PAP vs. TUG
Hello everyone, this is my first post here. I'm scheduled to have a TUG in 3 weeks and met with my surgeon today for our final pre-op consult. After repeating all the information on the TUG, she offered a "new" procedure if I'm interested, a PAP. I've done some homework but know that real life experience is the best info. This is one of the only sights where I've even found people who have had PAPs done, so I would love your input.
A little about me...I was diagnosed in August of 2009. State III multifocal IDC. I had chemo and then a bilateral mast with expanders placed (right side prophy). Rads to the cancer side after I was fully expanded and then the implant swap. I knew the chance of success was not good with the implants and radiation, but my docs didn't want to radiate a flap, so implants were my only option for immediate recon. I figured nothing ventured nothing gained. Two years later, the radiated side is really not great (a grade 2 or 3 CC) and the prophy side is droopy, heavy and likes to wonder off into my armpit. I hate the feel of both of them (one high, tight and painful all the time and the other flopping around everywhere). I'm not all that thin, but apparently too thin for a double DIEP. I do, however, have a fair amount of excess inner thigh fat. I'm really looking forward to getting rid of a part of my anatomy that I have always hated. So I'm scared, but really excited too. I want to sleep on my stomach and run without my thigh rubbing together!!! 
But now in a last minute curve ball this PAP option is on the table. I like the fact that the scars would be much better hidden with the PAP, but with the natural shape of my thighs I already opt for skirted swim suits or shorts. With the TUG I was hoping to get to boy shorts or, dare I even say, regular bottoms if the scars fade enough. BUT the PAP sounds like an easier surgery and recovery. Has anyone chosen between these two options? Is the cosmetic result for the boobs better with one over the other?
Thanks in advance for the advice
Comments
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Hey Amac! Welcome to the forum. I just have a few minutes now and will briefly respond with what I know. The PAP and TUG have similar donor sites at least with some doctors (i.e I had the PAP and a huge amount of inner thigh was taken and it curved around to under my butt crease (i.e some posterior tissue as well). Historically, the TUG has taken muscle as well and I didn't like the idea of that. But I have heard it may be possible without muscle and that would be something to check into. As for the TUG, I have heard that some who want greater volume elect for a vertical incision down the inner thigh verses a TUG that is below the leg line of the panties. As for my PAP the incision starts below my panties in front and goes 50% around my leg to just below the butt crease. It is good that you are doing the research. You may want to look at the PAP threads and TUG threads on this forum for more information and Dr. Chen has a website that talks some about both. I think the cosmetic results for the boobs are about the same unless one wants more volume and goes for the vertical TUG or a long vertical TUG, but ask the Dr. about that. If I can help you further, please let me know on this thread or PM me. I am headed to work now. I wish you well as you navigate this decision. P. S. My thighs don't touch anymore by a long shot - just an FYI.
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Thanks Stac, I really appreciate your response. The more I look at it the more tempted I am by the PAP. But my doc's experience is in DIEPs and TUGs. She is new to PAPs (although she says it is really just the back of a TUG -- using a different blood supply of course). Still, I would feel better going with one of her "regular" procedures--don't want to be the guinea pig!
So aside from less noticeable scars (which sounds GREAT) it seems the primary difference is in preserving the muscle with the PAP vs. the TUG. Has anyone out there had trouble with strength or pain (or anything else) as a result of having a TUG and moving muscles around?
Thanks!
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Hey Amac, I suggest you talk to some TUG ladies about your last question. Maybe go to the TUG thread and ask and also get some names from your Dr. and other sources and ask them about their experience with the TUG. Ask your Dr. if it is possible to do that surgery without taking muscle. Maybe some of the TUG ladies will post here too. Wishing you well as you proceed!
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Hi Stac. I am brand new on this site so not to sure how to connect with indiviidual people, or even locate the correct forums. I met with Dr. Robert Allen in Charleston last week and if I receive approval from my insurance company I will be having a PAP procedure done by he and Dr,. Ahn in NYC. I can't tell you how much I appreciated your blow by blow diary of the first few weeks of your surgery. I have MANY practical questions I would like to ask you ...clothing, bathroom issues, ability to lift arms to wash hair, etc. etc. ...and wonder if there is any way I can get in touch with you by phone. Once I hear from you I will give you my phone number. Many thanks.
This goes for any others reading this that might have some tidbits to share. Any and all would be greatly appreciated !
Stac, can't tell you how much I appreciated your blow by blow diary of your first two weeks after surgey !
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Bientot,
Welcome to this forum! I sent you a PM a little while ago. The PAP sounds like a good option for you and you have a great team of Drs.. Keep us posted on how it goes. I wish you well as you navigate this. Thank you for the kind words. Let us know if you have any other questions.
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Amac, I don't know if I can offer much advice. I think the PAP is even newer than the TUG, so I was not offered that option. I was offered the option of vertical versus horizontal incision, but both used inner thigh. I had vertical. My thighs look way better. I always had heavy thighs and I do not miss them! Did the doctor say the PAP would not improve your inner thighs? Maybe follow up with the doctor again to get a clear answer. One area may have more fat or maybe not. In the end maybe you just have to decide where you want your scar.
I can say I have not noticed any problems/muscle weakness with any activity I do, which is mostly walking, riding a bike, or gardening. I haven't heard any of the other TUG ladies say they had issues either. They all seem pretty active.
We had a thread going called "Inner thigh flap(TUG) anyone". Peruse through that if you want to get an idea of the TUG experience. Good luck with your decision and surgery.
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Thanks for the TUG board reference ladies. I'm working my way thru it now. TwoHobbies, so glad to hear you have not noticed any problems with the muscle issue. My doc is very experienced with TUGs and says you would only notice mild muscle weakness if you are an avid horseback rider (bare back at that). She does not do the vertical scar but has shown me what will go from my inner thighs. I must confess that I am REALLY excited to see it go,nearly giddy -- you have to find the silver linings right. My inner thighs are HUGE, really the biggest part of me, so she has a lot to work with. I specifically ask about whether the PAP would address them and she said no, not really. Maybe a little, and then we would follow with using the fat left over there for the second stage fat grafting, but the result would not have the same effect to my thighs that the TUG would. And although she didn't say so, I suspect I will be significanly larger chested after a TUG than a PAP. That's just the way I'm built.
I really hate feeling this way. I was set on the TUG, looking forward to it even. But I don't like moving muscle (learned that the hard way with my implants--the body is constructed the way it is for a reason!). But even with moving the muscle it offers me the hope of something so much better than what I have that I was/am willing to go for it. The PAP appears to answer this one last concern, which is so exciting despite it's potential lack of impact on my thunder thighs--I can always fix them some other way if I really want to. BUT the PAP is so new, and I would be one of (if not the first) for my doc, which makes me very, very nervous. She has performed many, many TUGS and DIEPs, I've seen the pics and they are great. She worked with Dr. Allen to learn the PAP procedure and says that it is very familiar to her because it's basically just the back half of a TUG minus the muscle removal, which actually makes it an "easier" procedure. But the fact remains that she is not as experienced in them.
So it's the risk of muscle removal vs. a new procedure for my doc with me as the guinea pig. YIKES! Why isn't there anything simple or good in the world of cancer.
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Hey! I thought having some additional information out there may help you and others as you proceed with this decision. The first website below describes in brief form the the TUG and PAP. The second is the abstract for the PAP Flap procedure. Others may be able to give a link to the full artical or you can track it down through the PRSJournal which this second link can take you to (If you are able to find the full artical it has pictures that are graphic). As for the third link, this is not for the faint at heart, it is a video of the PAP Flap surgery and it may freak you out. It did me, so don't watch unless you can stomach the most graphic of surgeries and know that it might be done on you.
http://www.constancechenmd.org/TUG-PAP.html
On the PAP Flap performed on me the incisions are visible from the front and more inner thigh was taken then anything else and it curves to under the rear bottom crease. So get your surgeons to mark on you or show you very tangibly where they will be removing the tissue from. The PAP and horizontal TUG are similar (except for the possible partial muscle taken with the TUG and the vessel that they choose for the blood flow). Hopefully, these sites, if you can stomach them can help in making a decision. Since these are so graphic, I must restate that only the first one listed is safe, the others are extremely graphic and could cause anyone to fear moving ahead, but for the medical types who can handle blood, tissue etc., they might be helpful.
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Thanks stac! Now I just have to decied how brave I am.....to watch or not to watch......
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I didn't have the guts to watch it before my surgery, and for me I think that was a good decision, but I decided to take a peek post-surgery.
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Hi amac,
I too had a PAP on Feb 6, in NY with Dr. Levine. and I am very happy i did. My incisions are not in the front of my leg. They start on the inner thigh and run horizontal to the back. I had debated between a Diep and the PAP, as I was "lucky enough" to have enough fat for both! Although bigger fobs with the PAP. I also had had BMX with TE, multiple problems with them and ended up with just one implant, one removed after two months due to infection. So I am so happy to have 2 boobs again. I will say my radiated side is still stiffer than the other and right now sits a little higher than the other. This will be fixed with a touch up surgery. I feel I recovered pretty quickly. I need to run but feel free to ask me anything and if u do have the PAP, I will add my 2 cents for a comfortable recovery.
Michelle -
Thanks Michelle. I'm so glad the PAP worked for you--very encouraging! Are your incisions visible from the rear? Did you get much "inner thigh lift" from the PAP--meaning do you notice a difference with the size of your inner thighs with the PAP? I know it wouldn't be as much as the TUG, but I think I'm willing to trade some to keep the muscle where it is supposed to be, especially if it turns out like stac's. I think my thighs touched at birth! How long is "pretty quickly" on the recovery? I'm really struggling with how much help I need to line up for my kids (3 and 8). Sorry for all the questions. As the big day approaches I'm getting more and more nervous.
Stac, I got brave! I looked at everything except the video (DH viewed it and didn't pass out). VERY helpful info. It really gives you a visual for what is going to happen. Thanks so much for the tip! I'm passing the links onto my family, with you rating warnings of course!
Thanks again everyone. I really appreciate the input and advice.
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Amac, yes there is a difference in my legs. I also carry my weightnin my thighs andi lost about an inch and a quarter in each leg. When I am dieting, which is always, I keep track of my measurements. I don't really care what the scale says as long as I lose inches, so that's how I know.
As far as recovery, I was five days in hospital, came home on a Friday. Rested most of the weekend. Stayed home second week but was not exhausted which surprised me. Tired but not the same as the mastectomy. I did some laundry, but never carried it. Dinners were dropped off from great friends and family so I didn't have to cook. By my third week, I was driving the car pool to school and worked 2 days in an office. I only work part time anyway. I was amazed by how much easier this recovery was than the mastectomy with TE. I was expecting the same and for me but this was much easier.
Do u have a recliner? For me that was key when I came home. I would sit on a thin bed pillow on the recliner. It took some pressure off the incisions. I was able to sit at the dinner table from day one, though. But I always used that bed pillow to sit on. Even when I started driving.
My left incision is a little lower on my leg than my right one. So that one is more visible, my butt cheek kinda hides the right one. If I ever get to the point where I can where a bathing suit without a skirt bottom, I figure so what if my incision shows. I look at it as a battle wound!
When is your surgery scheduled for? I am sure you told us, but I don't remember. Please ask any questions you have and I will be quicker to answer, I promise.
Have a great day, Michelle -
Thank you everyone, and especially stac and Michelle, for your responses. They were/are so helpful. I've spoken with my docs, and we are going to take a look at the blood supply to determine which looks the most promising (PAP or TUG). I'm going with the one that looks the best (meaning it has the best odds of "taking." I figure either way I get to "real" boobs out of the deal and make some portion of my legs look better. I'm kind of hoping for the PAP to keep the muscle and lose my "second butt," but then I'm also pretty comfortable with the TUG and kind of rooting to get rid of my inner thighs. So, viewing things from the glass is half full view point, I can't lose. I'll let you know what happens. Taking a deep breath and taking the plunge (again....sigh.....)...... Again, THANKS
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Hi - Just wondering which of the procedures you will be having, PAP or TUG, with whom and where .
I have just been scheduled for a PAP July 17th (earliest avail. date) , with Drs. Allen and LoTempio in NYC at the NYEE. Dr. Allen's second was supposed to be Christina Ahn, but she was completely booked in May and is leaving the country June 1 for 3 months. Have been waiting in pain, for way too long ...searching for workable options, finding one, finding the doctor, then getting approved so opted for not waiting until September. Once the big decision is made you just want to get it over with !
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Hey bientot,
I just wanted to touch base until you can hear from amac. I believe she was to have surgery last Thursday so she may not be back to the forum yet. She was going to have the PAP or the TUG depending on what the Drs. thought would be best at the time of surgery. I don't think her Drs. had much experience with the PAP specifically, but offered it as a consideration in recent weeks. I hope that helps as you wait for her response. I wish you well as you wait for your upcoming surgery...I know waiting is hard, especially when you are in pain.
Amac, Let us hear from you when you can and let us know how your surgery went and how your recovery is going.
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Thanks Stac,
Just got on the site as wanted to tell you about my success in getting the surgery approved - and it suddenly occurred to me to check here first. And Voila ....here was a sweet message from you ! Thanks so much Stac, and thank you also for the update on amac's surgery..Hope all went well for her. I'll be checking up on her , and will also drop you a PM.
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Bientot,
Great news on the approval!! Keep us posted.
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Hello ladies, I'm back! Sore as hell, but back and feeling really great about everything. Had surgery last Thursday (13 hours in surgery). And, get this, I ended up getting a TUG on the left and a PAP on the right. So I believe I will be able to compare the two with great authority.
I was leaning PAP but going in with an open mind. After looking at the imaging and drawing everything out, we found that the difference in location between the two different flaps (at least on my legs) was only 2 cm (2 cm forward for the TUG versus 2 cm toward the back for the PAP). They could see a strong supply for the PAP on my right but were unsure about my left. So I went into surgery planning for the PAP but knowing they would choose TUG if the blood supply looked chancy. Turned out my right leg was perfect for the PAP whereas my left was a TUG or nothing, and even with a TUG they apparently had to work pretty hard to make the supply work (hence the extra hours in surgery).I'm still really swollen, but my legs truly look almost exactly the same. The scars are the same on both legs. The only difference is my inner thigh on the TUG side is just a little straighter/tighter. Pain is about the same too. Maybe a little more ache on the TUG side, but not much. There was a difference with the drains. They removed the drains from my PAP leg and chest sites before I left the hospital. The drain for the chest site for the TUG came out today, leaving me with just the TUG leg, and I think it will be with me for awhile.
All in all, I am THRILLED. My chest feels so much better already--such a HUGE improvement over the implants. I actually called my husband crying today because when I changed shirts I got cold (goose bumps), and I actually felt the same sensation I used to get when the CWIs used to come out. Nothing there to react of course, but the sensation was the same. I didn't think I would ever feel that again.
So put me down on the two thumbs up for the TUG or the PAP. They are both great if you ask me.
I'll keep you updated on my progress. Thanks again!
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Amac, we certainly didn't expect that! You'll have to joke that you couldn't decide so you had both! You will certainly be the resident expert on the subject. When you asked the question, I was thinking well none of us will have had both so its hard to compare - now you have both!
It sounds like you are doing well. Wishing you a smooth recovery.
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TwoHobbies, I said the same thing. I woke up asking everyone Pap or Tug. They kept saying both, but in my drug induced fog I couldn't figure that out. My PS could have done the Tug on the right too, but with all of our discussions regarding sparing the muscle she thought I would like the pap more. She is correct. At this point, if you have a qualified doc, I would pick the PAP over the TUG because, as near as I can tell, there is very little difference in the cosmetic result after and it is just generally an easier procedure for your body. But I would not fear the TUG the way I was. It's just not that different from the PAP and would not be worth risking failure of the flap to spare a known, good blood supply.
I feel great today (10 days out). I'm still walking at a snail's pace and very tight in the legs/butt, but I just generally feel better than I have for the last two years.
Have a great weekend everyone!
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Amac, Thanks for the report! You are defintely the PAP vs. TUG expert now!!!! Thanks for giving us an update and I am so glad that it went well for you and that your breasts feel better.and that you feel better...Wow! Yes, the tightness stays for awhile, but it does get better and better. I know by week nine I was walking at a normal pace and didn't notice it much any more and even gradually started playing "tennis-lite" then. But since I was expecting a quicker recovery it felt like forever.
How wonderful that you are feeling great at 10 days out!!! Do keep us posted on your recovery....very interesting that it was just a 2 cm. difference...that is good to know. Wishing you well on your continued recovery!
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Question for you TUG (or PAP) ladies. How long does it take for your legs to lose the tight feeling, and were (or are) your upper thighs and butt numb? If so for how long?
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Hey Amac, How are you doing? As for your question about tightness, I think I answered it in my last post above. As for numbness, I am going to repost below my answer when someone else asked such a question on another thread (i.e about complications/numbness):
There are few different things that I know of that can take place. One is a freaky deaky sensation that happens throughout the thighs (more inner thigh) that is about highly sensitive nerve endings and nerve regeneration that I believe takes place somewhere btwn 2 and 8 wks (mine was highly sensative at 3 to 6 wks). Then there is the potential of various numb areas. I have a one inch strip down my left thigh that extends to the calf. It is superficial (mainly at a skin level and does not have feeling) and am told these nerves can sometimes regenerate at 1 mm to 1 inch a month (depending on who you read or ask), so it may not recover or could regenerate in a year or two or more. The other potential numb area that I think is more common is having a numbness around the rear thigh incision site for about an inch or two and potentially long term. I have emailed with other women who have that at more than a year out, but they say it is not bothersome to them. I am 11 weeks out today and am now feeling better about my surgery. I am returning to my normal activities and am just a little slower to be careful. I have now played tennis, bowled, moved enormous tree debris into burn piles, walked a flea market for hours and am feeling more normal. I am still working on stretching the inner thighs which are somewhat tight, but getting better.
One more thing, I also had an inner thigh irritation (it felt like a muscle pain when I walked) that was potentially caused by sutures that were loose that eventually poked through the skin, and since there was no resistance and it was 8 to 10 wks after surgery they were pulled out. My inner thigh felt much better after that and then I was able to do more normal things including starting to stretch my inner thighs which was too painful to do before that. My butt never bothered me; just an FYI my incision is about 1 cm to 1 inch (depending on the area) below my butt crease.
Amac, I am at just over 4 months now and can do anything I used to do with the exception of touching my knees to the ground when I am in a sitting position with my feet together. That is, my inner thighs have not yet totally streched out yet. Keep us posted on your recovery and on the PAP vs. TUG. I hope you get some other answers.
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Wow, I just found out about the PAP flap today. I had my implant exchange in February and am not happy. So I talked to Constance Chen's assistant and Dr. Chen sounds amazing, but she doesn't take my insurance. Does anyone know if Dr. Allen takes Aetna? I'm really interested in this procedure - I hadn't thought that I was a candidate for a tissue procedure, but it looks like I am!
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Amac, I had numbness that spanned probably three inches on both sides of my incision. It dissapates. One year later I am still a little numb directly over the incision, but not too bothersome.
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Do you lose your nipples with a PAP?
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Sweetbean,
I don't know the answer to your insurance question. As for the nipple question, I had the nipple sparing bilateral mastectomy with PAP flap reconstruction. Wishing you well as you proceed whatever you decide. Its sure good to have options!
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Whoa. That is so cool. Where are your incisions? I had radiation but was able to keep my nipples and I have the IMF incision, so it's not very visible.
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Mine is from the areola to the side, and only b/c that is what the BS wanted in order to make sure he could get all the tissue for the removal. The PS was good with the incision wherever I wanted including below the breast, but he and the BS had to agree and hence the determination of where my incisions are located.
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