Profunda artery perforator characteristics and outcomes: a systematic review

The profunda artery perforator (PAP) flap is a versatile autologous tissue option for breast reconstruction, offering a secondary option when the traditional abdominal-based flaps are not available. This study aims to systematically evaluate the use of the PAP flap in autologous breast reconstruction (ABR) by analyzing patient characteristics, flap parameters, surgical outcomes, and patient-reported satisfaction.

We conducted a systematic review of databases for studies the use of the PAP flap within ABR, namely, measures of patient characteristics, flap profile, surgical measures, and surgical/satisfaction outcomes. We excluded cadaveric, non-breast, and secondary research studies.

A total of 30 studies were included in our systematic review. Mean pooled values and (standard deviations) reported in the studies were as follows: age of patients was 48.16 (3.51) years; body mass index (BMI) was 24.20 (1.87) kg/m²; PAP pedicle length was 9.87 (1.14) cm; flap weight was 311.93 (61.51) g; number of perforators per flap was 1.60 (0.15); ischemia time was 53.71 (8.96) min; operative time was 389.89 (99.21) min; and length of stay was 3.42 (3.67) days. Mean pooled rates and standard deviations reported in the included studies were as follows: donor site complication rate was 14.89% (9.94%); flap complication rate was 11.63% (9.75%); unplanned return to operating room (OR) rate was 6.17% (6.31%); and total flap loss/failure rate was 1.61% (1.52%). BREAST-Q results were provided by three studies and were also analyzed. Subgroup analysis of transverse PAP (tPAP; 14 studies) versus vertical PAP (vPAP; 8 studies) yielded a non-inferiority of the vPAP in all measured results. However, rare complications, such as compartment syndrome and lymphedema, were only reported in studies examining non-traditional, extended PAP flaps.

The PAP flap is a well-studied, continually refined option for ABR. Its use is dependent on surgeon experience and patient profile. The classic tPAP and newer vPAP display similar outcomes and can be utilized on an individualized, case-by-case basis. Relatively novel PAP flap variants, such as extended and fleur-de-PAP, require further study before they can be recommended as possible options in ABR.