Breast: Original Articles
Patients who are candidates for free tissue-based breast reconstruction have several available options for donor sites. For most surgeons and patients, the abdomen is the preferred choice—it generally provides a large amount of skin and subcutaneous tissue, has reliable vascular anatomy, and has excellent donor-site cosmesis. However, on occasion, abdominal tissue is not an option or cannot provide adequate volume. Alternatively, additional tissue may be necessary for secondary procedures following the primary reconstruction. In these situations, other donor sites must be used. These include gluteal-based flaps (e.g., superior and inferior gluteal artery perforator flaps) and thigh-based flaps (e.g., transverse upper gracilis).
The profunda artery perforator flap is a novel alternative for breast reconstruction that can be used in these cases. It is a versatile option that can provide a large area of skin and volume of tissue in selected patients, or a smaller flap for an adjunctive procedure. There is a limited body of literature regarding the use of the profunda artery perforator flap in breast reconstruction. Allen et al. reported a series of 27 profunda artery perforator flaps used for breast reconstruction in 2012.1 Most of these (24 of 27 flaps) were used for bilateral reconstruction. Blechman et al. reported a case of stacked profunda artery perforator flaps used for unilateral breast reconstruction,2 and Stalder et al. reported a series of 44 profunda artery perforator flaps that were used in stacked perforator flap breast reconstruction.3 Hunter et al. reported a series of 22 profunda artery perforator flaps, but felt that they were not universally favorable compared with the transverse upper gracilis flap.4 We report here our experience with the use of profunda artery perforator flaps for breast reconstruction in a variety of situations, including primary and secondary procedures, immediate and delayed reconstructions, and as adjuncts for other free flaps.
PATIENTS AND METHODS
Approval was obtained from the Institutional Review Board at the University of Texas Southwestern Medical Center. All patients at our institution who underwent breast reconstruction with profunda artery perforator flaps before January of 2015 were identified. A chart review of these patients was carried out and demographic and perioperative data were recorded. Postoperative complications including flap complications (i.e., partial or total flap loss, seroma, hematoma, infection, and fat necrosis), donor-site complications (i.e., wound dehiscence, seroma, hematoma, and infection), and any systemic complications were recorded.
Surgical Planning and Technique
All patients underwent preoperative computed tomographic angiography to identify perforators in the posterior thigh. Patients were positioned supine—flap harvest and recipient vessel preparation were carried out simultaneously using a two-team approach. Recipient vessels included internal mammary, thoracodorsal, and serratus vessels. In one case with stacked profunda artery perforator flaps, a profunda artery perforator side branch was used for the second flap. The superior extent of the flap was 1 cm below the inferior gluteal crease and the craniocaudal dimension of the flap was generally 7 cm, and care was taken to ensure that the previously identified perforators were included in the flap design. The transverse landmarks for flap harvest were the medial border of the adductor longus and the lateral border of the gluteal crease. This created a crescent-shaped flap, with the scar well hidden in the gluteal crease. Dissection proceeded from medial to lateral in a subfascial plane. The gracilis cutaneous perforator was identified and transected. The profunda perforators were identified as they emerged through the adductor magnus. Dissection was carried out through the adductor magnus to follow the pedicle to the profunda femoris. Lateral dissection was then carried out in a suprafascial plane. The flap was harvested after recipient vessels had been prepared.
A total of 42 patients underwent breast reconstruction with 73 profunda artery perforator flaps. Mean patient body mass index was 24.5 kg/m2 (range, 18.2 to 34.6 kg/m2). Mean flap weight was 384.6 g (range, 235 to 695 g). Flaps were used for immediate reconstruction [n = 16 (22 percent)] (Fig. 1), for immediate-delayed reconstruction [n = 32 (44 percent)] (Fig. 2), for delayed reconstruction [n = 14 (19 percent)] (Fig. 3), and for adjunctive procedures [n = 11 (15 percent)]. In 18 cases, a profunda artery perforator flap was combined with a deep inferior epigastric perforator (DIEP) flap to perform a double-flap breast reconstruction either primarily [n = 13 (18 percent)] (Figs. 3 and 4) or as secondary volume augmentation after prior DIEP flap reconstruction [n = 5 (7 percent)] (Figs. 5 and 6). One profunda artery perforator flap was similarly used after superior gluteal artery perforator flap reconstruction. Four stacked profunda artery perforator flaps were used for unilateral reconstruction in two patients [n = 4 (5 percent)] (Fig. 7).
Of note, two planned profunda artery perforator flaps were converted to medial circumflex femoral artery perforator flaps based on the caliber and location of perforators that were found intraoperatively. These two flaps were not included in this analysis.
There were two total flap losses (2.7 percent) and no partial flap losses. One patient had clinically apparent fat necrosis of the flap. There were no other flap complications. Donor-site complications included one thigh hematoma (1.4 percent), wound infection in two thighs (2.7 percent), and wound dehiscence in six thighs (8.2 percent). All wound dehiscences were minor and healed secondarily. The total take-back rate during the initial hospitalization was 5.5 percent. Secondary revision of widened scar was carried out at the time of adjunctive breast procedures in six thighs (8.2 percent).
The profunda artery perforator flap is a relatively new addition to the reconstructive repertoire. Free and local flaps based on the profunda artery perforators were first used for reconstruction of pressure sores, burn contractures, and extremity wounds by Angrigiani in 2001.5 Allen et al. described its use as a free flap for breast reconstruction in 2012.1 Others have shown that perforators of adequate caliber for free tissue transfer can be consistently found in the posterior thigh region.6–8
This is one of the largest clinical series of profunda artery perforator flaps to date. Our flap failure rate (2.7 percent) was in line with reported failure rates for DIEP flaps.9 Our series differs significantly from the other large series (that of Allen et al.) in that a large number of our flaps [25 flaps (34 percent)] were used in conjunction with other flaps. Furthermore, although most of our flaps were used for reconstruction of total mastectomy defects, they were also used in several partial mastectomy defects [20 flaps (27 percent)] and adjunctive procedures [11 flaps (15 percent)].
The profunda artery perforator flap can provide a large volume of tissue (as large as 695 g in this series), but more often, it is a smaller flap (mean, 384.6 g). As such, it can be used as a single flap for reconstruction of total mastectomy defects in selected patients with small breasts. However, this case series shows that the flap has applications in other patients as well. Our patients had a mean body mass index of 24.5 kg/m2—in combination with another flap (most commonly, DIEP), the profunda artery perforator flap was effectively used to reconstruct relatively large breasts, even in patients with minimal available abdominal and thigh tissue. It can be used for the reconstruction of partial mastectomy defects, providing an alternative to the latissimus dorsi flap in patients who may not desire its associated donor-site morbidity.
For the majority of our patients, the DIEP flap remains the first choice for autologous free tissue breast reconstruction. It usually has several advantages over the profunda artery perforator flap: larger arterial caliber, simpler patient positioning, and larger flap weight. However, selected patients can be better candidates for a profunda artery perforator flap than for a DIEP—these include thin patients who have relatively greater skin and fat excess in the medial/posterior thigh than in the abdomen, nulliparous patients who want to avoid abdominal morbidity in anticipation of future childbearing, and patients who have undergone an abdominoplasty. Similarly, in patients who have already undergone a DIEP flap breast reconstruction and present with secondary deficiencies of volume or skin, the profunda artery perforator flap has advantages over other autologous tissue options such as the latissimus dorsi flap—these include the absence of a need for patient repositioning in bilateral cases, no muscle sacrifice, and overall minimal donor-site morbidity.
The profunda artery perforator flap is an excellent free tissue option for breast reconstruction. It has reliable anatomy, success rates in line with abdominal free tissue flaps, and low donor-site morbidity. Finally, it is a very versatile flap in that it can be used for reconstruction of both partial and total mastectomy defects and as a single flap or in combination with other flaps.
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2. Blechman KM, Broer PN, Tanna N, Ireton JE, Ahn CY, Allen RJStacked profunda artery perforator flaps for unilateral breast reconstruction: A case report.J Reconstr Microsurg201329631634
3. Stalder MW, Lam J, Allen RJ, Sadeghi AUsing the retrograde internal mammary system for stacked perforator flap breast reconstruction: 71 breast reconstructions in 53 consecutive patients.Plast Reconstr Surg2016137265e277e
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5. Angrigiani C, Grilli D, Siebert J, Thorne CA new musculocutaneous island flap from the distal thigh for recurrent ischial and perineal pressure sores.Plast Reconstr Surg199596935940
6. Saad A, Sadeghi A, Allen RJThe anatomic basis of the profunda femoris artery perforator flap: A new option for autologous breast reconstruction. A cadaveric and computer tomography angiogram study.J Reconstr Microsurg201228381386
7. Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris SFThe posterior thigh perforator flap or profunda femoris artery perforator flap.Plast Reconstr Surg2007119194200; discussion 201
8. Haddock NT, Greaney P, Otterburn D, Levine S, Allen RJPredicting perforator location on preoperative imaging for the profunda artery perforator flap.Microsurgery201232507511
Copyright © 2017 by the American Society of Plastic Surgeons
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