Posteromedial thigh perforators in contemporary profunda artery perforator flap surgery: An anatomical reappraisal

Why clinicians should know about it

• Picked for Anatomy (paper of the day, 4 October 2026): Posteromedial thigh perforators anatomical reappraisal

Abstract

INTRODUCTION: The vascular anatomy underlying contemporary profunda artery perforator (PAP) flap harvest remains incompletely defined. Although PAP flaps are traditionally considered as profunda femoris artery perforator flaps, the perforators encountered within the surgically relevant posteromedial thigh territory may arise from multiple vascular sources. This study aimed to reappraise the anatomy of posteromedial thigh perforators relevant to PAP flap harvest, characterize their anatomical variability, and develop a descriptive framework for these variations. METHODS: One hundred posteromedial thighs from 50 fresh female cadavers were prospectively dissected. Perforators that were encountered within the PAP flap harvest territory were identified and dissected retrogradely to their source vessels. Perforator origin, pedicle multiplicity, course, branching pattern, pedicle length, venous anatomy, and spatial distribution were analyzed. Anatomical configurations were organized into a 4-level descriptive classification. RESULTS: Profunda femoris perforators were present in all dissections (100%). Additional perforator origins arose from the common femoral (14%), superficial femoral (7%), obturator (5%), and inferior gluteal vessels (2%). A single profunda pedicle was identified in 64% of the thighs, double pedicles in 33%, and triple pedicles in 3%. Mean pedicle length was 11.7 ± 2.2 cm. Distal branching ranged from 1 to 5 perforators, with single and double branching predominating. Most perforators (97%) followed a musculocutaneous course. Paired venae comitantes were present in 39% of profunda pedicles. The highest-density perforator zone was located approximately 13 cm distal to the genitofemoral fold and 2.8 cm posterior to the gracilis border. CONCLUSIONS: Posteromedial thigh perforators encountered within the contemporary PAP harvest territory demonstrated substantial but structured anatomical variability. Although a profunda femoris-derived perforator was present in every thigh, perforators arising from several additional vascular systems were also identified. These findings provide quantitative anatomical support for interpreting the PAP flap primarily as a posteromedial thigh territory flap rather than as a strictly vessel-defined anatomical entity.

Abstract as published, via PubMed.