**5.3 Flap elevation**

Elevation of the flap begins with the anterior approach. The patient is positioned supine in lithotomy. The adductor longus and gracilis muscles are palpated and transposed to the skin surface. Dissection is carried down to the muscular fascia of the gracilis and proceeds posterior. In the anteromedial thigh the greater saphenous vein and tributaries will likely be encountered. Although these tributaries, if present, may aid venous drainage of the flap, supplemental outflow is typically not required and therefore they can be ligated with impunity. Once the gracilis muscle is identified, the dissection proceeds in the subfascial plane posteriorly. Skin perforators through the gracilis may be encountered and should be ligated. The septum between the gracilis and adductor magnus is important. The gracilis muscle is retracted anterior, and the adductor magnus fascia is incised and elevated. Dissection proceeds cautiously in the subfascial plane until the perforators are identified. Meticulous intramuscular dissection is performed to isolate the perforator(s) to the source vessel of the profunda artery and vein. This typically yields a pedicle length of 8–12 cm and caliber of 2.2 mm for artery and 2.7 mm for vein [4].

After circumferential dissection is completed, the anterior incision is stapled closed, and the posterior incision is completed. Care is taken not to bevel proximally as to preserve the ischial fat pad. The flap is harvested, weighed, and transplanted to the chest for microsurgical anastomosis. Most commonly, flap coning is performed prior to inset, and the flap may be completed de-epithelialized and buried in nipplesparing mastectomies, or a skin paddle may be retained for monitoring and/or resurfacing of the breast skin (**Figure 4**).

#### **Figure 4.**

*Intraoperative dissection of the left vertical PAP flap. Perforators can be seen piercing the adductor magnus (AM). Flap characteristics: : 367 g; Average flap dimensions: 27 × 6 cm; Average pedicle length: 10.2 cm; Average artery diameter: 2.2 mm; and Average vein diameter: 2.8 mm.*

#### **Figure 5.**

*Pre-operative picture of markings for an extended PAP or 'fleur-de-PAP' including both vertical and transverse extension centered over the perforators (stars).*
