Technical Pearls for Breast Reconstruction in Low BMI Asian Women With the Profunda Artery Perforator Flap

Background: The deep inferior epigastric perforator (DIEP) flap is currently the gold standard for autologous breast reconstruction. In cases where the DIEP is contraindicated, the profunda artery perforator (PAP) flap is now the preferred second-line option in our institution. The PAP flap poses unique challenges to the reconstructive surgeon, especially in Asian women with low body mass index (BMI). Herein, we share the unique technical pearls when performing breast reconstruction in this population.

Methods: This is a retrospective cohort studies, where data were collected on all consecutive patients who underwent breast reconstruction by the senior author, from June 2015 to February 2023. Only patients who underwent the PAP free flap reconstructions were included in this study. The PAP flap design was based on the transverse pattern in the upper medial third of the thigh. The flap is inset in the transverse fashion in the mastectomy pocket, utilizing either the internal mammary pedicle, lateral thoracic pedicle, or the thoracodorsal pedicle.

Results: A total of 32 free PAP flaps were performed for 31 Asian patients. The average age was 39.5 years old (range 25-60), and the average BMI was 21.3 (range 18.5-27.4). An average of 5.0 of myocutaneous perforators (range 1-7) can be identified in each donor site. The average flap was 7.8 cm wide (range 6-10), 21.3 cm long (range 15-30), weighing 259.6 g (range 145-555), with an average of 1.3 perforators (range 1-3) and a pedicle length 5.9 cm (range 4-10). The critical steps to a successful reconstruction with the PAP flap lie with the appropriate patient selection, pre-operative imaging, flap design, inset, and donor site management.

Conclusions: East Asian women tend to have lower BMI and smaller breasts and are good candidates for the PAP flap.