**9. Complications**

Flap-related complications are low regarding breast reconstruction with PAP flaps. Profunda artery perforator perfusion is robust and therefore the risk of fat necrosis generally is minimal, both in incidence and volume. Fat necrosis is mostly seen at the tips of the flap and can be avoided by careful intra-operative clinical assessment and prophylactic excisional debridement of presumptive nonviable fat.

Donor site complications are more common. These include, but are not limited to, seroma, delayed wound healing, dehiscence, prolonged edema, dysesthesia, adverse scarring [5, 7].

Seroma should be distinguished easily from prolonged edema, which may also occur. This is done with a clinical exam and confirmed with ultrasound imaging. Prevention is the primary focus. This includes limiting undermining, closed suction drain, quilting sutures, layered closure, and post-operative compression garments. Persistent or recurrent seromas are treated with aspiration and/or drain placement as needed.

Due to the dynamic nature of the surgical site with ambulation, as well as being located near an intertriginous zone, delayed wound healing can occur. Dehiscence is much less common. Appropriate pre-operative planning with pinch-test and conservative skin markings support tension-free closure and routine wound healing. The Fleur-de-PAP is more susceptible to wound healing complications due to the creation of a T-junction with the skin flaps.

Prolonged edema is typically caused by disruption of major lymphatic channels in the lower extremity. The PAP flap dissection avoids the femoral triangle and major lymphatic channels; therefore, the risk is quite low. Preserving the greater saphenous vein, tributaries, and surrounding lymphatics can help prevent edema. Early ambulation with compression dressings or garments is standard of care.

Post-surgical dysesthesia, like the infraumbilical skin after DIEP flap, is a result of cutaneous nerve disruption after flap elevation and is best treated with reassurance and time.

Adverse scarring, namely widened or hypertrophic scars, can occur and is thought to be due to motion and dynamic tension at the suture line, like a thigh lift or brachioplasty.

#### **10. Discussion**

Since its introduction to breast reconstruction in 2010, the profunda artery perforator flap has been a reliable autologous alternative to the DIEP flap within the armamentarium of the reconstructive microsurgeon. It has also been an important additional method when the DIEP flap is not enough. The PAP boasts a large skin paddle (average 27 x 6 cm), ample pedicle length and good caliber, and mild-to-moderate volume of soft, pliable tissue. The ability to harvest the flap from a supine position with a two-team approach increases efficiency. The vascular anatomy is constant which has been corroborated with the routine use of pre-operative CT/MR angiography. The donor site results in acceptable scars with minimal exposure and complication rate. This is expounded by the recently described 'fleur-de-PAP' which enhances the volume at the cost of minimal excess scarring. Pedicle length and caliber enhances its utility in stacked flap procedures. The ability to immediately mold the flap into an esthetically excellent three-dimensional breast mound cannot be overstated.

The primary disadvantage of the flap is volume. However, this can be circumvented with proper patient selection and flap planning, including stacked flaps, hybrid procedures, and subsequent fat grafting (**Figure 9A–D**).

#### **11. Conclusion**

The profunda artery perforator flap is an alternative approach to flap-based breast reconstruction. As breast reconstruction continues to advance, the prevalence of alternative approaches such as the PAP flap will increase. Familiarity with anatomy, microsurgical elevation, contouring and donor site management is critical to achieving excellent esthetic outcomes and professional success.

*Alternative Flap-Based Breast Reconstruction: The PAP Flap DOI: http://dx.doi.org/10.5772/intechopen.112765*

#### **Figure 9.**

*(A, B) Pre and post-operative images of a patient with left breast cancer who underwent stacked DIEP and PAP flap reconstruction of the bilateral breasts. (C and D) Pre and post-operative images well-hidden PAP flap donor sites, without disruption of the infragluteal fold. (Reprinted from Artz et al. [8]).*

## **Acknowledgements**

We would like to acknowledge Dr. Robert Allen for his incredible contributions to both this chapter and the innovation of the profunda artery perforator flap in breast reconstruction. We would also like to acknowledge his home institution, Louisiana State University Division of Plastic Surgery for their supportive efforts, and where Dr. Allen continues to contribute to the field of reconstructive microsurgery.

#### **Conflict of interest**

The authors declare no conflicts of interest.
