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Posteromedial Thigh Perforator (PMTP) Propeller Flap

The posteromedial thigh perforator (PMTP) propeller flap is a pedicled perforator-based island flap harvested from the posteromedial thigh, based on perforators of the profunda femoris artery (PFA), and transferred by rotating up to 180° around a skeletonized perforator to reach an adjacent defect. The small Kwon PMTP series reported survival of all eight flaps, no major complications and primary donor-site closure; the related pPMT and vPMT series include other transfer designs and defect sites. It is a muscle-sparing option alongside gracilis and VRAM for appropriately selected defects.[1][2][3]

For the broader propeller-flap framework (Tokyo Consensus, design principles, venous-congestion mitigation across all donor sites), see the propeller flap page. For the medial-thigh donor-region overview, see the medial thigh flap family.

What Is a Propeller Flap?​

The Tokyo Consensus on Propeller Flaps (Pignatti 2011) defined a propeller flap as an "island flap that reaches the recipient site through an axial rotation." The classification axes are:[4]

  • Nourishing pedicle type. Subcutaneous-pedicled, perforator-pedicled (the modern default), or supercharged
  • Degrees of skin-island rotation. 90° to 180° (the PMTP propeller uses 180°)
  • Artery of origin of the perforator (when known)

A perforator-based propeller flap is completely islanded and rotates around a skeletonized perforator pedicle; selected designs retain two nearby perforators, as in Scaglioni's PMT case.[4][11] This allows reach to defects adjacent but not directly accessible by simple advancement or transposition.[4][5]

Vascular Anatomy of the Posteromedial Thigh​

The posteromedial thigh has a profunda femoris perforator system that has been mapped in cadaveric, CT-angiographic and clinical series (below). Perforator diameter is larger in the lateral thigh, at higher BMI and in younger patients, and men more often have perforators sharing a common trunk.[9]

StudyMethodKey anatomic findings
Scaglioni 201523 head-and-neck free PMT flaps; 40 perforatorsPerforators lay 8–10 cm from the pubic crease along a perineum-to-semitendinosus-insertion line. There were 1.7 perforators per flap (range 1–3); mean pedicle length was 10.3 cm (8–13 cm). Of 40 perforators, 32 (80%) were musculocutaneous and 8 (20%) septocutaneous; 95% arose from PFA and 5% from MCFA.[6]
Ahmadzadeh 200711-thigh cadaver study5 ± 2 PFA cutaneous perforators in the posterior thigh; 65% septocutaneous, 35% musculocutaneous; internal diameter 0.8 ± 0.3 mm; pedicle length 29 ± 14 mm from deep fascia. Average cutaneous territory 229 ± 72 cm².[7]
Largo 202083 PAP flaps (mostly head and neck and breast reconstruction)Perforators A, B and C averaged 7.5, 12.7 and 17.6 cm distal to the pubic tubercle and 7.9, 7.3 and 6.1 cm posterior to the pubic-tubercle–medial-condyle axis, respectively. Flaps were most often based on A or B (33.7% each); no flap loss was reported.[8]
DeLong 2014CT angiography, 100 thighsAll 100 thighs had ≥ 2 perforators (85% had ≥ 3); mean diameter at origin 2.7 mm; located on average 6.2 cm below the gluteal crease. Larger perforators laterally, in younger patients, and at higher BMI.[9]
Mohan 20173D perforasome mappingHot spot for dominant perforators: the proximal medial quadrant, 5–10 cm from the inferior gluteal crease. Large linking-vessel networks were associated with a broader perforasome and greater overlap between adjacent perforators.[10]

The cited anatomic and PAP-flap series locate useful proximal posteromedial thigh perforators in sampled thighs; individual perforator count and dominant location require mapping. Map the actual perforator and arc of rotation in the individual patient; whether handheld Doppler is sufficient or cross-sectional vascular imaging is needed depends on anatomy, prior surgery and the reconstructive plan.

Design Variants​

The PMTP flap appears in the literature under several closely related names. These related designs recruit posteromedial-thigh skin, but source vessel, skin-island orientation and transfer mechanism can differ; Scaglioni reported PFA perforators in 12/15 pPMT flaps and MCFA perforators in 3/15.[1]

VariantAbbreviationOrientationTransfer mechanismKey series
Pedicled posteromedial-thigh perforator flappPMTTransverse or obliqueV-Y advancement, interpolation, or propellerScaglioni 2018 (15 flaps)[1]
Vertical posteromedial-thigh propeller flapvPMTVertical (long axis along thigh)Propeller (180°) or V-YWishart 2021 (21 flaps)[3]
PMTP propeller flapPMTP propellerVariablePropeller (180°)Kwon 2021 (8 flaps)[2]
PMT propeller flap (scrotal)PMT propellerOblique / verticalPropeller (180°)Scaglioni 2015 case report[11]

Surgical Technique​

The technique synthesized across the series:[1][2][3][11]

  1. Patient positioning. Lithotomy or lateral decubitus, depending on defect location.
  2. Perforator identification. Use handheld Doppler to map the selected perforator and rotation arc. Scaglioni located perforators 8–10 cm from the pubic crease on a perineum-to-semitendinosus-insertion line; Mohan found a dominant-perforator hot spot 5–10 cm from the inferior gluteal crease in cadaveric mapping. Largo measured from a different pubic-tubercle–medial-condyle axis and found perforators posterior to it.[6][8][9][10] CT angiography can help delineate individual anatomy, but the cited CTA study maps the distal thigh rather than proximal PMTP perforators.[12]
  3. Flap design. Skin island designed around the identified perforator, with the perforator as the pivot point. Dimensions tailored to defect:
    • pPMT series: 5 × 4 cm to 29 × 8 cm[1]
    • vPMT series: 5–9 cm width × 18–35 cm length[3]
    • PMTP-propeller series: average 256.5 cm² (range 136–400 cm²)[2]
  4. Incision and elevation. Incise the skin island and elevate it subfascially, or suprafascially when a thinner flap is required. Identify the perforator entering from the deep surface through adductor magnus or an intermuscular septum; establish its course during the individual dissection.[6]
  5. Perforator skeletonization. Carefully dissect the selected perforator free of surrounding muscle fibers and fascia to create a mobile pivot without tension or kinking. Scaglioni reported pedicles up to 13 cm in 15 mixed-site pPMT flaps; individual PMTP reach depends on the perforator and rotation arc.[1]
  6. Propeller rotation. The flap is rotated 180° around the skeletonized perforator. The larger blade covers the defect; the smaller blade fills the secondary defect created by rotation. Avoid kinking or twisting the perforator; pedicle torsion is a recognized cause of propeller-flap loss.
  7. Inset. Layered tension-free closure into the recipient defect.
  8. Donor-site closure. Primary in all published series, with the scar concealed on the medial / posterior thigh.[1][2][3]

Technical considerations​

  • Two-perforator design. Scaglioni described one scrotal reconstruction using a PMT propeller flap based on two PFA perforators; its comparative effect on perfusion is unknown.[11]
  • The flap can also be transferred as a V-Y advancement (3 of 21 flaps in the vPMT series) when propeller rotation is unnecessary or the defect is directly adjacent.[3]
  • Bilateral flaps are frequently used for large or circumferential defects: 9 of 12 patients in the vPMT series required bilateral reconstruction.[3]

Applications in Urology and Urogynecology​

1. Perineal reconstruction after oncologic resection​

Dedicated PMTP propellers have been reported for extensive perineal defects due to infection or skin cancer. Related vPAP and vPMT designs have been described after APR and pelvic exenteration, respectively.[2][14][23]

Kwon 2021 is the dedicated PMTP propeller series for perineal defects:[2]

  • 8 patients, average age 65 (52–80)
  • Etiologies: Fournier's gangrene and skin cancers (squamous cell carcinoma, extramammary Paget's disease)
  • Average flap size 256.5 cm² (136–400)
  • All flaps PFA-perforator-based; all rotated 180°
  • 8/8 flap survival in Kwon's series, no major complications, all donor sites closed primarily[2]
  • Average follow-up 22.4 months; all eight patients satisfied during follow-up[2]

2. Scrotal / perineoscrotal reconstruction (Fournier's gangrene)​

Scaglioni 2015 is a single-patient case report of a PMT propeller flap for perineoscrotal reconstruction after Fournier's:[11]

  • 58-year-old male, 10 × 12 cm scrotal defect with large dead space
  • PMT propeller flap 9 × 23 cm with 2 PFA perforators
  • 180° rotation reconstructing scrotum and obliterating dead space
  • Complete flap survival; no recipient or donor-site morbidity at 3 months

3. Vulvar reconstruction​

The vPMT propeller flap has been used for vulvar defects after oncologic resection:[3][13]

  • Wishart 2021. 5 of 12 patients had vulvar defects (some combined perianal); all flaps survived without major complications.[3]
  • Huang 2015. In a series of 27 pedicled perforator flaps in 16 patients undergoing vulvar reconstruction, 11 were profunda artery perforator (PAP or DFAP) flaps. Across all 27 mixed flaps, survival was 100% and all donor sites closed primarily. Three of 16 patients required debridement and closure of small wounds, and one had temporary peroneal nerve palsy; all patients reported cosmetic and functional satisfaction except one who underwent debulking.[13] The authors describe fewer donor-site morbidities than with traditional myocutaneous flaps.[13]

4. Perianal reconstruction​

The largest application in the vPMT series:[3]

  • 8 of 12 patients had perianal defects (some combined with genital defects)
  • Etiologies: anal SCC, Crohn's disease, hidradenitis suppurativa
  • All flaps survived; propeller rotation used in 18 of 21 flaps

5. Combined pelvic-floor and vaginal reconstruction​

For complex three-dimensional pelvic defects after exenteration, the vPMT propeller flap can be combined with bilateral gracilis muscle flaps in a "quadruplet" configuration:[14]

  • Wishart 2020. 59-year-old with recurrent SCC of anus and vulva requiring rectum amputation, partial colectomy, hysterectomy and partial vaginectomy; defect 14 × 11 cm with 8 cm deep space
  • Reconstruction: bilateral gracilis (rotated 120°, advanced to fill deep space) and bilateral vPMT propeller flaps (27 × 10 cm, rotated 180°) for vagina and perianal area
  • All four flaps survived without major complications; minimal donor morbidity; acceptable cosmesis at 6 months

Sharp 2021 described 18 combined gracilis and PAP flaps in six previously irradiated patients after extended abdominoperineal resection or pelvic exenteration. One PAP flap had 1 cm of tissue loss after postoperative bleeding; four patients developed partial perineal wound dehiscence. Median healing time was four months, with median follow-up of 10 months.[15]

6. External genital reconstruction in irradiated fields​

Weisberger 2023 compared islandized perforator flaps (PAP or ALT; 6 patients) versus local fasciocutaneous flaps (18 patients) for external-genital reconstruction in 24 patients:[16]

  • Perforator flaps had significantly higher rates of prior radiation (50% versus 11.1%, p = 0.019)[16]
  • In six islandized PAP-or-ALT and 18 local fasciocutaneous cases, the authors described similar observed necrosis, healing delay and infection.[16]
  • Operative time longer with perforator flaps (237 versus 129 min, p = 0.003); LOS comparable
  • The authors suggest perforator flaps may be a suitable option in irradiated fields where local tissue is compromised; the perforator group was small

Outcomes Summary​

Seriesn (flaps)Defect locationFlap sizeTransferFlap survivalMajor complicationsDonor closureFollow-up
Scaglioni 2018 (pPMT)[1]15Inguinal (4), perineal / genital (3), thigh (5), popliteal (3)5 × 4 to 29 × 8 cmV-Y, interpolation, propeller100%0%100% primary6–14 months
Kwon 2021 (PMTP propeller)[2]8Perineal (infection, skin cancer)Avg 256.5 cm²Propeller (180°)100%0%100% primaryAvg 22.4 months
Wishart 2021 (vPMT)[3]21Scrotal (3), perianal (8), vulvar (5), combined5–9 × 18–35 cmPropeller (18), V-Y (3)100%0%100% primaryNR
Scaglioni 2015 (PMT propeller)[11]1Perineoscrotal (Fournier's)9 × 23 cmPropeller (180°)100%0%Primary3 months
Wishart 2020 (quadruplet)[14]2 vPMT + 2 gracilisPelvic (exenteration)27 × 10 cm (vPMT)Propeller (180°)100%0%Primary6 months

Advantages​

  • No muscle sacrifice. Fasciocutaneous harvest preserves gracilis and the thigh adductors; Scaglioni reported good functional recovery at 6–14 months in a selected 15-flap pPMT series.[1][3]
  • Large skin territory. Flaps up to 29 × 8 cm (232 cm²) or 400 cm², sufficient for extensive perineal defects.[1][2]
  • Thin and pliable tissue. pPMT, PMT and mixed pedicled perforator reports describe fasciocutaneous coverage for perineal, scrotal and vulvar defects; comparative cosmetic superiority over gracilis or VRAM has not been established.[1][11][13][26]
  • Consistent perforator anatomy. At least 2 profunda perforators, spread across the medial and lateral thigh, in every one of 100 CT-angiographic thighs; most perforators lay 8–10 cm from the pubic crease in Scaglioni's 23-flap head-and-neck series.[6][8][9]
  • Long pedicle. Skeletonizable up to 13 cm, allowing reach to perineal, genital, and inguinal defects.[1]
  • Primary donor-site closure. All donor sites in the cited, selected pPMT, PMTP and vPMT cohorts were reported closed primarily.[1][2][3]
  • No microvascular anastomosis required.[2]
  • Radiation history. A posteromedial-thigh donor may avoid some pelvic radiation fields, but vulvar-cancer treatment can include the inguinofemoral region. Review the individual dose map and donor perforator territory before flap selection.[15][16][25]
  • Versatile transfer. Propeller (180°), V-Y advancement, or interpolation, depending on defect geometry.[1]

Limitations and Potential Complications​

  • Venous congestion. Pedicle torsion during 180° rotation can compromise outflow. Kwon reported no major complications among eight PMTP propeller flaps, but a separate 2024 series of 10 vertical pedicled PAP flaps for abdominoperineal-resection defects reported two returns to the operating room for venous congestion and two partial flap failures. The 4% venous-congestion estimate from distal-leg propeller flaps is not a perineal PMTP rate.[2][17][23]
  • Learning curve. Perforator skeletonization through adductor magnus (80% musculocutaneous) requires microsurgical dissection skill.[6]
  • Operative time in a mixed cohort. Weisberger reported a mean 237 minutes for six PAP-or-ALT islandized flaps versus 129 minutes for 18 local fasciocutaneous flaps.[16]
  • Dead-space strategy. The PMTP offers fasciocutaneous coverage with limited bulk, and related pedicled PAP skin can be de-epithelialized for internal fill. For large three-dimensional pelvic defects, combined gracilis flaps have been used to fill deep space or reconstruct the pelvic floor.[14][15]
  • Hair-bearing skin. Can be problematic for vaginal or urethral reconstruction; consider preoperative laser depilation.
  • Limited published experience and wound outcomes. The dedicated Kwon series has eight patients; related pPMT and vPMT cohorts mix transfer designs and sites. In separate APR pedicled-PAP cohorts, Arquette reported complications in 8/15 patients despite 15/15 stable coverage[21], while Lavie reported perineal dehiscence in 5/10, abscess drainage in 3/10 and fistula excision in 2/10.[23] Long-term comparative data remain limited.[21][23]
  • Partial necrosis. Lavie reported partial flap failure in 2/10 patients after vertical PAP-flap reconstruction of abdominoperineal-resection defects.[23] A separate distal lower-extremity propeller-flap meta-analysis reports flap necrosis in 12% (total flap necrosis 2%).[17]

Comparison with Other Perineal / Urogenital Flaps​

Dimensions and donor morbidity vary with patient anatomy and the particular operative design.

FeaturePMTP propellerGracilis myocutaneousVRAMPAP (non-propeller)Singapore (PTF)
TissueFasciocutaneousMusculocutaneousMusculocutaneousFasciocutaneousFasciocutaneous
Muscle sacrificeNoneGracilis (expendable)Rectus abdominisNoneNone
Bulk / volumeLow–moderateModerate–highHighLow–moderateLow–moderate
Deep-space obliterationLimitedGoodExcellentLimited; de-epithelialized PAP skin has provided internal fill with gracilis pelvic-floor reconstruction[15]Limited
Max flap sizeUp to 400 cm² (Kwon)————
Pedicle lengthUp to 13 cm (15 pedicled PMT flaps)[1]6.7 cm (TMG, 26-limb cadaver study)[29]—8.8 cm (same cadaver study)[29]Short
Donor-site complicationsNo major complication in Kwon's eight patientsSeries-specific; no matched PMTP comparisonSeries-specific; no matched PMTP comparisonSeries-specific; no matched PMTP comparisonSeries-specific; no matched PMTP comparison
Flap survival (perineal)8/8 in Kwon's selected cohort[2]————
SensatePotentiallyNoNoPotentiallyYes
Irradiated recipientSuitable if donor perforator territory is outside the treated fieldSuitable if donor muscle and pedicle are outside the treated fieldSuitableSuitable if donor perforator territory is outside the treated fieldAssess donor vascularity and prior irradiation; Gleeson's selected vaginal-reconstruction series had substantial morbidity[24]
MicrosurgeryPerforator dissection onlyNoNoPerforator dissection onlyNo
Operative timeNo direct comparative estimateNo direct comparative estimateNo direct comparative estimateNo direct comparative estimateNo direct comparative estimate
Best indicationExtensive perineal surface defectsComplex fistulas; moderate dead spaceLarge 3D pelvic defects; exenterationPerineal coverage; vaginal reconstructionNeovagina; non-irradiated fistulas

References: Scaglioni 2018, Kwon 2021, Wishart 2021, Eseme 2022, Stein 2019, Benedict 2023, Arquette 2022, Höckel 2008, Huang 2015.[1][2][3][18][19][20][21][22][13]

Several related perforator propeller flaps cover overlapping perineal indications:

FlapPerforator sourceBest for
PMTP (this page)Profunda femoris perforatorExtensive perineal defects
DEPAP (deep external pudendal artery perforator)Deep external pudendal a.Fournier's perineal defect (one case report, in a man with colon cancer awaiting chemotherapy)[30]
SCIP propellerSuperficial circumflex iliac a.Perineoscrotal defects up to 22 × 10 cm; rotation 150–180°
EPAP (external pudendal artery perforator)External pudendal perforator; branch not specified in the penile caseCircumferential penile-shaft coverage in one case[27]

PMTP Propeller in the Reconstructive Algorithm​

The following teaching framework matches flap design to defect geometry; it is not a comparative treatment guideline, and selection depends on individual vascular anatomy and surgical goals:

Defect characteristicsOptions described in the cited reports
Small perineal / vulvar defectLocal fasciocutaneous flaps (labial, pudendal-thigh / Singapore, lotus petal)[13]
Medium-to-large surface defect without significant dead spacePMTP propeller flap can provide thin, pliable tissue without muscle sacrifice when the mapped perforator and donor territory are suitable[1][2][3]
Large 3D defect with significant dead space (post-exenteration)Related vPMT propeller or pedicled PAP designs combined with gracilis muscle have been reported; gracilis supports the pelvic floor and the thigh skin island supplies lining or coverage.[14][15]
Very large defect requiring maximum volumeVRAM is the most commonly used flap for large pelvic defects, with more donor-site complications than gracilis in a meta-analysis (pooled 57.6% vs 16.0%)[18][20]

Ricotta's 2025 Toulouse location-based algorithm discusses perforator and musculocutaneous options for vulvar reconstruction without ranking PMTP specifically.[28]

Technical Pearls​

  • Skeletonize conservatively. Leave a small soft-tissue cuff around the vessel to preserve venous drainage during rotation
  • Rotate carefully. Rotate in stages, checking Doppler between stages; torsional perforator kinking is a recognized cause of flap loss
  • Inset under no tension. Tight closure can cause focal necrosis
  • Plan the pivot before incision. Doppler the perforator, mark the rotation arc, and confirm the flap will reach
  • A delay procedure has been used for very large designs where the distal blade depends on a single perforator
  • Consider a gracilis component for substantial residual dead space. In one reported large pelvic defect, bilateral gracilis flaps filled an 8 cm deep space while bilateral vPMT propeller flaps provided vaginal and perianal coverage.[14] During combined PAP–gracilis harvest, identify shared perforators before vessel division; Sharp encountered one common perforator.[15]
  • Plan hair-removal strategy preoperatively if the recipient site requires hair-free skin (vaginal, urethral)

Key Takeaways​

The PMTP propeller flap is a muscle-sparing option in perineal and urogenital reconstruction. Its defining feature is the 180° propeller rotation around a skeletonized PFA perforator, enabling coverage of selected extensive defects with thin, pliable tissue. Kwon's eight-flap perineal series reported complete flap survival, no major complications and primary donor closure without a comparator; the other cited series mix defect sites and flap designs.[1][2][3] Limited volume for significant deep space can be addressed with a separately selected tissue component, as illustrated by a combined gracilis and vPMT case report.[14][15]

See Also​

References​

1. Scaglioni MF, Franchi A, Giovanoli P. Pedicled posteromedial thigh (pPMT) perforator flap and its application in loco-regional soft tissue reconstructions. J Plast Reconstr Aesthet Surg. 2018;71(2):217–23. doi:10.1016/j.bjps.2017.10.005

2. Kwon HJ, Seo JH, Choi JY, et al. Propeller posteromedial thigh perforator flaps for coverage of extensive perineal defects. Microsurgery. 2021;41(4):335–40. doi:10.1002/micr.30726

3. Wishart KT, Fritsche E, Scaglioni MF. Pedicled vertical posteromedial thigh (vPMT) flap for the reconstruction of extensive perianal-genital defects. J Plast Reconstr Aesthet Surg. 2021;74(1):123–9. doi:10.1016/j.bjps.2020.08.001

4. Pignatti M, Ogawa R, Hallock GG, et al. The "Tokyo" consensus on propeller flaps. Plast Reconstr Surg. 2011;127(2):716–22. doi:10.1097/PRS.0b013e3181fed6b2

5. Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC. Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction. J Hand Surg Am. 2011;36(5):853–63. doi:10.1016/j.jhsa.2010.12.021

6. Scaglioni MF, Kuo YR, Yang JC, Chen YC. The posteromedial thigh flap for head and neck reconstruction: anatomical basis, surgical technique, and clinical applications. Plast Reconstr Surg. 2015;136(2):363–75. doi:10.1097/PRS.0000000000001414

7. Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris SF. The posterior thigh perforator flap or profunda femoris artery perforator flap. Plast Reconstr Surg. 2007;119(1):194–200. doi:10.1097/01.prs.0000244848.10434.5f

8. Largo RD, Chu CK, Chang EI, et al. Perforator mapping of the profunda artery perforator flap: anatomy and clinical experience. Plast Reconstr Surg. 2020;146(5):1135–45. doi:10.1097/PRS.0000000000007262

9. DeLong MR, Hughes DB, Bond JE, et al. A detailed evaluation of the anatomical variations of the profunda artery perforator flap using computed tomographic angiograms. Plast Reconstr Surg. 2014;134(2):186e–192e. doi:10.1097/PRS.0000000000000320

10. Mohan AT, Zhu L, Sur YJ, et al. Application of posterior thigh three-dimensional profunda artery perforator perforasomes in refining next-generation flap designs: transverse, vertical, and S-shaped profunda artery perforator flaps. Plast Reconstr Surg. 2017;139(4):834e–845e. doi:10.1097/PRS.0000000000003224

11. Scaglioni MF, Chen YC, Yang JC. Posteromedial thigh (PMT) propeller flap for perineoscrotal reconstruction: a case report. Microsurgery. 2015;35(7):569–72. doi:10.1002/micr.22479

12. Finkemeyer JP, Koehl EM, Mah E. Distal profunda femoris artery perforator island flap for distal thigh and knee reconstruction: a CT-based anatomical analysis and a case-series study. ANZ J Surg. 2023;93(11):2736–41. doi:10.1111/ans.18725

13. Huang JJ, Chang NJ, Chou HH, et al. Pedicle perforator flaps for vulvar reconstruction — new generation of less invasive vulvar reconstruction with favorable results. Gynecol Oncol. 2015;137(1):66–72. doi:10.1016/j.ygyno.2015.01.526

14. Wishart KT, Fritsche E, Scaglioni MF. Reconstruction of a large pelvic defect by transfer of a quadruplet combination of pedicled flaps from the medial thigh using bilateral muscular gracilis flaps and bilateral vertical posteromedial thigh (vPMT) propeller flaps — a case report. Microsurgery. 2020;40(4):486–91. doi:10.1002/micr.30544

15. Sharp O, Kapur S, Shaikh I, Rosich-Medina A, Haywood R. The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: a cohort study. J Plast Reconstr Aesthet Surg. 2021;74(10):2654–63. doi:10.1016/j.bjps.2021.03.038

16. Weisberger JS, Park JB, Cortes R, et al. Reconstruction of acquired defects of the external genitalia: a 24-patient, single-institution experience. Ann Plast Surg. 2023;90(6S Suppl 5):S578–82. doi:10.1097/SAP.0000000000003501

17. Huang SC, Yeh YS, Chen WH, et al. Optimizing perforator-based propeller flap design for distal leg, ankle and hindfoot reconstruction: a systematic review and meta-analysis. Plast Reconstr Surg. 2026;published online. doi:10.1097/PRS.0000000000012993

18. Eseme EA, Scampa M, Viscardi JA, et al. Surgical outcomes of VRAM vs gracilis flaps in vulvo-perineal reconstruction following oncologic resection: a proportional meta-analysis. Cancers. 2022;14(17):4300. doi:10.3390/cancers14174300

19. Benedict KC, Songcharoen SJ, Stephens KL, et al. Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds. J Plast Reconstr Aesthet Surg. 2023;84:514–20. doi:10.1016/j.bjps.2023.06.020

20. Stein MJ, Karir A, Ramji M, et al. Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection. J Plast Reconstr Aesthet Surg. 2019;72(4):565–71. doi:10.1016/j.bjps.2018.12.044

21. Arquette C, Wan D, Momeni A. Perineal reconstruction with the profunda artery perforator flap. Ann Plast Surg. 2022;88(4):434–9. doi:10.1097/SAP.0000000000002986

22. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–68. doi:10.1016/S1470-2045(08)70147-5

23. Lavie JL, Guidry RF, Palines PA, et al. "The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction." Ann Plast Surg. 2024;93(2):239–245. doi:10.1097/SAP.0000000000004021

24. Gleeson NC, Baile W, Roberts WS, et al. "Pudendal thigh fasciocutaneous flaps for vaginal reconstruction in gynecologic oncology." Gynecol Oncol. 1994;54(3):269–274. doi:10.1006/gyno.1994.1209

25. Oonk MHM, Planchamp F, Baldwin P, et al. "European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023." Int J Gynecol Cancer. 2023;33(7):1023–1043. doi:10.1136/ijgc-2023-004486

26. Wendelspiess S, Kouba L, Stoffel J, et al. "Perforator versus non-perforator flap-based vulvoperineal reconstruction—a systematic review and meta-analysis." Cancers (Basel). 2024;16(12):2213. doi:10.3390/cancers16122213

27. Tsukuura R, Engmann T, Miyazaki T, Yamamoto T. "The sensate external pudendal artery perforator (EPAP) hemi-scrotal flap for the circumferential skin defect of the penile shaft: a case report and literature review." Microsurgery. 2025;45(7):e70123. doi:10.1002/micr.70123

28. Ricotta G, Russo SA, Ferron G, Meresse T, Martinez A. "The Toulouse algorithm: vulvar cancer location-based reconstruction." Int J Gynecol Cancer. 2025;35(4):100065. doi:10.1016/j.ijgc.2024.100065

29. Zaussinger M, Tinhofer IE, Hamscha U, et al. "A head-to-head comparison of the vascular basis of the transverse myocutaneous gracilis, profunda artery perforator, and fasciocutaneous infragluteal flaps: an anatomical study." Plast Reconstr Surg. 2019;143(2):381–390. doi:10.1097/PRS.0000000000005276

30. Kim DG, Lee KA. "The usefulness of DEPAP flaps for reconstructing perineal defects caused by Fournier's gangrene: a case report." J Clin Med. 2025;14(24):8732. doi:10.3390/jcm14248732