AbstractThe authors present the case of a 42-year-old female patient who underwent autologous breast reconstruction using a new perforator flap designed from the medial and posterior thigh. Due to a prior abdominoplasty, the patient's abdominal donor site was unavailable to reconstruct her large, ptotic breasts, so an alternate approach was undertaken. The fleur-de-PAP flap is based on the same perforators employed by the standard profunda artery perforator (PAP) flap, but simultaneously incorporates tissue from both the transverse and vertical PAP flap skin paddles. This design maximizes flap volume at a single donor site and provides a reasonable secondary option for autologous reconstruction in large-breasted patients in whom the abdomen is not available.