PAP Flap
A PAP (profunda artery perforator) flap is a type of breast reconstruction that uses your own skin and fat from the upper back of the thigh, just beneath the buttock crease. The tissue is transferred to the chest and shaped to create a new breast. Using microsurgery techniques, its blood vessels are carefully connected to blood vessels in the chest.
Unlike a TUG flap, the PAP flap does not usually include muscle. This helps preserve strength and function in the thigh.
A PAP flap can be particularly suitable for women who do not have enough abdominal tissue for a DIEP flap, have previous abdominal scarring or prefer not to use their abdomen. It is generally best suited to creating a small- or moderate-sized breast. Occasionally, tissue from both thighs may be required to provide sufficient volume.
Where will the scars be?
You will have a scar on the reconstructed breast. Its position and shape will depend on whether the reconstruction is performed at the same time as your mastectomy or at a later stage.
The donor-site scar usually runs across the upper back of the thigh, immediately beneath the buttock crease. It may extend towards the inner or outer thigh, depending on the amount of tissue required and the design of the flap.
The scar is positioned so that it can often be concealed by underwear or swimwear. However, its final position varies, and the outer part may occasionally remain visible. The scar can also settle slightly lower than the natural buttock crease or become widened with time.
Initially, scars are usually firm, red or darker than the surrounding skin. They generally soften and fade over 12–18 months but will not disappear completely. The operated thigh may appear slightly slimmer or have a contour difference compared with the other side.
Recovery
Most patients remain in hospital for approximately 3–5 days. During this time, the blood supply to the flap is checked regularly. You will usually be helped to stand and walk within the first day or two.
The back of the thigh may initially feel tight, bruised or swollen. Sitting upright can place pressure and tension on the donor-site wound and may be uncomfortable during the early recovery period. You may be advised to limit prolonged sitting, use a suitable pressure-relieving cushion and change position regularly.
Supportive shorts or a compression garment may be recommended for approximately six weeks.
Recovery varies between individuals, but as a general guide:
- First 2 weeks: gentle walking and light activities at home, with regular rest. Avoid prolonged sitting, deep bending at the hips, squatting and movements that stretch the back of the thigh.
- Around 4–6 weeks: many patients can drive and return to light or office-based work, provided the wounds have healed and sitting is comfortable.
- Around 6–8 weeks: most normal daily activities can be resumed gradually.
- Around 8–12 weeks: exercise and more strenuous activities may usually be restarted with guidance from your surgical team.
It can take three months or longer for energy levels, swelling, numbness and thigh tightness to settle fully. Recovery may take longer if surgery is performed on both breasts, tissue is taken from both thighs or a donor-site wound-healing problem develops.
Risks and possible complications
All surgery carries risks. Your individual risk will depend on factors including your general health, previous treatment, smoking or nicotine use, body weight and whether the reconstruction is immediate or delayed.
| Risk or complication | What it may mean |
|---|---|
| Pain, bruising and swelling | Expected during the early recovery period and usually improves gradually. Sitting may initially be uncomfortable because the scar is close to the buttock crease. |
| Numbness or altered sensation | Common around the posterior-thigh scar and can extend to the skin inferior to the scar. Sensation may improve over time, but a permanently numb area can remain. The reconstructed breast will also have reduced sensation. |
| Visible or raised scars | Scars may become widened, thickened, lumpy, darker or lighter than the surrounding skin. |
| Scar migration | The scar may settle below the natural buttock crease and become more visible than expected. |
| Thigh asymmetry or contour change | The donor thigh may appear slightly slimmer, indented or different from the opposite thigh. The lower buttock crease may also look different. |
| Delayed wound healing | The donor wound is exposed to movement, tension and pressure when sitting. A small area may separate or take longer to heal, particularly towards the inner thigh. Dressings or, occasionally, further surgery may be required. |
| Seroma | A collection of clear fluid can develop in the thigh or breast and may require drainage with a needle. |
| Infection | Usually treated with antibiotics, although drainage or further surgery is occasionally required. |
| Haematoma | A collection of blood may require an urgent return to theatre. |
| Blood-vessel blockage | A clot can interrupt the flap’s circulation. Urgent surgery may be needed to restore the blood flow. |
| Total flap failure | Rarely, the transferred tissue does not survive and must be removed. Another form of reconstruction may then be considered. |
| Breast asymmetry | Further surgery, such as fat transfer, reshaping or surgery to the opposite breast, may be offered to improve symmetry. |
| Persistent discomfort when sitting | Tenderness or pressure sensitivity around the scar usually improves, but occasionally persists. |
| Thigh tightness or weakness | Temporary tightness is common. Lasting functional weakness is unusual because the PAP flap normally preserves the thigh muscles. |
| Nerve-related pain | Small sensory nerves can be stretched or injured, causing tingling, burning discomfort or sensitivity around the scar. This usually improves but can occasionally persist. |
| Leg swelling or lymphoedema | Persistent swelling of the leg is uncommon but may occur following disruption of small lymphatic vessels. |
This information provides a general guide and does not replace an individual consultation. I surgeon will discuss the expected scar pattern, available tissue volume, recovery and risks specific to you.
TUG versus PAP flap breast reconstruction
Both TUG and PAP flaps use tissue from the upper thigh to reconstruct the breast. They are useful alternatives when a DIEP flap is unsuitable or when a patient prefers not to use tissue from the abdomen.
The most appropriate option depends on the amount and distribution of thigh tissue, the required breast volume, previous surgery, blood-vessel anatomy and the surgeon’s experience.
| Feature | TUG flap | PAP flap |
|---|---|---|
| Full name | Transverse upper gracilis flap | Profunda artery perforator flap |
| Tissue used | Skin and fat from the upper inner thigh, together with a small portion of gracilis muscle | Skin and fat from the upper back of the thigh; muscle is normally preserved |
| Best suited to | Patients with suitable inner-thigh tissue who require a small- or moderate-sized breast reconstruction | Patients with suitable posterior-thigh tissue who require a small- or moderate-sized reconstruction, sometimes with greater projection |
| Available volume | Usually modest; occasionally tissue from both thighs is required | May provide more volume and projection in patients with sufficient posterior-thigh tissue |
| Muscle sacrifice | Includes part of the gracilis muscle. Lasting weakness is unusual because the other thigh muscles compensate | Muscle-sparing; the perforating vessels are dissected through or around the adductor magnus muscle |
| Scar position | Across the upper inner thigh, close to the groin crease, extending towards the buttock crease | Across the upper back of the thigh, immediately beneath the buttock crease |
| Scar visibility | Usually concealed by underwear, although the scar may migrate downwards or become visible at the groin | Often well concealed in the buttock crease, although the outer end may be visible in some underwear or swimwear |
| Effect on thigh contour | May produce a subtle inner-thigh lift, but can cause groin asymmetry or a contour change close to the labia | May slim the posterior thigh but can alter the lower buttock crease or produce a posterior-thigh indentation |
| Blood-vessel pedicle | Generally shorter, with relatively consistent anatomy | Usually longer, which can make connection to the chest vessels easier |
| Difficulty of raising the flap | Generally considered the more straightforward and predictable flap to raise because the gracilis muscle and its main blood supply are readily identified | Usually more technically demanding. The perforating blood vessels can vary in size and position and require careful dissection through the adductor magnus muscle |
| Preoperative imaging | Imaging not required as vascular anatomy is generally more predictable | CT angiography is used to locate the profunda perforators and plan the operation |
| Possibility of changing the plan during surgery | Relatively uncommon once a suitable TUG flap has been planned | Occasionally, the expected perforator is too small or unsuitable and an alternative flap may be required. |
| Flap shaping | Soft tissue shapes well into a small- or moderate-sized breast, but the shorter pedicle and position of the blood supply can limit flexibility | The longer pedicle and more central perforator can provide greater flexibility when positioning and shaping the flap |
| Donor-site wound healing | The groin wound is exposed to moisture, movement and tension, which can contribute to delayed healing | The posterior-thigh wound is exposed to tension and pressure when sitting; wound separation can occur, particularly at the inner end. |
| Early mobility | Walking is encouraged, but wide steps and separating the legs can initially be uncomfortable | Walking is encouraged, but prolonged sitting, squatting and deep bending at the hips may initially be uncomfortable |
| Return to light work | Commonly around 4–6 weeks, depending on healing and the nature of the work | Commonly around 4–6 weeks, although sitting tolerance may affect return to desk-based work |
| Return to normal activity | Usually gradual over 6–12 weeks | Usually gradual over 6–12 weeks |
| Flap failure | Uncommon. Contemporary reports generally describe successful reconstruction in more than 95% of flaps, with some experienced centres reporting failure rates below 1%. Published results vary between centres and older series | Uncommon. A systematic review of 516 PAP flaps reported approximately 99% flap success. Published results vary according to patient selection and surgical experience |
| Direct failure-rate comparison | Comparative evidence has not demonstrated a statistically significant difference in total flap loss between TUG and PAP flaps | Comparative evidence has not demonstrated a statistically significant difference in total flap loss between PAP and TUG flaps |
| Blood-vessel complications | A comparative meta-analysis found more reported vascular complications with gracilis-based flaps, although most flaps remained successful | The same analysis found fewer reported vascular complications and fewer unplanned early reoperations than with TUG flaps |
| Main advantages | Predictable anatomy, relatively straightforward dissection and a long-established technique | Preserves muscle, provides a longer pedicle, may offer more volume or projection and places the scar beneath the buttock crease |
| Main limitations | Modest volume, short pedicle, removal of part of the gracilis muscle and potential groin-scar problems | More technically demanding dissection, variable perforator anatomy, pressure on the donor wound when sitting and a recognised learning curve |
Is one flap better than the other?
Neither flap is universally better. A TUG flap may be preferred when the inner-thigh anatomy is favourable and a predictable, established flap is required. A PAP flap may be preferred when preserving muscle, obtaining a longer vascular pedicle or placing the scar beneath the buttock crease is particularly important.
Although the PAP flap is generally more difficult to raise, this does not appear to produce a higher overall flap-failure rate in experienced hands. Published comparisons suggest that total flap survival is similarly high for both procedures. I will assess the amount of available tissue, your preferred scar position, the required breast volume and your blood-vessel anatomy before recommending the most appropriate option.
I personally plan and perform every stage of your PAP flap reconstruction, using a muscle-sparing approach designed to protect thigh function while achieving a natural result.
Planning and Markings
Before surgery, I assess and mark the upper posterior thigh to plan the flap design, ensuring the donor scar sits within the natural crease beneath the buttock where it is easily concealed.
Flap Harvest
The skin and fat are carefully raised from the back of the thigh, sparing the gracilis and other thigh muscles, while preserving the blood vessels supplying the tissue.
Microsurgical Transfer
The tissue is transferred to the chest, where the flap's tiny blood vessels are reconnected under the operating microscope to vessels in the chest wall, restoring its blood supply.
Shaping and Closure
The tissue is shaped to recreate a natural breast contour, and both the breast and thigh donor site are closed carefully to support the best possible scar.
Who is it for?
A PAP flap may be a good option for you if:
You do not have sufficient abdominal tissue for a DIEP flap, or wish to avoid abdominal surgery.
You have small to moderate-sized breasts and need a reliable volume of tissue.
You would like a completely muscle-sparing donor site with minimal impact on thigh function.
You want a well-hidden scar, positioned along the upper back of the thigh beneath underwear or swimwear lines.
You want a soft, warm, natural-feeling reconstruction using your own tissue, with the option to combine techniques if additional volume is needed.
Before & After
Coming soon
Before-and-after photographs are shared only with each patient’s consent. Examples will be added here in due course — in the meantime, Dr Borges is happy to discuss expected results at your consultation.
Why choose this procedure
Advantages of a PAP flap include:
Muscle-sparing technique
Only skin and fat are transferred, preserving the gracilis muscle and helping to maintain thigh function.
Uses your own tissue
Creates a soft, warm and natural-looking breast that changes naturally with your body over time.
Excellent alternative to a DIEP flap
Ideal for women with limited abdominal tissue or previous abdominal surgery.
Well-hidden donor site scar
The scar is positioned along the upper posterior thigh and is usually concealed beneath underwear or swimwear.
Natural thigh contouring
Removing excess tissue from the upper thigh can provide a subtle improvement in thigh contour.
Long-lasting reconstruction
As no implant is used, there are no implant-related complications or replacement procedures.
Versatile option
Can provide sufficient volume for many women with small to moderate breast sizes, and may be combined with other techniques when additional volume is required.
As a reconstructive procedure following breast cancer treatment, a PAP flap is typically eligible for NHS funding and is recognised by most private medical insurers. Costs for private treatment vary depending on individual circumstances and will be discussed and quoted following your consultation.
Book a ConsultationLocations
Consultations and surgery take place at accredited hospitals and clinics across Kent and London, with consultations available in English, Portuguese and Spanish.
Nuffield Health Tunbridge Wells Hospital
Kingswood Road, Tunbridge Wells, Kent, TN2 4UL
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Wells Health, Fordcombe Hospital
Fordcombe Road, Fordcombe, Tunbridge Wells, Kent, TN3 0RD
Google Map →Wells Health, Tunbridge Wells Hospital
Tonbridge Road, Pembury, Tunbridge Wells, Kent, TN2 4QJ
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