Evolution from the TUG to PAP flap for breast reconstruction: Comparison and refinements of technique.
BACKGROUND
Limitations of the transverse upper gracilis (TUG) flap for autologous breast reconstruction include: short pedicle, modest volume, muscle sacrifice and a problematic donor site. The Profunda Artery Perforator (PAP) flap utilises large perforators posterior to the gracilis muscle. We describe our preliminary experience of its use and compare it to our large series of TUG flaps.


METHODS
Our technique has evolved from frog-leg to lithotomy position, and from an anterio-posterior to cranio-caudal raise. This allows either the descending branch of the inferior gluteal artery perforators (IGAP) or the TUG flap as alternatives should PAP perforators be unsuitable intra-operatively. A prospective database was utilised to compare TUG and PAP flaps undertaken 2010-2013.


RESULTS
54 TUG and 22 PAP flaps were performed. 4 PAP flaps were converted to IGAP flaps and 1 to TUG intra-operatively. 97% of all flaps were successful. Mean flap weight was 295 g (TUG) and 242 g (PAP). Donor site complications for both series included seroma (4 TUG, 1 PAP) sensory disturbance (2 TUG, 1 PAP) and scar revision (3 TUG, 1 PAP).


CONCLUSIONS
Our preliminary experience of the PAP flap has not been universally favourable compared to the TUG flap. It is a more challenging flap to raise, which carries with it a learning curve, especially if raised in the supine position; we present our learning points for safer flap harvest, allowing the TUG as a bail out option. The benefits of the PAP include a longer pedicle, without the need to sacrifice muscle; the perforators should have a more defined and larger perfusion zone. The scar is better hidden, but we have not yet proven significant improvements to the donor site compared to the TUG flap.


METHODS
III.
Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, UK. Electronic address: missjudehunter@doctors.org.uk.
J E
JE
Hunter
Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, UK; Department of Plastic and Reconstructive Surgery, Pyramid Clinic at the Lake, Bellerivestrasse 34, Zurich, Switzerland.
A M
AM
Lardi
Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, UK.
D R
DR
Dower
Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, UK; Department of Plastic and Reconstructive Surgery, Pyramid Clinic at the Lake, Bellerivestrasse 34, Zurich, Switzerland.
J
J
Farhadi
D034861:Abdominal Wall / Q000601:surgery; D000328:Adult; D001943:Breast Neoplasms / Q000601:surgery; D016208:Databases, Factual; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000637:transplantation; D061525:Perforator Flap; D011446:Prospective Studies; D013524:Surgical Flaps / Q000098:blood supply*; D013536:Suture Techniques; D013848:Thigh / Q000601:surgery; D016896:Treatment Outcome
Breast reconstruction; Donor site; Profunda artery perforator flap; Transverse upper gracilis flap