The perineum is a hard place to heal: it stays moist, carries a high bacterial load, and bears pressure every time a patient sits.
Dr. Annie Wang is a faculty member and attending physician in the Division of Plastic Surgery at Mayo Clinic Arizona. She presented ‘Pedicled Profunda Artery Perforator (PAP) Flaps: A new workhorse for genital and perineal reconstruction’ at Plastic Surgery The Meeting 2026, organized and hosted by the American Society of Plastic Surgeons (ASPS). The meeting was held October 15 to 18, 2026, in Houston, Texas. Her talk was part of the panel ‘Perineal reconstruction in the age of robotic surgery.’ She explained why the pedicled PAP flap has become her preferred option for perineal and pelvic defects.
Each standard option has drawbacks. A rectus abdominis flap requires entering the abdomen, which undercuts the smaller incisions that robotic surgery now offers patients. The gracilis muscle shrinks over time, and a flap from the outer thigh struggles to reach the back of the pelvis.
A Shrinking Gracilis Flap Led Dr. Wang to the Pedicled PAP Flap
She illustrated the gracilis problem with her own patient. After a resection of the rectum and anus, she filled the pelvic space with a gracilis flap that looked bulky in the operating room. Months later, the patient developed a fluid collection, and imaging showed the flap had shrunk and no longer filled the space. She called this one of the issues she sees with the gracilis, ‘at least in my hands.’
The PAP flap addresses those weaknesses. Taken from the inner thigh, it brings a large area of skin and fat that does not shrink the way muscle does. It reaches deep into the pelvis, avoids entering the abdomen, and leaves no functional deficit, since no muscle is removed. She has used it after robotic resections.
Three Patients Show What the Pedicled PAP Flap Can Restore
Her first patient, a 32-year-old woman with recurrent cervical cancer, needed removal of her pelvic organs after chemoradiation. Her preoperative scan left Dr. Wang unsure about using a rectus abdominis flap, so she used a single PAP flap instead. Four months later, the flap still filled the pelvis.
The second, a man with Fournier gangrene, was left with a defect after repeated debridements. Dr. Wang folded a PAP flap onto itself to recreate the scrotum.
The third patient had long-standing hidradenitis suppurativa that did not respond to medical treatment and made sitting very painful. After a radical vulvectomy, she chose flap reconstruction over skin grafting. Dr. Wang rebuilt the area in stages using PAP flaps from both thighs and other flaps. At 3 months, the patient had healed, could sit, and had met her functional goals.
Dr. Wang concluded that the pedicled PAP flap is a strong option for perineal reconstruction. It keeps its bulk, reaches where other flaps struggle, and leaves little lasting cost at the thigh.
Abbreviation: PAP, profunda artery perforator.