**5. Standard profunda artery perforator flap markings and elevation**

#### **5.1 Transverse PAP flap**

Since its introduction, approaching the PAP flap has been consistent. Variability does exist regarding orientation of the flap. The initial orientation was transverse in

#### **Figure 3.**

*Pre-operative picture with markings for transverse PAP flap showing the extend of posterior dissection. Perforators are marked on either side.*

the upper thigh. This has been studied and expanded on, with alternative orientations including vertical, oblique, and combined vertical-transverse also known as the 'fleur-de-PAP' [12].

The standard transverse profunda artery perforator flap begins with marking the landmarks of the groin crease, mid-axial thigh, and inferior gluteal crease. Most commonly, the preferred perforator will be found within 7 cm of the inferior gluteal fold and within 4 cm of the posterior border of the gracilis. This is often identified with pre-operative imaging and confirmed with doppler ultrasound. Standard PAP flap markings are that of a transverse elliptical pattern performed with the patient standing. The width of the flap is determined by a pinch test (**Figure 3**).

#### **5.2 Vertical PAP flap**

The vertical design is oriented orthogonal to the transverse design. Anatomic landmarks include marking the pubic symphysis, the adductor longus and gracilis muscle borders. The perforator is marked using the doppler. The ellipse is centralized over the perforator and a pinch test is used to determine the width of the flap. This orientation is more commonly used by the senior author for multiple reasons—able to incorporate multiple perforators, assuring the dominant perforator is captured, lower chance for wound complications, less pain when sitting [8].
