PAP Flap: a cutting-edge technique in breast reconstruction

The PAP flap (Profunda Artery Perforator flap) is an advanced surgical technique primarily used for breast reconstruction. In recent years, reconstructive surgery has made significant progress not only in terms of function but also in aesthetics and patients’ emotional well-being.

After procedures such as mastectomy, it’s crucial to restore not only the body’s shape but also confidence, well-being, and a sense of self-recognition.
«Nowadays, the challenge lies in offering our patients a reconstruction that allows them to feel comfortable even when looking in the mirror», says Andrea Figus, Professor of Reconstructive and Aesthetic Plastic Surgery at the University of Cagliari. He currently provides clinical care at Niguarda Hospital in Milan and carries out his private practice at Columbus Clinic.

In this context, the PAP flap stands out, enabling natural-looking results while minimizing the aesthetic impact of scarring. «The PAP flap refers to a block of tissue, fat, and skin that can be harvested from the area under the buttocks. Its name derives from its blood supply, as it branches from the profunda femoris artery nourishing this tissue area».

The post-operative protocols are similar to those used for other microsurgical flaps. Generally, recovery is quick, depending on the individual’s healing speed. During this time, «patients must use drains, which are removed once fluid output is minimal. Then, they need to wear compression garments for about 30 to 40 days. After that, patients can resume their normal lives».

PAP Flap vs. DIEP Flap

The PAP flap is a relatively recent technique, first described in 2012 as a breast reconstruction option following mastectomy. In just over a decade, it has become a valid alternative to other methods such as the DIEP flap (Deep Inferior Epigastric Perforator), which has been used since 1992.

One of the main advantages of the PAP flap is related to the donor site, which can be completely hidden in the crease under the buttock. «When a patient showers and looks in the mirror, they can’t see where the tissue was taken from. It’s only visible, for example, when bending over to lay down a towel at the beach».

Additionally, the PAP flap contains very mobile fat, which makes it easier to sculpt the shape of the new breast. For this reason, it’s often used in immediate reconstructions, those performed at the same time as gland removal. «When the gland is removed, the skin above it is preserved like a ‘natural bra,’ and this block of tissue is inserted inside it – the surgeon explains -. Another unique aspect is that a tissue volume between 190 and 450 grams can be harvested, depending on the individual’s body. This allows reconstruction of small, medium, and sometimes even large breasts». The PAP flap does not involve moving any muscles. The only area involved in dissection is near the adductor muscles of the thigh, preserving the function of the donor site. Figus notes, «Among the many surgeries I’ve performed, I’ve had athletes who were able to continue their sports activities». In contrast, the DIEP flap involves dissecting blood vessels located within the rectus abdominis muscle, a muscle frequently used in everyday movements.

Who is it meant for?

The PAP flap can be used in any patient with sufficient tissue to reconstruct a breast, depending on the desired size and volume. «From a vascular point of view, we must remember these vessels originate from the lower limb. They already have a strong venous return, so the risk of venous congestion is much lower than with other flaps – explains the surgeon -. Its blood supply is also very consistent, which allows for faster dissection and a very high success rate because of its robust vascularization».

It’s important to note this is a microsurgical procedure. The tissue block is harvested with its artery and vein and must be reconnected under a microscope in the chest area. «It’s a complex operation, but in high-volume centers, it can be completed in about three hours. Even though Italy has one of the lowest rates of autologous tissue reconstruction in Europe, we’re seeing an increasing demand from patients looking to avoid implants».

Low complication rate

Complications related to the PAP flap are generally those seen with any autologous tissue transplant. Most issues arise at the donor site, such as fluid buildup (seroma) or minor delays in wound healing due to the area’s anatomical position, which is affected by everyday movements like sitting or bending. Figus explains, «Once transplanted, arterial blood supply problems occur in less than 0.5% of cases. Venous return issues with the PAP flap are also rare: under 5%». A noteworthy point is that patients often experience little to no pain or discomfort. Normal activities can typically be resumed about three weeks after the surgery. The surgeon concludes, «This may lead to a few complications, but the rate remains quite low, between 10% and 15%».