Stack, PAP and Bury: Technical refinements from a case series of 56 profunda artery perforator flaps for breast reconstruction

Aims: To share experiences and learning curve of the introduction of profunda artery perforator (PAP) flaps in breast reconstruction. The secondary aim was to share techniques to improve outcomes. Methods: Case series reviewing outcomes of 56 consecutive PAP flaps performed by a single surgeon across five institutions between March 2021 and May 2023 were reported. The senior author's preference is to routinely stack and bury the flaps to optimise cosmetic outcomes. Results: Fifty-six PAP flaps were performed in 30 patients. The majority of the PAPs were stacked (n = 43, 77%). The mean age at surgery was 46 years (SD 8.44 years) and mean body mass index was 23.86 (SD 3.59). The mean flap weight was 198.83 g (SD 82.86 g) and the mean combined weight for stacked flaps was 369.57 g (SD 98.65 g). Mean ischaemia time was 56.59 min (SD 17.83 min). There was one flap loss (2%). Of the immediate flaps, 90% were buried and monitored using flow couplers. Conclusion: The routine use of PAPs, in particular stacked PAPs, allows for adequate volume and height for breast reconstruction in patients who may have otherwise been deemed un- suitable for autologous breast reconstruction. The PAP flap has replaced the transverse upper gracilis and superior gluteal artery perforator flaps as the second line flap choice in our practice. (c) 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.