the lumbar artery perforator flap in autologous breast ......association of plastic surgeons, in...

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In the search for the ideal autologous breast reconstruction, we strive to give our patients a durable and aesthetically pleasing breast while

causing minimal donor-site morbidity. The deep inferior epigastric artery perforator (DIEAP) flap remains the gold standard. However, when a

DIEAP flap is contraindicated, we should be able to provide an alternative to those patients insist-ing on an autologous breast reconstruction. Sev-eral perforator flaps have been suggested, but few have the volume, shape, or feel of native breast

Disclosure: None of the authors has a financial interest to declare in relation to the content of this article.

Copyright © 2018 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0000000000004522

Dries Opsomer, M.D.Filip Stillaert, M.D.

Phillip Blondeel, M.D., Ph.D.

Koenraad Van Landuyt, M.D., Ph.D.

Gent, Belgium

Background: The lumbar artery perforator flap is an alternative flap in breast reconstruction for those patients who are not eligible for a deep inferior epigastric artery perforator (DIEAP) flap. Shaping of this flap is easier com-pared with other flaps because of the quality of the lumbar fat and the gluteal extension.Methods: Between October of 2010 and June of 2017, a total of 100 lum-bar artery perforator free flap breast reconstructions were performed in 72 patients. Patient demographics, indications, flap specifics, and complications were reviewed retrospectively.Results: Twenty-eight bilateral and 44 unilateral breast reconstructions with a lumbar artery perforator flap were performed. Mean patient age was 48 years, and the average body mass index was 23.11 kg/m2. The authors report 43 pre-ventive mastectomies for elevated cancer risk with subsequent immediate recon-struction, 34 secondary reconstructions, and 14 tertiary reconstructions. Mean operative time was 7 hours 4 minutes, including the mastectomy in primary cases. Mean flap weight was 499 g (range, 77 to 1216 g) and mean follow-up time was 30 months. The revision rate was 22 percent and nine flaps were lost.Conclusions: The lumbar artery perforator flap is a valuable alternative to the DIEAP flap in breast reconstructive surgery. It is an excellent flap for BRCA-positive patients who are typically young and have limited excess tissue at the conventional donor sites. Despite higher revision rates compared with the DIEAP flap, the lumbar flap is superior in mimicking the shape and feel of native breast tissue. Scarring at the donor site remains a sore point but can be easily treated and used to an advantage to contour the flanks. (Plast. Reconstr. Surg. 142: 1e, 2018.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

From the Department of Plastic and Reconstructive Surgery, Gent University Hospital.Received for publication August 1, 2017; accepted January 3, 2018.Presented at the 27th Annual Meeting of the European Association of Plastic Surgeons, in Brussels, Belgium, May 25 through 28, 2016; the Mayo Clinic Chang Gung Sym-posium in Reconstructive Surgery, in Munich, Germany, October 19 through 22, 2016; and the 9th Congress of the World Society for Reconstructive Microsurgery, in Seoul, Republic of Korea, June 14 through 17, 2017.

The Lumbar Artery Perforator Flap in Autologous Breast Reconstruction: Initial Experience with 100 Cases

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Plastic and Reconstructive Surgery • July 2018

tissue in combination with limited donor-site mor-bidity and acceptable scarring.

Musculocutaneous and adipofascial flaps from the lumbar region have been around since the 1970s. Also known as “reversed latissimus dorsi flaps,” they were mainly used as pedicled flaps for the reconstruction of sacral pressure sores and low lumbar defects.1–5 Since its first application as a free flap for breast reconstruction in 2003 by de Weerd et al., the lumbar artery perforator flap has increased in popularity6–11 (Fig. 1).

PATIENTS AND METHODSBetween October of 2010 and July of 2017,

a total of 100 lumbar artery perforator free flap breast reconstructions were performed in 72 patients. All patients were operated on by the three senior authors in three different institu-tions. Patient demographics were reviewed retro-spectively. We looked at medical history, oncologic history, body mass index, and the indications for surgery. We listed our revision procedures, early and late complications, and donor-site problems.

All patients underwent preoperative com-puted tomographic angiography to evaluate the presence, patency, and caliber of the lumbar per-forators and the mammary recipient vessels. If a suitable vessel was identified, surgery was planned for the patient. Bilateral cases are now performed with an interval of 3 to 6 months between both operations. In the beginning of our series, we per-formed subsequent reconstructions during the same hospitalization period with an interval of 7 days. Since we started operating on patients in the

prone position, we like to avoid pressure on the neobreast for at least 6 weeks.

Operative TechniqueWith the patient in the standing position, the

footprint of the breast and the midline are drawn. A pinch test is performed at the donor flank to assess the amount of skin that can be maximally resected during flap harvest (Fig. 2).

In the report of our early experience with lumbar artery perforator flaps, we described two operative sequences.6 We have abandoned the lateral decubitus technique where simultaneous mastectomy and flap harvest were performed by two teams with the patient positioned on her side. We now routinely follow a supine–prone–supine sequence. One team performs the mastectomy or the mastectomy scar resection and prepares the recipient vessels while the other team harvests an artery and vein interposition graft from the deep inferior epigastric vessels (Fig. 3). This interposi-tion graft obviates the need for a longer pedicle dissection and, more importantly, provides a bet-ter caliber match between the mammary vessels and the flap pedicle. The thoracal defect is then temporarily covered and the patient is positioned prone.

The perforators are marked according to the computed tomographic graphic coordinates on an x axis through the iliac crests and the y axis over the posterior midline. Their presence is confirmed with a handheld unidirectional Dop-pler probe. We conducted a study on perforator location in our first 24 patients and found the fol-lowing: dominant perforators usually originate

Fig. 1. A computed tomographic angiography scan is obtained routinely preoperatively. The large arrow marks the lumbar artery and the small arrow marks the superior gluteal artery.

Fig. 2. A pinch test determines the maximal dimensions of the skin island. The red dotted line marks the iliac crest and the black dotted line marks the area of undermining for the gluteal exten-sion. PSIS, posterior superior iliac spine.


Volume 142, Number 1 • Lumbar Artery Perforator Flap

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from the lumbar arteries at the level of the third or fourth vertebra. Approximately 85 percent of these lumbar artery perforators enter the skin at 7 to 10 cm lateral to the midline (mean: left, 8.6 cm; right, 8.2 cm).12

Once again a pinch test confirms the skin resection and the flap skin island is designed around the chosen perforator. A gluteal extension is marked with bars. This is the area where sub-cutaneous bevelling will take place over the iliac crest to incorporate extra tissue for upper pole fullness (Fig. 4).

The patient is draped and a suprafascial dis-section of the flap proceeds from medial to lat-eral with the surgeon standing at the contralateral side of the flap. Although a pedicle length up to 7 cm is possible, we no longer pursue this length and clip the vessels once we have obtained at least 4 cm. This avoids neurapraxia to the leg caused by nerve root damage and obviates the deep and difficult dissection in the transverse process region (Fig. 5). Special care is given to closure of the donor site with drains, quilting sutures, and vest-over-pants closure to avoid seroma formation and scar retraction (Fig. 6). In the meantime, the second team performs the first microvascu-lar anastomoses of the lumbar artery and vein to the interposition graft on a separate table. After redraping, the second microvascular anastomo-sis is performed with insetting of the flap. Hardly any shaping will be necessary after flap transfer (Figs. 7 and 8). (See Video, Supplemental Digital Content 1, which is an illustration of a prophylac-tic lumbar artery perforator flap breast recon-struction in a BRCA-positive 37-year-old woman. The secondary reconstruction at the contralateral side was performed 6 weeks later, available in the

Fig. 3. One team performs the mastectomy and recipient-site prepa-ration while the other team harvests the interposition graft from the deep inferior epigastric vessels.

Fig. 4. By bevelling underneath the superficial fascia overly-ing the iliac crest, a gluteal extension is created for upper pole fullness.

Fig. 5. Deep dissection in the transverse process region can be difficult.


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“Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C836.)

Postoperatively, traditional flap monitoring consists of temperature, color, and turgor moni-toring, performed every hour during the first day. The donor-site drains are removed when there is less than 30 ml/24 hours of exudate. Compressive garments are worn after drain removal to prevent seroma formation. Patients can start ambulating from postoperative day 1.

RESULTS

DemographicsOne hundred lumbar artery perforator free

flaps were performed in 72 patients from Octo-ber of 2010 until June of 2017. All operations were performed by three surgeons in three differ-ent hospitals. We report 44 unilateral cases and 28 bilateral reconstructions. The mean age of the patients was 48 years, and the average body mass index was 23.11 kg/m2. We report 43 preventive mastectomies for elevated cancer risk with sub-sequent immediate reconstruction, 34 secondary reconstructions, and 14 tertiary reconstructions after previous free flap (DIEAP, n = 8; transverse rectus abdominis musculocutaneous, n = 21; and superficial epigastric artery perforator, n = 2) or implant reconstruction (n = 3). Twenty-four patients received chemotherapy and 19 patients underwent radiotherapy for breast cancer. The mean follow-up time was 30 months.

Operative DetailsAverage operating time was 7 hours 4 min-

utes. Average flap weight was 499 g (range, 77 to 1216 g) and pedicle length was 4.5 cm (range, 3 to 7 cm). Ischemia time was 2 hours 28 minutes (range, 55 to 290 minutes). Mean artery and vein diameter were 2 and 2.2 mm, respectively. A deep inferior epigastric artery and vein interposition graft was harvested with a typical length of 4 to 5 cm (Table 1).13–17

ComplicationsWe experienced a total revision rate of 22 per-

cent. Indications were hematoma (n = 3), venous thrombosis (n = 14), and arterial thrombosis (n = 6). Nine flaps were lost. Thirty-one patients developed a donor-site seroma that required puncture aspiration.

DISCUSSIONTypical candidates for a lumbar artery perfo-

rator flap breast reconstruction are BRCA-positive young women who seek immediate reconstruc-tion after preventive amputation. They usually lack sufficient infraumbilical bulk for a bilateral reconstruction (Figs. 9 through 11). Other good candidates are patients who already underwent DIEAP flap breast reconstruction and those who underwent abdominoplasty or have severe scar-ring to the abdominal wall because of surgery or liposuction. Our second-choice flap used to be the superior gluteal artery perforator flap with

Fig. 6. Vest-over-pants closure and quilting sutures reduce seroma formation.

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its known disadvantages of distortion of the but-tock contour and “shelving” of the flap on the thorax.18 Thigh flaps such as the transverse mus-culocutaneous gracilis and profunda artery perfo-rator flaps have been tried by our team but were found to yield insufficient bulk in these often slim women. Furthermore, we observed pain in our patients when sitting down and the descent of the donor-site scar over time, leading to a suboptimal

appearance. Profunda artery perforator flaps are reported to have an average of 366 g but, because of anthropomorphic differences, our patient pop-ulation rarely presents with such an excess volume in the upper thigh.15

When a DIEAP flap is contraindicated and a patient desires an autologous breast reconstruction, we should be able to provide a valuable alternative. We believe the lumbar artery perforator flap is an

Fig. 7. Unilateral lumbar artery perforator flap breast reconstruction in a patient with a previous history of abdominoplasty; hardly any shaping is necessary after flap transfer. (Left) Preoperative photograph; (right) appearance after first stage.

Fig. 8. Same patient as shown in Figure 7, (left) after nipple reconstruction and (right) final result after 34 months.


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aesthetically superior flap for two reasons: intrinsic flap tissue properties and donor-site contour. Dur-ing flap dissection, a gluteal extension is included in the flap by bevelling caudally over the iliac crest underneath the superficial fascia. Figure 12 com-pares the shape of a typical lumbar flap with a pen-dulous breast implant, showing a similar teardrop form because of gravitational forces. The feel of the reconstructed breast greatly mimics native breast glandular tissue, as it is firmer than the abdominal fat of a DIEAP flap, yet softer and more pliable than the gluteal fat of a superior gluteal artery perforator or inferior gluteal artery perforator flap.

What distinguishes the lumbar flap from its competitors is the donor site. By bevelling dur-ing flap harvest and mainly caudal undermin-ing of the wound edges during closure, one can beautifully contour the flanks of the patient. In our initial series, we observed many donor-site seromas. Since we have adopted closure in a vest-over-pants fashion with quilting sutures, the incidence of donor-site seromas has dropped significantly. The donor-site scar will be outside of regular underwear, but will give the surgeon an opportunity to contour the flanks. In uni-lateral cases, liposuction of the contralateral

Table 1. Properties of Different Flaps in Total Autologous Breast Reconstruction

DIEAP* LAP SGAP† PAP‡ IGAP§ TMG║

Weight, g Variable 499 451 367 425 330Pedicle length, cm 9.8 4.5 9.1 10.2 8–11 6–8Donor-site contour Improves Improves Distorts Improves Distorts ImprovesScar Border of

underwearOutside

underwearIn underwear In underwear In underwear In underwear

Sensate Lower intercostal

nerves

Superior cluneal nerves

Superior cluneal nerves

Posterior femoral

cutaneous nerve

Posterior femoral

cutaneous nerve (S1–S2)

Cutaneous branches obturator

nerveLAP, lumbar artery perforator; SGAP, superior gluteal artery perforator; PAP, profunda artery perforator; IGAP, inferior gluteal artery perfora-tor; TMG, transverse musculocutaneous gracilis.*Blondeel PN. One hundred free DIEP flap breast reconstructions: A personal experience. Br J Plast Surg. 1999;52:104–111.†Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery perforator (GAP) flaps: A critical analysis of 142 cases. Ann Plast Surg. 2004;52:118–125.‡Allen RJ Jr, Lee ZH, Mayo JL, Levine J, Ahn C, Allen RJ Sr. The profunda artery perforator flap experience for breast reconstruction. Plast Reconstr Surg. 2016;138:968–975.§Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg. 2006;118:333–339.║Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: Guidelines for flap and patient selection. Plast Reconstr Surg. 2008;122:29–38.

Fig. 9. Preoperative appearance of BRCA-positive patient with insufficient infraumbilical bulk. Preventive bilateral breast amputation and lumbar flap reconstruction.

Video. Supplemental Digital Content 1 is an illustration of a pro-phylactic lumbar artery perforator flap breast reconstruction in a BRCA-positive 37-year-old woman. The secondary reconstruc-tion at the contralateral side was performed 6 weeks later. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C836.





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flank is usually indicated to optimize symmetry (Figs. 13 and 14).

It must be stipulated that the lumbar flap remains a second-choice flap reserved for those patients who are not candidates for DIEAP flap reconstruction. We are aware of the high revision rate of our initial series but believe this is partly attributable to a steep learning curve and the fact that in the beginning an interposition graft was not consistently used. Similar is the high frequency of postoperative seromas, which are now largely avoided by an adjusted careful and meticulous closure technique. As a referral center, we have performed lumbar flap breast reconstructions in patients presenting with several risk factors for free flap surgery. Age older than 60 years, smok-ing, and diabetes are not considered absolute con-traindications for free flap reconstruction. Each time, this elevated failure risk was discussed with the patients, but they usually insisted on a recon-structive attempt with autologous tissue. This also partly explains the higher revision and failure rates encountered in our population. We believe that by carefully selecting out patients, these numbers can drop significantly. The ideal patient would be the bilateral preventive mastectomy case not eligible for DIEAP flap reconstruction.

CONCLUSIONSThe lumbar artery perforator free flap is an

excellent alternative in autologous breast recon-struction for those patients who are not eligible for the DIEAP flap. Flap dissection may be more technical and time consuming compared with alternatives, and the lumbar flap technique in our initial series was troubled by higher revision and failure rates compared with the DIEAP flap. Nevertheless, the shape and feel of the lumbar tis-sues after transfer lead to a superior aesthetic and

Fig. 10. Same patient as shown in Figure 9, after first stage.

Fig. 11. Final result of patient shown in Figures 9 and 10, after 34 months.

Fig. 12. Similar shape of a breast implant and a typical lumbar flap.


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functional result and therefore it has replaced the superior gluteal artery perforator flap as our favorite second-choice flap.

Dries Opsomer, M.D.Graaf Van Vlaanderenplein 21b601

9000 Ghent, [email protected]

REFERENCES 1. Stevenson TR, Rohrich RJ, Pollock RA, Dingman RO,

Bostwick J III. More experience with the “reverse” latissimus dorsi musculocutaneous flap: Precise location of blood sup-ply. Plast Reconstr Surg. 1984;74:237–243.

2. Bostwick J III, Scheflan M, Nahai F, Jurkiewicz MJ. The “reverse” latissimus dorsi muscle and musculocutaneous flap: Anatomical and clinical considerations. Plast Reconstr Surg. 1980;65:395–399.

3. Kroll SS, Rosenfield L. Perforator-based flaps for low poste-rior midline defects. Plast Reconstr Surg. 1988;81:561–566.

4. Ao M, Mae O, Namba Y, Asagoe K. Perforator-based flap for coverage of lumbosacral defects. Plast Reconstr Surg. 1998;101:987–991.

5. Roche NA, Van Landuyt K, Blondeel PN, Matton G, Monstrey SJ. The use of pedicled perforator flaps for reconstruction of lumbosacral defects. Ann Plast Surg. 2000;45:7–14.

6. Peters KT, Blondeel PN, Lobo F, van Landuyt K. Early experience with the free lumbar artery perforator flap for breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68:1112–1119.

7. Hamdi M, Craggs B, Brussaard C, Seidenstueker K, Hendrickx B, Zeltzer A. Lumbar artery perforator flap: An anatomical study using multidetector computed tomo-graphic scan and surgical pearls for breast reconstruction. Plast Reconstr Surg. 2016;138:343–352.

8. Satake T, Nakasone R, Kobayashi S, Maegawa J. Immediate breast reconstruction using the free lumbar artery perfora-tor flap and lateral thoracic vein interposition graft for recip-ient lateral thoracic artery anastomosis. Indian J Plast Surg. 2016;49:91–94.

9. de Weerd L, Elvenes OP, Strandenes E, Weum S. Autologous breast reconstruction with a free lumbar artery perforator flap. Br J Plast Surg. 2003;56:180–183.

10. Koenraad Van Landuyt SFM. Free lumbar artery perfora-tor flap for autologous breast reconstruction. In: Levine JL, Vasile JV, Chen CM, Allen RJ Sr, eds. Perforator Flaps for Breast Reconstruction. New York: Thieme; 2016:60–71.

11. Bissell MB, Greenspun DT, Levine J, et al. The lumbar artery perforator flap: 3-dimensional anatomical study and clinical applications. Ann Plast Surg. 2016;77:469–476.

12. Sommeling CE, Colebunders B, Pardon HE, Stillaert FB, Blondeel PN, van Landuyt K. Lumbar artery perforators: An anatomical study based on computed tomographic angiogra-phy imaging. Acta Chir Belg. 2017;117:223–226.

13. Blondeel PN. One hundred free DIEP flap breast reconstruc-tions: A personal experience. Br J Plast Surg. 1999;52:104–111.

14. Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery perforator (GAP) flaps: A critical analysis of 142 cases. Ann Plast Surg. 2004;52:118–125.

15. Allen RJ Jr, Lee ZH, Mayo JL, Levine J, Ahn C, Allen RJ Sr. The profunda artery perforator flap experience for breast reconstruction. Plast Reconstr Surg. 2016;138:968–975.

16. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg. 2006;118:333–339.

17. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: Guidelines for flap and patient selection. Plast Reconstr Surg. 2008;122:29–38.

18. Blondeel PN. The sensate free superior gluteal artery per-forator (S-GAP) flap: A valuable alternative in autologous breast reconstruction. Br J Plast Surg. 1999;52:185–193.

Fig. 13. The donor-site scar is usually outside of regular under-wear but contours the flank. Unilateral case after liposuc-tion of the contralateral flank. Patient is shown 34 months postoperatively.

Fig. 14. The donor-site scar is usually outside of regular under-wear but contours the flank. Bilateral case. Patient is shown 34 months postoperatively.

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the lumbar artery perforator flap in autologous breast ......association of plastic surgeons, in...

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