Challenging Autologous Breast Reconstruction in Low BMI Patients with Profunda Artery Perforator (PAP) Flap: Impact of Skin Island Design on Complication Rates and Long-Term Aesthetic Outcomes

Area of Science:

• Plastic Surgery
• Breast Reconstruction
• Microsurgery

Background:

• Profunda Artery Perforator (PAP) flap is an alternative to Deep Inferior Epigastric Perforator (DIEP) flap, especially for low BMI patients.
• High complication rates in PAP flap breast reconstruction, particularly in low BMI populations, necessitate design modifications.
• The vertical skin island design was adapted to potentially mitigate complications.

Purpose of the Study:

• To compare complication rates and long-term outcomes between vertical and horizontal skin island designs in PAP flap breast reconstruction.
• To evaluate patient-reported quality of life and scar quality.
• To assess cosmetic outcomes from a surgeon's perspective.

Main Methods:

• Prospective, single-center study involving 20 patients undergoing PAP flap breast reconstruction.
• Assessment of quality of life and scar quality using BREAST-Q and POSAS questionnaires.
• Cosmetic outcome analysis by four independent plastic surgeons.

Main Results:

• The vertical skin island group showed fewer donor site complications (Clavien-Dindo Classification 3b: p=0.25).
• Patients with the horizontal design reported significantly better psychosocial well-being (BREAST-Q: p=0.04).
• The vertical group experienced superior scar quality (thinner, less pigmented, less relief; POSAS: p<0.05), while surgeons favored the horizontal design's aesthetics.

Conclusions:

• The vertical skin island design in PAP flap breast reconstruction is associated with reduced complications and better scar quality.
• Aesthetic outcomes were rated more favorably for the horizontal design by surgeons.
• Balancing donor site morbidity with aesthetic results is crucial in PAP flap breast reconstruction design choices.