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PAP Flap

The PAP flap may be a good reconstruction option for women who don’t have enough belly tissue for reconstruction.

PAP stands for profunda artery perforator, a blood vessel that runs through your thigh. A PAP flap uses this blood vessel, as well as a section of skin and fat from the back of your upper thigh, to reconstruct the breast. Because no muscle is used, a PAP flap is considered a muscle-sparing type of flap.

With this type of reconstruction, a section of skin, fat, and blood vessels is cut from the back of your upper thigh, just below the buttocks, and moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the PAP flap to the blood vessels in your chest using microsurgery.

The PAP flap may be a good reconstruction option for women who don’t have enough belly tissue for reconstruction, either because they are very thin or had major abdominal surgeries, and are not good candidates for TRAM, DIEP, or SIEA flaps. It also tends to work better for women with small- to medium/small-sized breasts. If you have larger breasts and your doctor recommends PAP flap reconstruction because of your unique situation, you may need a saline or silicone implant to achieve your desired size.

Because skin, fat, and blood vessels are moved from your thigh to your chest, having a PAP flap means your thigh will be tighter -- as if you had a thigh lift. PAP flap scars are hidden in the crease of your thigh and buttocks. If PAP flap surgery is used to reconstruct one breast, there could be some unevenness in the back thighs. If you want to avoid this, talk to your surgeon about other options. (A newer type of DIEP surgery, called “stacked DIEP,” is often a good option for women with not enough belly tissue for standard DIEP. However, this surgery is not widely available.) If you’re having both breasts reconstructed, though, your surgeon would take a PAP flap from both thighs, which means both thighs would be thinner. PAP flap surgery is possible even if you’ve had previous liposuction on the thighs.


PAP flap reconstruction: What to expect

During PAP flap surgery, an incision is made in the back of your upper thigh just below your buttocks, and a triangular section of skin, fat, and blood vessels is taken from your thigh and moved up to your chest and formed into a breast shape. The tiny blood vessels that feed the tissue of your new breast are matched to blood vessels in your chest and carefully reattached under a microscope.

PAP flap reconstruction surgery takes about 3 to 5 hours.

After PAP flap reconstruction surgery: You’ll be moved to the recovery room after surgery, where hospital staff members will monitor your heart rate, body temperature, and blood pressure. If you’re in pain or feel nauseated from the anesthesia, tell someone so you can be given medication.

You’ll then be admitted to a hospital room. For a PAP flap, you usually stay in the hospital for about 3 days.

Your doctor will give you specific instructions to follow for your recovery. For detailed information on how to care for the dressings, stitches, staples, and surgical drains, visit the Mastectomy: What to Expect page.

It can take about 4 weeks to recover from PAP flap reconstruction surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery. Because you’ve had surgery at two and maybe four sites on your body (your chest and your thigh or both thighs), you might feel worse than someone who had mastectomy alone and it will probably take you longer to recover. You’ll have to take care of two and maybe four incisions: on your breast(s) and on your thigh(s). You may have another incision and a surgical drain if you also had axillary dissection (under-arm lymph node removal) at the same time.

It’s important to take the time you need to heal. Follow your doctor’s advice on when to start stretching exercises and your normal activities. You usually have to avoid strenuous sports, sexual activity, and lifting anything heavy for about 4 to 6 weeks after PAP flap reconstruction. Because of the incision location, PAP flap procedures may be more likely to have healing problems in the area where the donor tissue was removed.


PAP flap surgery risks

Like all surgery, PAP flap surgery has some risks. Many of the risks associated with PAP flap surgery are the same as the risks for mastectomy. If you’ve had an implant inserted along with PAP flap reconstruction, there are also risks unique to implant reconstruction. However, there are some risks that are unique to PAP flap reconstruction.

Tissue breakdown: In rare instances, the tissue moved from your thigh to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap.

Lumps in the reconstructed breast: If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. They also might cause you some discomfort. If the fat necrosis lumps don't go away on their own, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having it removed can give you greater peace of mind, as well as ease any discomfort you might have.

Center for Restorative Breast Surgery

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— Last updated on July 27, 2022, 1:46 PM