Assessment of Aesthetic Outcomes in Autologous Breast Reconstruction Using Profunda Femoris Artery Perforator Flap

While autologous breast reconstruction using the profunda femoris artery perforator (PAP) flap is becoming increasingly popular, no aesthetic evaluation has been reported. The aim of this study is to evaluate the reconstructed breast using the PAP flap quantitatively and to clarify which factors contribute to the aesthetically favorable results.

We identified 127 patients who underwent breast reconstructions using the vertically designed PAP flap for unilateral breast cancer between April 2018 and December 2021. The PAP flap was elevated vertically to avoid disrupting lymphatic pathways and was inserted between the pectoralis major muscle and the subcutaneous fat after the anastomoses. We classified cases into two groups: the "Favorable cosmesis group" and the "Unfavorable cosmesis group" based on aesthetic evaluations using the vectra three-dimensional (3D) imaging system. Patient characteristics and outcomes between two groups were compared.

Of the 127 patients, 15 were excluded: three with stacked PAP flaps, two with flap necrosis, and 10 with missing aesthetic outcome data. Among the remaining 112 patients, 18 were classified in the "Favorable cosmesis group" and 94 in the "Unfavorable cosmesis group." Comparative analysis revealed that the "Favorable cosmesis group" showed significantly higher ratio with small volume in the upper pole of the unaffected side (21% vs. 72%, p < 0.01) and had a smaller final inset flap weight (147 vs. 190 g, p = 0.028) compared to the "Unfavorable cosmesis group." All 112 patients were evaluated using vectra 3D system at 12 months postoperatively, and their postoperative flap courses were uneventful.

In our study, inherent small volume of the upper pole and smaller flap inset weight contribute to more favorable outcomes.