Figure 2.

Preoperative surgical site markings and patient positioning for a planned diagonal PAP. (A) Patient positioning in lithotomy. (B) Preoperative marking delineating the adductor longus (AL) muscle, gracilis (G) muscle, and a 22×10.5 cm anticipated diagonal skin paddle. (C) The anterior skin incision is made and carried down through the fascia investing the gracilis, at which point the gracilis is retracted anteriorly. Forceps identify the gracilis pedicle. (D) The investing fascia overlying the adductor magnus is incised and subfascial dissection proceeds. Meticulous posterior dissection of the adductor magnus fascia reveals a large perforator with 2 cutaneous branches (E) A microvascular bulldog was then placed on the main perforator and its associated vena comitans, at which point the vessels were clipped and divided. (F, anterior; G, posterior) The posterior incision was completed to allow for flap harvest and weighing (512g). Flap preparation proceeded on the back table and revealed a pedicle length of 10.5 cm. The flap was then transferred to the left mastectomy defect and microvascular anastomoses were performed in a standard fashion to the internal mammary system. (H) SPY-PHI (Stryker Corp., Kalamazoo, MI; manufactured by Medical London LP, London, Ontario, Canada) angiography of the free flap reveals excellent tissue perfusion (I) The flap was then selectively de-epithelialized and inset with absorbable sutures to recreate a youthful breast mound and the wound was closed over a drain (J) Layered closure of the donor site over a closed-suction drain. (K) Postoperative appearance of the breast and (L, M) lower extremities. Note improved contour of the left upper thigh with an inconspicuous donor site scar.