flap compromise
  Arterial 1 (1.4)
  Venous 0 (0)
Donor-site complications 10 (14.3)
 Infection 1 (1.4)
 Superficial wound dehiscence 8 (11.4)
 Contour deformity 1 (1.4)

The donor site was closed primarily in all cases. In the overwhelming majority of patients [61 of 70 (87 percent)], the donor sites healed without complication; however, eight patients (11.4 percent) developed a superficial wound dehiscence that was managed conservatively. An infection occurred in one patient (1.4 percent), which was successfully treated with oral antibiotics. One patient developed a contour deformity of her donor site, which was addressed with fat grafting 2 years postoperatively. There were no reported cases of lymphedema or neurologic/functional impairment of a lower extremity following profunda artery perforator flap harvest.

DISCUSSION

Our retrospective study of 83 free profunda artery perforator flap reconstructions demonstrates that the three main profunda artery perforators (A, B, and C) have consistent anatomical locations in the posteromedial thigh. Precise knowledge of the locations of the perforators eliminates the need for a handheld Doppler device or preoperative computed tomographic angiography. Although the size of the flap that can be harvested will vary considerably on the basis of patient body habitus, we found the maximum profunda artery perforator flap dimensions to be 26 × 14 × 5.5 cm, which is consistent with the literature.12,19–21 In all of our patients, even the patient with the 14-cm-wide flap, primary closure was achieved. In general, however, the flap width should not exceed 10 cm to achieve primary closure of the donor site.

Most of the profunda artery perforators followed intramuscular courses through the adductor magnus muscle, but the large caliber of the perforators, especially perforators A and B, facilitated straightforward intramuscular dissection. The exceptional septocutaneous course, extending between the adductor magnus and either the gracilis or the semimembranosus, was most frequently observed in perforator A (15.4 percent). In keeping with a previous study by Scaglioni, perforator A also demonstrated the most variability in vessel origin, with 4.8 percent of the A perforators branching from the medial femoral circumflex artery rather than directly from the deep femoral vessel.22

Perforator presence was consistent among the 57 vertically oriented profunda artery perforator flaps, as all patients had at least two sizable perforators. This observation is consistent with a prior study that analyzed computed tomographic angiograms of 100 thighs and reported at least two perforators in all of the thighs and three or more perforators in 85 percent.23 More than half of the vertical profunda artery perforator flaps demonstrated some pattern of perforator branching before fascial penetration. Perforator divergence allows for the design of dual skin islands and other chimeric flap options, strategies that may obviate the need for a second free flap. For transversely oriented profunda artery perforator flaps for breast reconstruction, reliance on the presence of a suitable A perforator for proper scar positioning typically mandates preoperative computed tomographic angiography, particularly if harvest is undertaken with the patient in the supine or lithotomy position using an anterior to posterior approach.

The anterolateral thigh flap has become a workhorse flap for restoring soft-tissue defects of the head and neck, especially those requiring a high volume-to–surface area ratio and chimeric components.15,20,24–27 However, the inconsistent vascular anatomy associated with the anterolateral thigh occasionally necessitates alternative strategies such as the use of the anteromedial thigh flap or contralateral thigh exploration.15,28,29 In a systematic review conducted by Lakhiani et al. and encompassing 1895 thighs, the vascular supply to the anterolateral thigh flap was most commonly from the descending branch of the lateral femoral circumflex artery (57 to 100 percent), followed by the oblique (14 to 43 percent) and transverse (4 to 35 percent) branches.29 Furthermore, the authors encountered no sizable perforators in 1.8 percent of cases. A separate study of 74 patients demonstrated the absence of anterolateral thigh perforators in 5.4 percent of cases.30 In contrast, we found consistent anatomy during profunda artery perforator flap harvest with at least two sizable perforators in every patient. When 23 anterolateral thigh flaps and 18 profunda artery perforator flaps were compared in head and neck reconstruction, patients who underwent reconstruction with profunda artery perforator flaps reported superior donor-site cosmesis and a satisfaction rate of 100 percent compared to 70 percent in the anterolateral thigh group.20 The posteromedial thigh typically creates a thicker flap with softer skin and more pliable adipose tissue than the anterolateral thigh. Our study found an average posteromedial thigh pinch of 4.6 cm compared to 3.3 cm in the anterolateral thigh. The increased thickness of the profunda artery perforator flap is ideal for reconstructions with high volume demands.

The profunda artery perforator flap’s volume, pliability, long pedicle length, and suitable vessel caliber render tremendous potential for a wide range of reconstructive indications, either as a primary or secondary choice. Given the retrospective nature of the present study, the ability to systematically analyze the rationale for profunda artery perforator flap selection was limited. However, it is evident that with our growing experience, the profunda artery perforator flap is no longer necessarily reserved as a secondary alternative at our institution. In head and neck reconstruction, the profunda artery perforator flap is useful for tongue, floor of mouth, buccal mucosa, maxillary sinus, or external skin defects. Given its volume and pliability, the profunda artery perforator flap is particularly suitable for subtotal or total glossectomy reconstruction. The more commonly used anterolateral thigh flap is more rigid and frequently requires inclusion of the vastus lateralis for bulk, which results in transient effectiveness, as muscle atrophy after radiation therapy can cause aspiration.

In the setting of autologous breast reconstruction, the profunda artery perforator flap has become a primary alternative if abdominal tissue is unavailable or undesirable. The profunda artery perforator has clear advantages compared with the transverse upper gracilis flap, including longer pedicle length, larger skin paddle with more variety of skin paddle orientation, less scar visibility in the anterior thigh, and no muscle harvest. The profunda artery perforator flap delivers a soft, natural reconstruction that is amenable to cosmetically favorable shaping and inset with minimal donor-site morbidity. With its broad and robust blood supply and an average pedicle length of almost 12 cm, a single perforator is sufficient to support the entire flap. It is advisable to dissect out the pedicle up to its origin to provide adequate vessel length and diameter, especially for the arterial caliber. The long pedicle reaches the chest recipient vessels without compromising the aesthetics of the flap inset.

If a small-volume flap is adequate, a transverse orientation is preferred, in our opinion, to optimize donor-site cosmesis. If additional volume is needed, the orientation can be longitudinal, oblique, S-shaped, L-shaped, or trilobed.19 In eight of our patients (11.4 percent), we combined the profunda artery perforator flap with DIEP flaps in a stacked fashion to achieve the desired shape and size. The safety and efficiency of combining the profunda artery perforator flap with other flaps, such as the stacked DIEP/profunda artery perforator flap or profunda artery perforator/profunda artery perforator flap, have been repeatedly demonstrated in several studies.31–33

However, the profunda artery perforator flap has limitations. One of the main disadvantages of the profunda artery perforator flap is wound healing complications. Twelve percent of our patients suffered from superficial wound healing disturbances, although none required invasive interventions. The profunda artery perforator flap is a less ideal choice if a chimeric flap, lengthy nerve graft, or fascia graft is required to fulfill the reconstructive demands. Although feasible, the addition of the adductor magnus muscle may reduce pedicle length. The potential for multiple skin island chimeric design is limited by perforator branching anatomy distally, because individual profunda artery perforator perforators typically originate in discrete fashion from the profunda artery. In contrast, the entire descending branch with all the desired perforators is typically harvested with anterolateral thigh flaps, resulting in greater opportunity for chimeric design.

This study is limited by its single-institution retrospective design, which carries an inherent risk of bias. Six different surgeons evaluated the perforator patterns in the patients in a standardized manner, but measurement bias among the surgeons cannot be excluded. For practical reasons, the surgeons only analyzed the most anterior profunda artery perforator location. It would be more challenging to harvest a profunda artery perforator flap based on a more posterior perforator, unless the patient is in the prone position. It cannot, therefore, be excluded that more perforators from the profunda artery existed in more posterior locations.

CONCLUSIONS

The profunda artery perforator flap is a technically safe and reliable primary or secondary option for head and neck, breast, trunk, and extremity reconstruction. With its consistent and robust vascular anatomy, ease of harvest, and low donor-site morbidity, the profunda artery perforator flap provides a favorable approach for reconstructing a broad spectrum of soft-tissue defects, particularly those requiring durability, volume, and pliability.

ACKNOWLEDGMENT

The authors thank David Aten, M.A., C.M.I., for creating the medical illustration.

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