Medium- and Large-Sized Autologous Breast Reconstruction using a Fleur-de-lys Profunda Femoris Artery Perforator Flap Design: A Report Comparing Results with the Horizontal Profunda Femoris Artery Perforator FlapFunding None.
14 January 2018
25 March 2018
02 June 2018 (online)
Background The volume of the profunda femoris artery perforator (PAP) flap limits its indications to small- and medium-sized breast reconstructions after modified radical mastectomy for cancer. We report a modified PAP flap design, including not only a vertical extension that increases its volume but also the skin surface, which suits larger breasts requiring immediate or delayed breast reconstructions and compare the results with our horizontal skin paddle PAP flap experience.
Patients and Methods In our center between November 2014 and November 2016, 51 consecutive patients underwent a PAP flap breast reconstruction following breast cancer. A retrospective analysis on the collected data was performed to compare 34 patients with a bra cup smaller than C who underwent 41 horizontal PAP flap procedures, with those (n = 17) of a bra cup greater than or equal to C who underwent 21 fleur-de-lys PAP flap procedures. Demographic, anthropometric, flap and surgical characteristics, postoperative complication rates, and hospital stay were compared between the two groups.
Results The average flap weight was 480 g (range: 340–735 g) for the fleur-de-lys PAP flap group compared with 222 g (range: 187–325 g) for the horizontal PAP flap procedure (p < 0.001). The mean flap dimensions were 25 × 18 cm for the fleur-de-lys PAP flap group compared with 25 × 7 cm in the horizontal PAP flap group. No flap failure was observed in the fleur-de-lys PAP flap group compared with two flap failures secondary to venous thrombosis in the horizontal PAP flap group (NS). Three patients (14%) experienced delayed healing at the donor site compared with four patients (10%) in the horizontal PAP flap group (NS).
Conclusion The fleur-de-lys skin paddle design not only allows an increase of the horizontal PAP flap volume, but also increases the skin surface, with an acceptable donor site morbidity. For medium- or large-sized breasts, the fleur-de-lys PAP flap seems to be ideal when a DIEP flap-based reconstruction is contraindicated.
- 1 Healy C, Allen Sr RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg 2014; 30 (02) 121-125
- 2 Cormack GC, Lamberty BG. The blood supply of thigh skin. Plast Reconstr Surg 1985; 75 (03) 342-354
- 3 Matar N, Quilichini J, Bosc R, Benjoar MD, Lantieri L. Breast reconstruction with superior gluteal artery perforator (SGAP) flap without intraoperative setup change. About eight cases. Ann Chir Plast Esthet 2010; 55 (06) 539-546
- 4 Allen RJ, Haddock NT, Ahn CY, Sadeghi A. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg 2012; 129 (01) 16e-23e
- 5 Lantieri L, Hivelin M, Benjoar MD. , et al. Setting of a breast autologous microsurgical reconstructive surgery evolution in 20 years and review of 1138 cases. Ann Chir Plast Esthet 2015; 60 (06) 484-489
- 6 Haddad K, Hunsinger V, Obadia D, Hivelin M, Lantieri L. Breast reconstruction with profunda artery perforator flap: a prospective study of 30 consecutive cases. Ann Chir Plast Esthet 2016; 61 (03) 169-176
- 7 Satake T, Muto M, Ko S, Yasumura K, Ishikawa T, Maegawa J. Breast reconstruction using free posterior medial thigh perforator flaps: intraoperative anatomical study and clinical results. Plast Reconstr Surg 2014; 134 (05) 880-891
- 8 Haddad K, Obadia D, Hunsinger V, Hivelin M, Lantieri L. Breast reconstruction with profunda artery perforator flap in lithotomy position. Surgical technique. Ann Chir Plast Esthet 2016; 61 (03) 217-222
- 9 Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 2000; 106 (04) 769-776
- 10 Hunsinger V, Hivelin M, Derder M, Klein D, Velten M, Lantieri L. Long-term follow-up of quality of life following DIEP flap breast reconstruction. Plast Reconstr Surg 2016; 137 (05) 1361-1371
- 11 Bodin F, Zink S, Lutz JC, Kadoch V, Wilk A, Bruant-Rodier C. Which breast reconstruction procedure provides the best long-term satisfaction? [Article in French]. Ann Chir Plast Esthet 2010; 55 (06) 547-552
- 12 LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg 2010; 126 (02) 393-401
- 13 Hunter JE, Lardi AM, Dower DR, Farhadi J. Evolution from the TUG to PAP flap for breast reconstruction: comparison and refinements of technique. J Plast Reconstr Aesthet Surg 2015; 68 (07) 960-965
- 14 Angrigiani C, Grilli D, Thorne CH. The adductor flap: a new method for transferring posterior and medial thigh skin. Plast Reconstr Surg 2001; 107 (07) 1725-1731
- 15 McKane BW, Korn PT. The fleur-de-lis upper gracilis flap for breast reconstruction: flap design and outcome. Ann Plast Surg 2012; 69 (04) 383-386
- 16 Saint-Cyr M, Wong C, Oni G. , et al. Modifications to extend the transverse upper gracilis flap in breast reconstruction: clinical series and results. Plast Reconstr Surg 2012; 129 (01) 24e-36e
- 17 Hupkens P, Hameeteman M, Westland PB, Slater NJ, Vasilic D, Ulrich DJ. Breast reconstruction using the geometrically modified profunda artery perforator flap from the posteromedial thigh region: combining the benefits of its predecessors. Ann Plast Surg 2016; 77 (04) 438-444
- 18 Ciudad P, Maruccia M, Orfaniotis G. , et al. The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction. Microsurgery 2015
- 19 Scaglioni MF, Chen YC, Lindenblatt N, Giovanoli P. The vertical posteromedial thigh (vPMT) flap for autologous breast reconstruction: a novel flap design. Microsurgery 2017; 37 (05) 371-376
- 20 Scaglioni MF, Eder M, Giovanoli P. The use of inverted-L posteromedial thigh (L-PMT) flap for autologous breast reconstruction: a case report. Microsurgery 2017
- 21 Gill PS, Hunt JP, Guerra AB. , et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113 (04) 1153-1160
- 22 Haddock NT, Greaney P, Otterburn D, Levine S, Allen RJ. Predicting perforator location on preoperative imaging for the profunda artery perforator flap. Microsurgery 2012; 32 (07) 507-511
- 23 DeLong MR, Hughes DB, Bond JE, Thomas SM, Boll DT, Zenn MR. A detailed evaluation of the anatomical variations of the profunda artery perforator flap using computed tomographic angiograms. Plast Reconstr Surg 2014; 134 (02) 186e-192e
- 24 Kolker AR, Xipoleas GD. The circumferential thigh lift and vertical extension circumferential thigh lift: maximizing aesthetics and safety in lower extremity contouring. Ann Plast Surg 2011; 66 (05) 452-456
- 25 Bauer EC, Koch N, Janni W, Bender HG, Fleisch MC. Compartment syndrome after gynecologic operations: evidence from case reports and reviews. Eur J Obstet Gynecol Reprod Biol 2014; 173: 7-12