Stacked PAP Flaps for Two-Stage Immediate Bilateral Breast Reconstruction: A Case Report

Although abdominal tissue remains the gold standard in autologous breast reconstruction,1 other donor sites like buttocks, thigh, dorsal area are often used. The posterior thigh flap was first described in 1980 by Hurwitz and posteriorly transferred as a free flap by Song et al. in 1984. Pap flap has gained popularity, as it offers a favorable response based on a consistent vascular anatomy, ease of harvest, and low morbidity profile,2 being considered, as an excellent alternative to the anterolateral thigh perforator flap for head and neck and limb reconstruction. Today, it is increasingly used for autologous breast reconstruction. The ideal patient for the latter has a breast of small to moderate size, with previous surgery or limited donor tissue on the abdominal area.2,3 A 57-year-old female with a right breast cancer, arrived to our unit in July 2015. Mastectomy and autologous reconstruction with a DIEP flap was the treatment suggested to our patient. At the same time, the contralateral breast was reduced to achieve symmetry with the reconstructed breast. On the histopathologic study of the left breast specimen a low grade intraductal carcinoma was evidenced. The patient was taken once again to the operating room to perform a mastectomy with an immediate reconstruction bearing in mind the family history and her request. A large flap was still needed to fill the mastectomy defect, so bilateral pap flaps measuring 17×9 cm were designed and harvested based on a single perforator artery, found by preoperative Doppler sonography. The perforator of the right flap was positioned anterior in our design and intraoperatively its course was found to be completely septocutaneos. The perforator of the left flap, being positioned in a more posterior way, had a muscular course of 4,3 cm through the adductor magnus muscle. The mean elevation time was about 75 min and 95 min respectively. The recipient site was prepared removing the third costal cartilage as well as some of the intercostal muscles to expose the internal mammary vessels. Once raised, both flaps were transposed to the mastectomy site, the right pap flap was positioned on the superior half and anastomosed to the anterograde mammary vessels in an end to end fashion. The left pap flap was anastomosed to the retrograde limb of the recipient vessels in and end to end fashion and positioned on the inferior portion of the pocket. Arterial anastomosis was quite challenging due to the high discrepancy between the flap and the recipient vessels. Both flaps were widely de-epithelizedand sutured together, only a small skin paddle was left over the flap, positioned in the areola Department of Plastic Surgery, Hospital 12 de Octubre, Madrid, Spain