**Region:** Lower Extremity # Profunda Femoris Artery Flap ## Anatomy - Pedicle: profunda femoris artery perforators (profunda → perforators to posterior/medial thigh); when traced to source the profunda pedicle caliber at its origin in PAP dissections is 2.2 mm arterial and 2.8 mm venous, with pedicle length to source approximately 10 cm (range 7–13 cm). Perforator-only pedicle length from the deep fascia (superficial portion) may be short (~30 mm) when not skeletonized to the profunda. (see PAP and posterior thigh perforator chapters) - Course: perforators most commonly arise from the profunda femoris and run from the profunda through/adjoining the adductor magnus and semimembranosus region to the posterior/medial thigh skin. The most commonly utilized proximal (first) profunda perforator lies posterior to the gracilis in the region of the adductor magnus and typically enters the skin about 5 cm inferior (caudal) to the gluteal fold and ~4 cm posterior to the medial thigh midline. A sizeable perforator is present in approximately 85% of thighs. (PAP) - Perforator pattern: at least two perforators arise from the profunda (reported range 2–5); about 25% arise from a common trunk off the profunda. Perforators are predominantly septocutaneous (course between adductor magnus and semimembranosus) but can take a short intramuscular route through adductor magnus; posterior-to-anterior/medial-to-lateral variability exists. (PAP) - Venae comitantes: accompany the perforator arteries and enlarge toward the profunda; venous caliber reported ~2.8 mm at the profunda level. Superficial perforator venous caliber may be smaller (see posterior thigh perforator metrics). (PAP; posterior thigh perforator) - Choke vessels / angiosomes: the profunda perforator territory communicates with adjacent thigh angiosomes; when harvesting large transverse skin paddles the surgeon should be aware of variable skin paddle position in relation to groin and gluteal creases due to perforator variability. (PAP) - Nerves: sensory innervation via branch of the posterior femoral cutaneous nerve to the flap (can be included for a sensate flap). Injury to the posterior femoral cutaneous nerve causes posterior-thigh paresthesia and should be avoided in transverse designs. (PAP; posterior thigh/perforator chapters) - Included tissues: skin, subcutaneous tissue (including Scarpa’s fascia when planned), variable fat thickness (typically thinner and more pliable than ALT when vertically designed), and optionally a cuff or portion of adductor magnus muscle (chimeric/myocutaneous variant) when bulk is needed. Flap weights typically used for breast reconstruction approximate 300–400 g (reported range 150–900 g). (PAP) - Thickness and arc: vertical paddles provide thinner, pliable tissue (useful for head/neck); transverse paddles recruit more posterior-medial thigh volume and create a more posterior scar. Pedicle reach is limited compared with abdominal flaps — internal mammary vessels are commonly used as recipients for breast reconstruction because of relative pedicle shortness. (PAP) - Common variants/anomalies: vertical, transverse, and fleur‑de‑lis skin paddles; myocutaneous chimeric flap with adductor magnus; conversion to a TUG (transverse upper gracilis) flap if PAPs are unsuitable; anatomical variability of perforator location and presence is the main anatomic caveat. (PAP) ## Dissection Steps 1. Positioning, markings, landmarks. - Position: supine is preferred for most cases; legs in frog‑leg or lithotomy for access. Prone harvest can be used (especially bilateral harvests) but may prolong ischemia for free transfer; ipsilateral harvest in supine is common to reduce operative time. (PAP) - Landmarks: gluteal fold (superior skin border), midline of medial thigh, gracilis/adductor magnus region. Mark the most proximal transverse paddle superior border at the gluteal fold; inferior border typically ~7 cm below the superior marking (adjust by pinch test and perforator location). Planned transverse paddle examples described as an ellipse ~27 cm width in published designs. Preoperative handheld Doppler is used to mark perforators; CT/MR angiography may be used for transverse/breast planning to locate the most proximal profunda perforator. (PAP) 2. Plane (suprafascial/subfascial), perforator identification (handheld/IO Doppler). - Incision and initial plane: for transverse paddles, incise down to subcutaneous fat and through Scarpa’s fascia caudally (include subcutaneous fat with flap caudal to inferior border). Cephalad/superior incision at the gluteal fold is taken down through muscle fascia. For vertical paddles the harvest proceeds anterior → posterior. (PAP) - Perforator identification: raise flap from posterior → anterior (for transverse paddle) in the plane between subcutaneous tissue and deep fascia (include Scarpa’s fascia where planned). Use preop Doppler to confirm perforator location; intraop identify the medial profunda perforator posterior to gracilis in adductor magnus region. If no adequate perforator is found proceed to TUG planning. (PAP) 3. Pedicle dissection: exposure, control, division; transfer/inset; perfusion checks. - Perforator selection: choose largest reliable perforator — medial perforator posterior to gracilis is commonly used to facilitate supine harvest and reduce OR time. If multiple perforators present, select based on caliber and intramuscular complexity; septocutaneous perforators simplify dissection. (PAP) - Dissection technique: dissect the perforator toward the profunda femoris artery by ligating side branches to adductor magnus and by careful intramuscular dissection if the perforator is short intramuscular — spread muscle fibers rather than divide when possible. Skeletonize pedicle to achieve desired length (reported pedicle length to profunda ~10 cm). Preserve venae comitantes and avoid kinking/twisting of pedicle. If conversion to TUG is necessary, proceed to gracilis-based harvest. (PAP) - If muscle component required: include a cuff/segment of adductor magnus supplied by branches to add bulk or chimeric capability. (PAP) - Division and transfer: after pedicle control and hemostasis, clamp/ligate distal side branches and divide pedicle for free transfer; for pedicled perineal use mobilize flap into defect as a V–Y or propeller design. For breast reconstruction plan recipient internal mammary vessels due to short pedicle. Check perfusion clinically (color, turgor, capillary refill) and by Doppler flow at pedicle/perforator. (PAP) - Immediate shaping: for breast reconstruction the flap can be coned immediately to create a mound; nipple reconstruction at apex of cone may be performed in the immediate setting for skin‑sparing mastectomy. (PAP) 4. Donor-site closure techniques. - Scarpa’s fascia: directly approximate Scarpa’s fascia to reduce risk of donor site dehiscence and scar widening. Close in layers with absorbable deep sutures, then running subcuticular absorbable skin closure. (PAP) - Drains and dressings: place closed‑suction drains beneath donor site; incisions in this area are difficult to dress — surgical glue or adhesive skin closure systems are useful. For large transverse defects that cannot be closed primarily plan split-thickness/full-thickness skin grafting or staged scar revision. (PAP) ## Indications and Contraindications - Indications: - Free flap breast reconstruction (primary indication in many centers), particularly when abdominal tissue is insufficient; flap weights commonly 300–400 g (range 150–900 g). (PAP) - Head and neck reconstruction (partial glossectomy): vertical paddle yields thin pliable tissue suitable for intraoral reconstruction. (PAP) - Perineal reconstruction as a pedicled flap (V–Y or propeller designs). (PAP) - Secondary option when ALT or abdominal donor sites are unsuitable; chimeric designs available when muscle required. (PAP) - Size limits / tissue character: - Transverse paddles recruit larger posterior‑medial thigh volume; vertical paddles yield thinner tissue. Flap ellipse examples up to ~27 cm width have been described; inferior and superior limits adjusted by pinch testing and planned closure. (PAP) - Sensate needs: - The flap can be sensate by including branches of the posterior femoral cutaneous nerve. (PAP) - Contraindications / relative cautions: - Anatomic absence or inadequate calibre of suitable profunda perforators (anatomic variability is the main disadvantage; conversion to TUG when perforators inadequate). (PAP) - High BMI: excessive flap thickness in head/neck reconstructions may be problematic; evaluate preoperatively. (PAP) - Prior surgery or trauma that has disrupted the medial/posterior thigh perforators (preop imaging or Doppler advised). (PAP) - (Note: avoidance of femoral triangle dissection is an advantage of this flap to reduce lymphedema risk; this is a favorable point rather than contraindication.) (PAP) ## Postoperative Care - Monitoring schedule/method: - Standard clinical monitoring of free flap perfusion (hourly checks in early postop period) and use of a handheld Doppler to confirm pedicle flow are typical practices described; implantable probes not specifically detailed in these sources. (general PAP guidance) - Drains and wound care: - Closed‑suction drains placed beneath donor site and recipient pocket; leave until output minimal. Donor incision best dressed with glue or adhesive skin closure systems due to difficult adherence in groin/anterior thigh region. (PAP) - Pressure and positioning: - For pedicled posterior thigh/perforator uses (ischial/ perineal reconstructions) avoid pressure on flap — use air‑fluid mattresses, frequent turning; sitting should be avoided for at least 3 weeks for posterior thigh perforator reconstructions to minimize pressure over the ischium. (posterior thigh perforator chapter) - Mobilization and activity: - Activity limitation and pressure off‑loading per defect and flap location; specifics individualized. (posterior thigh perforator / PAP) - Analgesia / nutrition: - Routine postoperative analgesia and standard nutritional optimization; no special diet specifics provided in these texts. - Antithrombotic practice: - No specific antithrombotic regimen detailed in the provided chapters; follow institutional microvascular protocols. - Return-to-OR thresholds and time windows: - No explicit numerical thresholds provided; general microvascular principle applies — return to OR immediately for suspected pedicle compromise. If perforator found inadequate intraoperatively, conversion to TUG or alternative flap is recommended immediately. (PAP; posterior thigh perforator) ## Complications (rates & management) - Flap vascular complications: - Arterial insufficiency / thrombosis: not numerically quantified in provided texts. Management principle: urgent re‑exploration if clinical signs of ischemia or absent Doppler signal (standard microvascular practice; specific algorithms not detailed in these chapters). (PAP) - Venous congestion: not numerically quantified; avoid by preserving venous comitantes, avoiding kinking, and leaving adequate subcutaneous bridges when pedicled to augment venous outflow. (PAP; posterior thigh flap) - Partial/total loss, fat necrosis, infection: - No explicit incidence percentages provided in these chapters. General preventive steps include careful perforator selection, adequate dissection, layered closure, drain placement, and pressure off‑loading. (PAP; posterior thigh perforator) - Donor-site issues: - Seroma/hematoma: closed‑suction drains are recommended beneath donor site to prevent seroma; direct approximation of Scarpa’s fascia reduces risk of dehiscence and scar widening. (PAP) - Contour deformity/scar location: transverse scars may sit caudally from groin crease depending on perforator and can be revised secondarily; donor scar widening reduced by Scarpa’s fascia approximation. (PAP) - Sensory disturbance: injury to posterior femoral cutaneous nerve causes posterior thigh paresthesia; avoid in transverse designs. (PAP) - Pressure-related complications for perineal/ischial applications: - Posterior thigh and posterior thigh perforator flaps are susceptible to pressure damage—this group of patients often immobile; prevention by air‑fluid mattress, frequent turning, and avoidance of sitting for at least 3 weeks. (posterior thigh perforator) - Management algorithms (what, when, how): - Intraoperative: if no adequate PAP perforator is found, convert to TUG flap immediately (documented bailout). (PAP) - Donor site: approximate Scarpa’s fascia and place drains to reduce dehiscence/seroma; use surgical glue/adhesive dressings for skin closure. (PAP) - Postoperative pressure issues: early proactive pressure off‑loading with air‑fluid beds and avoidance of sitting for 3+ weeks for ischial coverage. (posterior thigh perforator) ## Key Clinical Pearls - The most reliable proximal profunda perforator is commonly posterior to the gracilis in the adductor magnus region approximately 5 cm below the gluteal fold and ~4 cm posterior to the medial thigh midline; a sizeable perforator is found in ~85% of thighs — mark with Doppler preoperatively. (PAP) - Preoperative CT/MR angiography is useful when planning transverse paddles for breast reconstruction to localize the proximal perforator and avoid intraoperative surprises. (PAP) - Position supine with leg in frog‑leg (or lithotomy) for most PAP harvests; posterior→anterior elevation for transverse paddles allows early assessment of perforators and immediate conversion to TUG if needed. (PAP) - Incise caudally through Scarpa’s fascia including subcutaneous fat in the inferior flap to maximize volume; superior cephalad incision is carried through muscle fascia to facilitate perforator identification. (PAP) - When perforators are intramuscular, spread muscle fibers without dividing them to follow the perforator; ligate side branches to adductor magnus to achieve pedicle length (reported pedicle length to profunda ~10 cm, range 7–13 cm). (PAP) - Short functional pedicle favors internal mammary recipients for medial breast positioning; plan recipient vessels accordingly. (PAP) - Always approximate Scarpa’s fascia during donor closure to reduce risk of dehiscence and scar widening; close in layers and leave closed‑suction drains until minimal output. (PAP) - Protect the posterior femoral cutaneous nerve in transverse designs — injury causes troublesome posterior‑thigh paresthesia. (PAP)