1. General thoughts:

• What are your general thoughts on the PAP flap, is it a flap that you commonly use for breast reconstruction?
• When comparing this flap to other options for breast reconstruction including the DIEP and gluteal flaps what are some of the main advantages and disadvantages?

2. Preoperative:

• How do you preoperatively assess the vascular anatomy of the leg? Do you routinely obtain CTA’s on all of your patients preoperatively?
• Perforator Mapping Paper
• Can you take our listeners through where you typically find and mark these perforators with your A/B/C technique
• Are these your standard markings and has this replaced preoperative imaging
• How are the PAP flap markings typically described? You recently gave a great grand rounds lecture to Duke discussing breast reconstruction and you mentioned that you mark your patients for PAP flaps in a vertical orientation rather than horizontal or under the gluteal crease? What are the reasons that you made that change?
• In addition, do you mark your patients preoperatively or in the operating room?

3. Intraoperative:

• How do you position your patients for PAP flaps? Do you have them in lithotomy or frog legged?
• What are some operative pearls you can share for the PAP flaps?
• How many perforators are you typically taking? Is this most commonly a single perforator flap in your practice?
• Do you typically preserve a branch of the saphenous vein as a bail out for venous drainage?
• Dissection through the adductor magnus can be a tedious dissection – how do you optimize this dissection?
• What is the typical length that you can get on your pedicle
• How do you cone or position the PAP flap tissue in order to create the best possible breast shape?

4. Postoperative:

• One of the most common postoperative complications that we have seen in PAP flaps is donor site dehiscence? Do you have any pearls for closure of the donor site? What postoperative restrictions do you recommend?

5. Other

• I have heard several presentations on breast reconstruction where they use 4 flaps – bilateral DIEPs and PAPs. When, if ever, do you feel that a 4 flap case is necessary? If you have performed bilateral DIEPs and PAPs how do you streamline your operative time?
• PAP flaps in head/neck reconstruction