Profunda artery perforator characteristics and outcomes: a systematic review

Introduction

Background

Breast reconstruction following mastectomy is an integral component of comprehensive breast cancer care, offering patients the opportunity to restore body image, improve psychological well-being, and enhance overall quality of life (1). The selection of an optimal reconstructive approach is a complex, shared decision-making process, heavily influenced by a multitude of patient-specific factors, including individual anatomy, prior surgical history (breast and abdominal), body habitus, existing comorbidities, and patient preferences regarding aesthetic goals and donor-site morbidity (2). While various reconstructive options exist, autologous reconstruction is frequently favored for its potential to achieve natural and durable outcomes compared to implant reconstruction (3,4).

Perforator flaps have become a mainstay in autologous breast reconstruction (ABR), with the deep inferior epigastric perforator (DIEP), superior gluteal artery perforator (SGAP), lumbar artery perforator (LAP), and profunda artery perforator (PAP) flaps representing prominent examples. While the DIEP flap remains the gold standard for most reconstructive surgeons, limitations such as abdominal donor-site morbidity, prior abdominal surgeries, or insufficient abdominal tissue may necessitate alternative strategies (5,6). Even when muscle-sparing techniques are used, DIEP donor sites sometimes display bulging or abdominal wall weakness (7,8). In this context, the PAP flap has emerged as a reliable and versatile option for expanding the reconstructive armamentarium. It is of particular utility in patients for whom abdominal-based flaps are not feasible, including those with a previous failed abdominal-based flap reconstruction, or to generally avoid abdominal wall morbidity (9,10).

Rationale and knowledge gap

The PAP flap, harvested from the posterior inner thigh, offers unique advantages, including the avoidance of the abdominal donor site and associated morbidity, a relatively concealed donor-site scar, and favorable tissue quality for shaping the breast mound (11). Its application in breast reconstruction has been facilitated by a growing understanding of posterior thigh vascular anatomy and perforator mapping, as well as refinements in surgical technique (12). However, the flap presents distinct challenges, less general experience, and as such a significant learning curve, which underscores the careful intraoperative decision making, and thorough preoperative planning to optimize outcomes (13).

This review provides a critical appraisal of the current literature surrounding the PAP flap in breast reconstruction. We examine anatomical considerations, flap harvest techniques, and microsurgical nuances, and compare clinical outcomes with established flaps. In addition, we explore considerations for patient selection, flap design modifications, strategies to minimize donor-site morbidity, and techniques to enhance aesthetic results. As the field of ABR continues to evolve, the PAP flap has demonstrated increasing relevance and utility, particularly in the hands of experienced microsurgeons.

Objective

By synthesizing available evidence, this review aims to clarify the role of the PAP flap in modern breast reconstruction and provide guidance on its appropriate use, highlighting both its potential advantages and limitations, as well as compile existing data in the literature to aid surgical planning and inform surgeons on PAP as a flap choice. We present this article in accordance with the PRISMA reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-275/rc).

Methods

This study focused on PAP flap ABR. This review was not registered.

Search strategy

We searched PubMed, Medline, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Web of Science databases using variations of the search strategy: (“profunda artery perforator”) AND (“breast reconstruction”). Details of database search strategies and results are provided in Table S1.

Eligibility criteria

Studies were included if they were retrospective, prospective, or case series studies of human female patients undergoing ABR using the PAP flap with reported patient characteristics, flap properties, or operative outcomes. Systematic reviews, meta-analyses, narrative reviews, editorials, case reports, cadaveric studies, and letters to the editor were excluded, as well as the studies that did not include PAP-specific outcomes or reported non-breast reconstruction PAP use.

Additionally, we attempted to avoid overlapping patient cohorts by noting the reported institution and dates of recruitment/extraction in each study. When multiple studies were found to be reporting outcomes from overlapping cohorts (same institution and overlapping time interval for extraction), one study, with the largest sample size of relevant PAP flaps, was included. Thus, our review avoids inconsistence by avoiding the inclusion of the same patients multiple times.

Study screening

All obtained studies were screened by two independent reviewers (T.T. and D.S.); conflicts were resolved by a third, senior reviewer (N.H.). Studies were included or excluded in three stages.

We used Covidence systematic review management software to conduct our review.

Data extraction

Two authors extracted data from eligible studies, including study title, author, date, format, PubMed ID, and study type. Patient demographics included patient age and body mass index (BMI). Flap characteristics included pedicle length, flap weight, number of perforators, and flap ischemia time. Surgical outcomes included operative time and post-operative length of stay, as well as complication rates, divided between donor sites and flap complications, flap failure rate, and unplanned return to OR. Patient satisfaction measures were also extracted, including BREAST-Q questionnaires and donor site satisfaction surveys. We systematically analyzed these variables in the context of the sample size of each study to determine their contribution to our general understanding of the PAP flap in breast reconstruction.

Pooled means and standard deviations were calculated for each variable, and the number of studies reporting each measure, as well as the number of total flaps involved in these studies, was noted.

Subgroup analysis: transverse PAP (tPAP) and vertical PAP (vPAP)

We performed a sub-analysis for outcome measures focused on the difference between tPAP and vPAP harvest. From the 30 studies, we included those that included the transverse method of PAP harvest in the first arm (tPAP group) and those that included the vertical or equivalent method of PAP harvest in the second arm (vPAP group).

We excluded variables that are not reported by at least one study from each group from this subgroup analysis. After reporting the weighted means and standard deviations for all included variables, we used weighted linear regression to investigate significant differences between the groups in question.

P values of less than 0.05 were considered significant. Data management was performed using Microsoft Excel. Data analysis was performed using R.

Results

Study inclusion/exclusion

We initially obtained a total of 191 studies. After title and abstract screening, we excluded 42. The remaining 149 studies were screened for full-text relevance. Studies with overlapping cohorts were evaluated, and one study from each patient cohort was chosen based on relevant sample size, then relevant outcomes. After excluding non-relevant and overlapping studies, a final number of 30 studies was obtained to include in our systematic review. Our process is shown in the PRISMA diagram (Figure 1). The Newcastle-Ottawa Assessment Scale, cohort study version for each study, is shown in Table 1.

Figure 1 PRISMA diagram. CINAHL, Cumulative Index to Nursing and Allied Health Literature; PAP, profunda artery perforator.

Study characteristics

We obtained a total of 30 studies to be included in the data extraction (table available at https://cdn.amegroups.cn/static/public/gs-2025-275-1.xlsx). A total of 26 were retrospective studies and 4 were prospective observational studies.

A total number of 1,657 flaps were included in our analysis.

Patient characteristics

Our pooled average for age, weighted by sample size for each study, was 48.16±3.51 years. Average pooled BMI, also weighted by sample size, was 24.20±1.87 kg/m². Patient characteristics are shown in Table 2.

PAP properties

As with the previous variables, all of our PAP properties were adjusted according to the number of flaps involved in each study. Mean pedicle length was calculated to be 9.87±1.14 cm. Flap weight was reported at an average of 311.83±61.51 g. The number of perforators was found to be 1.60±0.15 perforators per flap. Mean ischemia time was 53.71±8.96 min (Table 3).

Operative time and length of stay

The pooled average of the operative times reported by the included studies was 389.89±99.21 min. Operative time was not divided clearly between unilateral and bilateral procedures in most reports. Mean pooled length of stay was 3.42±3.67 days (Table 4).

Complications

The weighted complication rate statistics are as follows: the donor site complication rate was, overall, the highest, at 14.89%±9.94% while the flap complication rate was 11.63%±9.75%. Unplanned return to the operating room (OR) was recorded in 6.17%±6.31% of cases. Total flap loss, calculated only when reported, was found to be 1.61%±1.52% (Table 5).

A total number of 314 complications were reported across all of our studies, divided into 194 thigh donor site complications and 120 recipient site complications. Details of each type of complication are shown in Table 6. One paper reported lower extremity lymphedema, and one reported a case of compartment syndrome. Both of these complications occurred in modified or extended PAP flap designs and not in the traditional description. Novel, under-researched flap designs may pose a greater risk of these events.

BREAST-Q

BREAST-Q results were provided by three studies, including an aggregate sample size of 132 patients and 160 flaps. The measures that were reported by all three studies were psychosocial well-being (74.19±5.61), sexual well-being (67.43±7.91), chest physical well-being (86.69±6.84), satisfaction with breast (73.38±7.31), and thigh physical well-being (76.09±1.52) (Table 7). However, there was marked heterogeneity in terms of the timing of questionnaire administration.

Subgroup analysis: tPAP and vPAP

A total of 14 studies examined tPAP exclusively, including 1,135 flaps. Similarly, eight studies reported on 269 vPAP flaps. We excluded studies that describe modified designs that do not fit into either categories clearly, such as fleur-de-PAP and transverse upper gracilis (TUG)-PAP flaps (Figure 2).

Figure 2 Illustration of PAP flap designs. Created in BioRender (Sidani M, 2025). Available online: https://biorender.com/n1ymgh4. PAP, profunda artery perforator; TUG, transverse upper gracilis.

No significant difference was found upon comparing demographic variables between the tPAP and vPAP groups (Table 8). Flap weight displayed a particular heterogeneity in the vPAP group, with a standard deviation more the twice the value of the weighted mean.

In terms of complications, no significance was found when comparing donor site and flap complications. Similarly, weighted means of unplanned reoperation and flap failure were not significant between the two groups (Table 9). However, the small number of studies scrutinizing vPAP and the heterogeneity in flap weight limit the generalizability of this result.

Discussion

Anatomy and flap design

Vascular anatomy and volume considerations

The PAP flap is based on musculocutaneous or septocutaneous perforators arising from the profunda femoris vessels, typically coursing through the adductor magnus. Our results indicate at least 1 perforator is present per flap (1.60±0.15), which corroborates reports from the literature indicating their presence in at least two branches. However, their precise location and caliber can vary substantially (43-45).

While the PAP flap offers reliable perfusion, its soft tissue volume and pedicle length are reported to be modest compared to abdominal-based options such as the DIEP flap (17). Our results indicate almost 10 cm of pedicle length (9.87±1.14 cm) and a 311.83±61.51 g weight. This can be a limiting factor in patients with low BMI or in cases requiring large-volume reconstructions. Nonetheless, the PAP’s vascular consistency, favorable donor site concealment, and, compared to the other thigh flaps, relatively sizeable pedicle, support its growing role in microsurgical breast reconstruction.

Patient selection and preoperative evaluation

Ideal candidates for PAP flap breast reconstruction typically have sufficient thigh tissue volume, no significant comorbidities affecting wound healing, and a preference for thigh donor sites. Preoperative evaluation includes a thorough physical examination, imaging studies to assess perforator anatomy, and discussion of risks, benefits, and alternative options with the patient.

Patient selection

Traditionally, the PAP flap was reserved for patients with low BMI and small to medium-sized breasts due to its relatively modest soft tissue volume (28,33,34,46,47). This approach was further supported by limited abdominal tissue availability in lower-BMI patients, making them less suitable for DIEP flap reconstruction, and by concerns regarding higher donor site complication rates in patients with elevated BMI (30,41,46). The results here show a moderate patient BMI (24.20 kg/m² with a small standard deviation of 1.87), but changes in practice patterns over time are not evaluated.

Growing surgical experience and refinement of flap design have expanded the indications for PAP use beyond the initial demographic. Emerging data support the efficacy of stacked configurations—including two stacked PAP flaps or PAP flaps in combination with other donor sites—for achieving adequate volume for patients requiring larger reconstructions (20,39,48). Furthermore, recent studies challenge the assumption that higher BMI increases donor site morbidity in PAP harvest. One analysis found no significant rise in seroma formation among high-BMI patients, while another reported improved patient-reported aesthetic outcomes in those with ptotic gluteal tissue undergoing two stacked PAP reconstruction (49). These findings suggest that, when safely executed, PAP flap breast reconstruction may confer both functional and aesthetic benefits in patients across a broader BMI spectrum.

Additionally, comparative studies in slim patients demonstrate complication rates for the PAP flap that are similar to those of the DIEP, with several reports establishing non-inferiority (10,47,50). One preliminary study indicates PAP as a valid option to replace implant-based reconstruction after single-port robotic nipple-sparing mastectomy (12). This growing body of literature suggests that the PAP flap is not always a second-line choice, but rather a primary autologous technique in appropriately selected patients, regardless of BMI.

Comparing vPAP and tPAP

As a relatively novel technique, the vPAP flap is reported as an alternate method that may present a more advantageous flap volume and vascular pedicle in slim patients, a tradeoff for a relatively difficult scar (as compared to the tPAP flap, where the healing incision can be concealed in the gluteal crease) (38,49). While the results suggest there is noninferiority of the vPAP flap in comparison to the tPAP flap, patients must be counseled on the options and the resulting thigh defect and scar.

Moreover, hybrid techniques, such as the fleur-de-PAP flap and the diagonal PAP flap, propose to combine the advantages of both the tPAP and vPAP flaps (26,51) (Figure 2). The literature about these flap designs is very preliminary; further research will help delineate their uses and pitfalls. As noted prior, however, rare complications, such as lymphedema and one reported case of compartment syndrome, only occurred in the non-traditional, novel design flaps. Caution should be exercised when considering these novel designs until further study can better elucidate their risk profiles. More rigorous comparisons of the PAP techniques are needed before any absolute recommendation can be made. Patient preference, surgeon experience, and aesthetic factors play a larger role in guiding specific PAP flap technique choice.

Outcomes and comparison with other autologous options

According to the literature, among thigh-based flaps, the PAP flap is now widely recognized as the superior option, outperforming alternatives such as the TUG, transverse myocutaneous gracilis, and inferior gluteal artery perforator flaps (35,52-54). While traditionally considered secondary, the PAP flap’s role as a viable alternative to the DIEP is increasingly being reconsidered.

Historically, the PAP flap has been associated with a higher complication profile compared to abdominal flaps, contributing to its perception as a second-line option after the DIEP (14,16,55-58). These complications are typically donor site-related, including wound dehiscence and infection; increased flap necrosis in PAP flaps as compared to DIEP flaps has also been described (30,59,60). Some reports cite increased revision rates and lower patient satisfaction compared to DIEP reconstruction, although these same studies note no significant difference in overall complication rates (17,61). In the context of our results, this remains to be researched further and examined in direct, possibly prospective, comparison.

Conversely, numerous studies support the non-inferiority of the PAP relative to the DIEP. Reported outcomes include comparable rates of flap survival, donor site morbidity, and breast fat necrosis, as well as favorable postoperative and long-term skin color match (31,36,37,50,62) (Figure 3). One study even demonstrated reduced operative time and earlier ambulation in PAP cases, despite slightly lower BREAST-Q scores compared to DIEP (41). Our results provide a pooled mean of more than 6 hours of operative time (standard deviation of around an hour and a half), which may have been inflated by the inclusion of stacked PAP flaps, and a 3–4-day length of stay with high standard deviation (3–4 days). This may also be reflective of evolving outcomes, with older studies reporting longer operative times and lengths of stay, but specific chronological analysis should be performed to determine whether or not this is a trend. However, this may also be skewed by practice patterns regionally.

Figure 3 Donor site and flap complication, reoperation, and flap failure rates across the reported starting year of data collection of published studies.

These mixed findings may be influenced by confounding factors. The PAP is often employed in stacked or conjoined flap reconstructions—settings inherently associated with increased surgical complexity and higher complication rates (25). Furthermore, the literature suggests that donor site complications may be more frequent in higher BMI patients, although seroma rates may not significantly vary across BMI groups (63,64).

Compared to abdominal flaps, the PAP flap offers several potential advantages, including reduced abdominal morbidity, a potentially more concealed scar, and the possibility of simultaneous thigh lift (49). However, it may be limited by flap volume in some patients and can result in thigh contour irregularities. The choice of flap ultimately depends on individual patient factors, surgeon preference, and the specific requirements of the reconstruction.

In broad strokes:

• The PAP flap is approaching the point where it has garnered enough research attention and surgical exposure to possibly rival the DIEP flap in some scenarios, with further refinement of its role to be made possible through further study.
• The PAP flap performance tends to worsen in higher BMI patients, but this trend is also under question and warrants more investigation.
• Variant PAP flap techniques have been proposed, and the utility of each is to be explored.

Limitations

Our systematic review results should be interpreted in the context of the limitations. For example, we excluded studies not available in English, which may limit generalizability. However, the studies excluded due to language were few.

Our systematic review was not registered prior to execution, which may have aided in a more rigorous methodology.

Standardization of the variables is also a limiter. For example, studies generally report flap weight, without specifying it is initial weight upon harvest or final weight prior to closure. For our purposes, when the study specified both, we chose final weight prior to closure. Similarly, complication outcome phrasing was sometimes difficult to generalize across studies, such as minor, major, partial, and total dehiscence. In some studies, complications were only reported when they required intervention, while in others, they were provided in all cases. The use of POSAS (Patient and Observer Scar Assessment Scale) for donor site satisfaction was used only twice and across multiple time frames, reducing our ability to include it in our review. Likewise, BREAST-Q was reported as ‘postoperative’ without indicating the time after surgery. All in all, these sometimes-inconsistent measure, coupled with varying follow-up durations, might explain some of the variability in our obtained measures.

The complication rates are an aggregate (meaning one flap/donor site can yield multiple complications), which could inflate the actual patient impact. The complication rates should also be interpreted as per flap, and not per patient.

Specifically for the three studies included in the BREAST-Q analysis, due to the heterogeneity and sometimes non-specificity of the time frame of BREAST-Q administration, the data should be interpreted with caution, and the results cannot be generalized.

Moreover, a comparative review, such as with DIEP outcomes, could provide more actionable information. However, as indicated prior, comparative measures are not standardized and would yield limited conclusive evidence.

Additionally, due to the rapidly evolving expertise and knowledge about the PAP flap, studies reporting data from patients who underwent ABR less recently might display outdated information and outcomes. Factoring in surgeon experience may be valuable for future research.

Conclusions

The PAP flap presents a rigorously studied, practical option for ABR. The transverse and vertical (tPAP and vPAP) variants are reported to have similar outcomes and can be used at the surgeon’s discretion, depending on surgical experience, patient expectations, and aesthetic preferences. While most studies reported using the PAP flap in slimmer patients, the literature shows a trend towards more BMI-indiscriminate use, with future research expected to either confirm or rectify this inclination. Additionally, novel, extended flap designs, such as the extended PAP, fleur-de-PAP, and sensate PAP, should be studied further in future research to ascertain their advantages, pitfalls, and surgical utility within ABR. This review presents a comprehensive collection of existing knowledge on PAP flap use in ABR, to serve as a guide and reference for clinicians considering the PAP flap.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-275/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-275/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-275/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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