PAP Flap

The Profunda Artery Perforator flap (PAP Flap) utilizes skin and fat from the posterior thigh for breast reconstruction. This tissue is transplanted to the breast with microsurgery for natural breast reconstruction that will last forever. The posterior thigh is an excellent donor site for women who have had previous abdominal surgery or have limited abdominal tissue. In addition, there are some young patients that prefer this donor site given the desire for future pregnancy. In many patients there is adequate tissue to perform total breast reconstruction.


This area of the body contains firm fat that lends to an aesthetic and youthful breast reconstruction. There are a number of other advantages to this surgery. The resulting scar from the PAP flap is typically inconspicuous and Dr. Haddock strives to hide it in the crease between the thigh and lower buttock. Furthermore, the blood vessels are lengthy and provide Dr. Haddock more control in positioning the tissue within the breast pocket. In addition to this, its elliptical design provides an ideal shape for coning to create a natural breast. Because the dissection avoids the inguinal lymphatics, there is also a potential reduction in the risk of lymphedema and seromas in comparison to other thigh flaps such as the transverse upper gracilis flap (TUG Flap). Like all other perforator flaps, the PAP flap transfers only the skin and fat, thereby leaving the muscle in place to preserve function.

  • PAP Flap Before and After
  • PAP Flap Before and After
  • PAP Flap Before and After
  • PAP Flap Before and After
  • PAP Flap Before and After
  • PAP Flap Before and After
  • PAP Flap Before and After
  • PAP Flap Before and After

When One Thigh Is Not Enough (Double PAP Flaps)

In a unique subset of patients one thigh does not provide enough volume for one breast reconstruction. There are three options in these situations. First, we can perform a double stacked PAP flap using both thighs for one breast reconstruction. Second, if both breast are being reconstructed then a 4 flap (DIEP and PAP flap) can be considered. Third, a standard PAP flap reconstruction can be followed with placement of an implant. Dr. Haddock has experience in all of these options.

4 Flap (DIEP and PAP Flaps)

The 4 flap breast reconstruction refers to bilateral DIEP flaps and bilateral PAP flaps performed at the same time. This is a unique operation that is only employed in specific situations. In a subset of patients the abdomen or thigh alone will not provide enough tissue for total breast reconstruction. By using both the abdomen and the thighs as is done in the 4 flap breast reconstruction we can obtain adequate skin and volume to perform total breast reconstruction. In these complex situations using only one location would compromise the final aesthetic result. The use of multiple flaps avoids this compromise to the breast. Additionally it allows a more conservative surgery at the donor site ultimately limiting the morbidity of the thighs and abdomen.

Dr. Haddock performs these procedures with his partner Dr. Teotia. Together they are pioneers in this procedure and have one of the largest experiences with 4 flap breast reconstruction in the country.

Choosing Your Surgeon

Flaps Performed in 2019
Flap Success

Dr. Haddock is an expert in the PAP Flap. He has performed hundreds of these procedures with very high success rates. He was one of the co-authors first describing this procedure. Dr. Haddock has multiple publications on this flap and has given numerous talks on the international level on the PAP Flap. His approach is focused on a few key goals including superior aesthetic results, limited thigh morbidity, and operative efficiency leading to quicker recovery. When choosing a surgeon to perform this operation experience is key. Dr. Haddock has one of the largest experiences in this procedure in the world.  Additionally, the focus of the operation can vary among surgeons. Dr. Haddock does not simply view success as flap survival but his goal is to achieve the result his patients desire.

PAP Flap Recovery

Dr. Haddock typically performs these operations at UT Southwestern Clemens University Hospital in Dallas, Texas. Here he uses an Enhanced Recovery After Surgery (ERAS) Protocol to provide for faster recovery and limit postoperative discomfort.
  • 2 night stay in the hospital
  • Extra nursing to watch the blood flow
  • 6 weeks of restricted activities.
  • Tightness in the posterior thigh (will improve over the first 3 months)

Patient Comments With PAP Flap Breast Reconstruction by Dr. Haddock

  • "The amazing, caring, genius, artist, surgeon….the only….Dr. Haddock. I am blown away by the standard of care I received by this incredible doctor and his staff."
  • "Now I have a better body then I did going into cancer treatment."
  • "Dr. Haddock said you’ve got some room on the back of your legs that I could take off, and I was like, ‘OK, that’s kind of a no brainer. This was almost like a mommy makeover."

Potential Complications

As in all procedures, there are complications associated with autologous breast reconstruction. The potential adverse outcomes of autologous tissue breast reconstruction are total flap failure or partial flap failure. Total flap failure, the most feared complication, typically occurs due to a venous or arterial thrombosis of the vessels supplying the flap. With improved operative technique, in experienced hands this risk is extremely low. Patients may also experience hematomas, seromas and wound healing problems at the donor site or the recipient site.

Dr. Haddock's PAP Flap Publications

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