Posterior Arm Artery Perforator Flap: An Ultrafast and Reproducible Perforator Flap Dissection Technique

Axillary reconstruction after wide excision for hidradenitis suppurativa (HS) remains challenging, with no consensus regarding the optimal technique. Although multiple reconstructive options exist, many are limited by prolonged operative time, imperfect tissue match, functional restriction, or significant donor-site morbidity. The posterior arm artery perforator (PAAP) flap offers a reliable and efficient alternative due to its constant anatomy, thin and pliable tissue, and low donor-site morbidity. We present a standardized, landmark-based, Doppler-free, ultrafast harvesting technique, designed to improve reproducibility and reduce operative time. Perforator localization is achieved using simple anatomical landmarks, enabling consistent flap elevation without routine preoperative Doppler mapping. We report 23 PAAP flaps undergoing radical excision for axillary HS. The mean flap elevation time was 9.1 minutes, the mean hospital stay was 2.1 days, and complications were rare (1 case of bilateral partial distal necrosis in a morbidly obese patient and 1 case of bilateral wound dehiscence related to substance abuse). Functional and aesthetic outcomes were favorable, with a discreet brachioplasty-like donor-site scar, preservation of shoulder mobility, rapid recovery, and no HS recurrence during a mean follow-up of 16.9 months. The principal limitation of the PAAP flap is the requirement for primary donor-site closure when excessive flap width is required, restricting its indication to small-to-moderate axillary defects (up to approximately 100 cm²). By combining anatomical reliability, procedural simplification, and ultrafast elevation, the PAAP flap should be considered a first-line reconstructive choice in modern algorithms for axillary defect reconstruction.