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high deep (‘DIEP')? A systematic review and meta-analysis comparing the clinical outcomes of PAP versus gracilis thigh flap as a second choice for autologous breast reconstruction.
Mimi R. Borrelli,1 Carole SL Spake,1 Vinay Rao,1 Joseph W. Crozier,1 Marten Basta,1 Daniel Kwan1, Rahim Nazerali

Background: Autologous breast reconstruction can produce natural-feeling breasts that alleviate the functional, social, and psychological sequel post-mastectomy. The deep inferior epigastric perforator (DIEP) is the gold standard choice, but when unsuitable, the transverse upper gracilis (TUG) or profunda artery perforator (PAP) flaps are a popular secondary alternative. There is only sparse data directly comparing outcomes of these two thigh-based alternatives

Methods: A systematic search was conducted on Medline and Embase (via Ovid) for all articles published across 10 years (06/20/2010 to 06/20/2020) on TUG and/or PAP flaps for breast reconstruction in post mastectomy patients. A proportional meta-analysis was conducted to statistically compare the frequency of outcomes between PAP and TUG flaps.

Results: The TUG and PAP flap have similar reported success, rates, of hematoma, flap loss, and flap healing rates (all p>0.05), but there were significantly more vascular complications in TUG vs PAP flaps (5.0% vs 0.6%, p<0.01) and significantly greater rates of return to theatre in TUG vs. PAP flaps (4.4% vs 1.8%, p=0.04)

Conclusion: Compared to TUG flaps, PAP flaps have fewer vascular complications and fewer revision surgeries in the acute postoperative period. The preservation of the gracilis muscle in PAPs may underlie these favorable outcomes by allowing for cutaneous grafts to be eccentric designed around the pedicle thus increasing vascularization. There is need for greater heterogeneity in reported outcomes between studies to enable for synthesis of other variables important in determining flap success.


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