A Head-to-Head Comparison of the Vascular Basis of the Transverse Myocutaneous Gracilis, Profunda Artery Perforator, and Fasciocutaneous Infragluteal Flaps: An Anatomical Study

Abstract

Background: Perforator flaps of the upper thigh or buttock provide a valuable secondary choice in autologous breast reconstruction. The purpose of this study was to compare the vascular territories and supplying vessels of the transverse myocutaneous gracilis flap, the profunda artery perforator flap, and the fasciocutaneous infragluteal flap. Methods: In total, 26 lower limbs from 13 fresh specimens were investigated. All flap pedicles were selectively injected with methylene blue, eosin red, or green ink. The pedicle external diameters, lengths, and locations were measured. The dimensions of angiosomes, their intraindividual and interindividual correlations, and their relations to anatomical landmarks were analyzed. Results: The profunda artery perforator pedicle had the greatest mean external diameter with 3.6 ± 0.7 mm, followed by the transverse myocutaneous gracilis and fasciocutaneous infragluteal pedicles with 2.9 ± 0.6 mm and 2.9 ± 0.7 mm, respectively. The fasciocutaneous infragluteal pedicle was longest with a mean length of 12.5 ± 1.5 cm, whereas the profunda artery perforator and transverse myocutaneous gracilis pedicles had lengths of 8.8 ± 1.0 cm and 6.7 ± 1 cm on average. The profunda artery perforator angiosome provided the largest size, with a mean area of 98.5 ± 26.7 cm2, followed by the fasciocutaneous infragluteal angiosome (77.2 ± 9.0 cm2) and the transverse myocutaneous gracilis angiosome (74.1 ± 32.1 cm2). Conclusions: The authors’ anatomical findings about the transverse myocutaneous gracilis, profunda artery perforator, and fasciocutaneous infragluteal territories provide clinically valuable data for flap selection in breast reconstruction if an abdominal flap is not feasible.

The PAP Flap Breast Reconstruction: A Practical Option for Slim Patients

“…The posteriorly located flap provides larger flaps that can be harvested safely, and more importantly, a PAP occupies a larger perforasome than a TUG perforator. 21 However, earlier PAP flap breast reconstructions were mainly performed in high BMI populations in whom thigh tissues are generally expected to be abundant. 14 In a recent report of 265 PAP flap breast reconstructions, the mean patient BMI was 26.5 kg/m 2 (range: 18-43).…”

“…The posteriorly located flap provides larger flaps that can be harvested safely, and more importantly, a PAP occupies a larger perforasome than a TUG perforator. 21…”

“…This is in accordance with the findings of previous reports of cadaveric and CT angiography studies. 21 27 28 Based on our experience, we frequently chose to remove less perfused medial thigh areas or at least prepared for possible fat necrosis by adjusting the medial part toward the breast upper pole. Moreover, we preoperatively checked the saphenous veins and tried to save them for flap supercharge, because they are likely to have a connection with the main PAPs.…”

Comparison of transverse upper gracilis and profunda femoris artery perforator flaps for breast reconstruction: A systematic review

“…Their series of 54 TUG and 22 PAP flaps demonstrated comparable donor complication rates and somewhat smaller flap weight for PAP flaps, failing to prove the advantages of the PAP flap. In contrast, a head‐to‐head cadaveric vascular comparison of TUG and PAP flaps demonstrated that the PAP provides larger angiosome than TUG flap, as well as a longer pedicle length (Zaussinger et al, 2019). The PAP flap is a more evolved form of a thigh‐based flap that could be offered to the same cohort of patients with TUG flap, considering that the PAP flap avoids unnecessary muscle sacrifice (Hunter et al, 2015).…”

Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction

“…Most of the stacked PAP flap cases utilize retrograde internal mammary vessels even when the flap is stacked with large DIEP flaps. However, the PAP flap has a greater technical difficulty in flap harvest compared to the TUG flap, while both flaps pose a partial flap loss risk at the apices [18, 22, 24].…”