PAP Flap Breast Reconstruction

The Profunda Artery Perforator flap (PAP flap) rebuilds the breast using skin and fat borrowed from the posterior thigh. The tissue is lifted with its own small blood vessels, moved to the chest, and reattached under a microscope to vessels at the mastectomy site. Because it is your own living tissue, the reconstructed breast changes with you over time in a way an implant cannot.

The posterior thigh is an excellent donor site for women who have had previous abdominal surgery or who have limited abdominal tissue. Some younger patients prefer it as well, wanting to leave the abdomen alone in case of a future pregnancy. In many patients there is enough tissue in the thigh to perform a complete breast reconstruction.

• It is permanent. The reconstruction is built from your own living tissue, so once it has healed it is simply part of you — there is nothing to exchange or replace later.
• It looks and feels natural. The reconstructed breast has the softness and movement of the tissue it is made from, and it typically blends into the chest rather than sitting on it.
• It is living tissue with its own blood supply. That means it stays at body temperature — it does not turn cold when the weather does, the way an implant can.
• It changes with you. Gain weight and the reconstruction gains with you; lose weight and it does the same. It follows your body over time instead of staying fixed.
• It stays fat — it never becomes breast tissue. The tissue that is moved is skin and fat, and it remains skin and fat, so it does not change your risk of breast cancer.

These advantages are shared by every natural-tissue reconstruction Dr. Haddock performs — DIEP, PAP, and LAP alike. Which donor site is right for you is a separate question, decided together after examination and imaging.

• The fat of the posterior thigh is firm, which lends itself to an aesthetic, youthful reconstruction.
• The scar is typically inconspicuous — it sits hidden in the crease between the thigh and the lower buttock.
• The blood vessels are of adequate length, typically giving Dr. Haddock good control over positioning and shaping the tissue within the breast pocket.
• The elliptical shape of the flap is well suited to coning — shaping the tissue into a natural breast.
• The dissection avoids the lymph channels of the groin, so there may be a lower risk of lymphedema (swelling from lymph fluid) and seroma (a fluid collection) compared with other thigh flaps such as the transverse upper gracilis (TUG) flap.
• Like all perforator flaps, it takes only skin and fat — the muscle is left in place and its function preserved.

The flap is designed horizontally, high on the back of the thigh. Its upper edge is placed in the crease between the thigh and the lower buttock, which is what allows the healed scar to sit hidden in that fold.

This is why Dr. Haddock prefers the horizontal design to the vertical PAP: it conceals the scar far better, and in his experience it holds up better over the long term.

The PAP flap is a specialized operation, and experience with it is not evenly distributed. Dr. Haddock was a co-author on the paper that first described the PAP flap for breast reconstruction, and has published repeatedly on the technique since — including the largest series of PAP flaps in the medical literature. He has lectured on the procedure internationally.

His approach is built around a few clear goals: superior aesthetic results, limited thigh morbidity (fewer problems at the thigh, where the tissue is taken), and operative efficiency that leads to a quicker recovery. Dr. Haddock does not view success as simply flap survival; his goal is to achieve the result each patient wants.

As with any procedure, there are risks associated with natural-tissue (autologous) breast reconstruction. The main adverse outcomes are total or partial flap failure. Total failure — the most feared complication — typically results from a venous or arterial clot in the vessels supplying the flap; with modern technique and in experienced hands, this risk is extremely low. Patients may also experience a hematoma (a collection of blood) or seroma (a collection of fluid) at either the thigh or the breast.

The most common complication of a PAP flap is a wound-healing problem at the donor site (upper back of the thigh). The incision sits in an area that is very hard to keep clean, and the thigh cannot be immobilized — sitting, standing, and walking all put tension on the donor-site closure.