Lumbar Artery Perforator Flap Research Articles

Donor Site Morbidity after Lumbar Artery Perforator Flap Breast Reconstruction.

The lumbar artery perforator flap is a second-choice flap in autologous breast reconstruction whenever a deep inferior epigastric artery perforator (DIEP) flap is not possible. Ideal candidates are pear-shaped women who do not have enough bulk on the abdomen or thighs. Patient-reported "satisfaction with breasts" is excellent but we were curious about the donor site morbidity. We performed a retrospective study of all lumbar flap breast reconstructions performed between 2010 and 2019. Patients were invited by e-mail and telephone to take part in a BREAST-Q survey. One hundred fifty-four flaps were performed in 110 patients. Sixty-three patients filled out the BREAST-Q questionnaire. The most frequently observed donor site complications are seroma (35.1%), dehiscence (8.4%), and hematoma (3.2%). Correction of the donor site scar was performed in 31.8% of patients, lipofilling of the donor flank in 5.2%, and liposuction of the contralateral flank in 18.3% of patients. Body mass index (BMI) was the only significant risk factor for donor site complications. Patient-reported "satisfaction with donor site appearance" was good but significantly lower for primary reconstructions compared with secondary and tertiary procedures. Flap weight significantly influences patient-reported "physical wellbeing of the donor site." Ninety-seven percent of patients would recommend the surgery to someone in a similar position and would do it all over. The lumbar artery perforator flap is a good alternative for breast reconstruction in selected patients. The donor site issues consist mainly of seromas, prolonged discomfort, and a scar that might be noticeable to others, but patient-reported satisfaction is very high.

Alternative flaps in autologous breast reconstruction.

The gold standard for autologous reconstruction in the post-mastectomy patient remains the deep inferior epigastric artery perforator flap, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap) and trunk (lumbar artery perforator flap, superior and inferior gluteal artery perforator flaps). This study will review the history, relevant anatomy, surgical technique and outcomes for alternative flaps in autologous reconstruction. Additionally, preoperative imaging (CTA, MRA) and novel applications (stacking flaps, neurotization) in breast reconstructive microsurgery will be discussed.

Breast Reconstruction with the Lumbar Artery Perforator Flap for Metachronous Breast Cancer that Developed After Contralateral Breast Reconstruction with the Deep Inferior Epigastric Artery Perforator Flap

Breast Reconstruction with the Lumbar Artery Perforator Flap for Metachronous Breast Cancer that Developed After Contralateral Breast Reconstruction with the Deep Inferior Epigastric Artery Perforator Flap

Latissimus Dorsi-lumbar Artery Perforator Chimeric Flap with Intra-flap Crossover Anastomosis for Breast Reconstruction.

Latissimus dorsi (LD) flaps are widely used in breast reconstruction for their ease of use and minimal sacrifice of the donor site. Various strategies to increase flap volume have been suggested, but tissue volume is often insufficient for patients with little subcutaneous fat. While lumbar artery perforator (LAP) flaps are advantageous for thin patients because they allow for the addition of a large amount of fat, the vascular pedicle is short and vascular grafts are often required. To address these shortcomings, we propose here a LD-LAP chimeric flap. Specifically, the LD flap and LAP flap are elevated as one piece, and the 6th or 7th intercostal artery perforators and lumbar artery perforators, which are harvested together with the flap, are connected via intra-flap crossover anastomosis. Anastomosis for both intercostal artery perforators and lumbar artery perforators was performed about 1 cm away from the flap. Indocyanine green angiography performed after anastomosis showed improved blood flow to the LAP flap portion of the chimeric flap. The chimeric flap was used in 4 patients, with a mean flap volume of 460 ml (range, 300-690 ml) and mean duration of 439 minutes (393-484 minutes) for reconstruction surgery. During the mean follow-up period of 29.5 months (range, 16-40 months), sufficient tissue volume was obtained and none of the patients developed flap necrosis. Although our method requires vascular anastomosis and may extend operative time, it substantially increases LD flap volume and thus is likely to be an effective auxiliary component to breast reconstruction using LD flaps.

Characteristics and outcomes of primary interposition vascular grafts in free flap breast reconstruction

There is paucity of data on primary interposition vascular grafts (IVG) use in microsurgery. Our study examines the characteristics, indications and outcomes of IVG in free flap breast reconstruction. All cases of breast reconstruction with free flaps between January 2013 and June 2018 were examined and cases with primary IVG were included. Data were collected on patient, flap and graft characteristics, indications and outcomes. A total of 76 IVG, specifically 65 vein grafts and 11 arterial grafts, were used for 49 (of 1547) flaps in 48 (of 1346) cases. Of these, 52 grafts were primarily used to lengthen the pedicle and aid flap inset and 24 grafts to augment venous flow; 49 grafts were harvested from the flap harvest site, 7 from the anastomosis recipient site and 20 from a separate site. Of the total, 16.7% (8/49 flaps) required salvage procedures - seven cases for venous congestion and one for ischaemic compromise - in comparison to 4.3% in cases without IVG (65/1498) (p<0.0001). Out of 49 IVG flaps, three (6.1%) failed in comparison to 1.7% (26/1498), where IVG flaps were not used (p<0.05). Two were transverse upper gracilis flaps with vessel calibre mismatch, and one lumbar artery perforator (LAP) flap with past infected implant and failed deep inferior epigastric artery (DIEP). We present the largest number of primary vascular grafts for free flap breast reconstruction in the literature. Primary IVG were used for at-risk flaps and had a success rate of 93.9%. This shows that IVG are a viable option to prevent venous congestion and lengthen the pedicle to aid inset and shaping; they are associated with higher complication rates bearing in mind the high-risk profile of the flaps these are used for.

Lumbar Artery Perforator Flap: Initial Experience with Simultaneous Bilateral Flaps for Breast Reconstruction.

Background:The lumbar artery perforator (LAP) flap is a useful alternative for patients who are not a candidate for breast reconstruction using the deep inferior epigastric perforator flap. Due to the positioning and concerns for prolonged ischemia time, bilateral breast reconstruction using LAP flaps is frequently performed in separate stages. We present our early experience performing simultaneous LAP flaps for bilateral breast reconstruction.Methods:We performed a retrospective review of all patients who underwent breast reconstruction with LAP flaps from December 2018 to September 2019. Demographics, flap data, and complication data were collected. Surgical sequence is presented.Results:A total of 30 simultaneous bilateral breast reconstruction were performed with LAP. We experienced 1 flap loss in an undiagnosed hypercoagulable patient. The average patient age was 52.7 years, and the average body mass index was 26.9. Most patients had a surgically absent abdominal donor site (66.7%). The average operative time was 510 minutes and ischemia time was 90.3 minutes. All flaps were performed using a composite deep inferior epigastric arterial/venous graft.Conclusions:The LAP flap is an innovative, yet technically challenging, choice for autologous breast reconstruction. In our experience, simultaneous bilateral breast reconstruction using LAP flaps can be safely performed in a single surgical stage; however, we recommend caution and a coordinated team approach. With simultaneously performing bilateral LAP flaps, there is an inherent prolonged ischemia time and, thus, an increased possibility for vasospasm and intraoperative revisions. This experience represents the first series of bilateral LAP flaps performed simultaneously.

Lumbar Artery Perforator Flap: Video Surgical Sequence.

Lumbar Artery Perforator Flap: Video Surgical Sequence.

Anatomical Study of Lumbar Artery Perforators in Male Subjects.

Introduction:The lumbar artery perforator (LAP) flap takes an important place in lumbosacral reconstruction and in breast reconstruction. Although studies on the location of lumbar perforators in women are common, no anatomical study has focused solely on male subjects. Our objective is to facilitate the surgical approach to the LAP flap in male subjects by precisely ascertaining the characteristics of the perforators.Methods:We performed a retrospective review of computed tomographic angiography images of a cohort of 30 patients evaluating the perforator position from the 4 lumbar arteries. In addition, 4 characteristics were studied: the length, the diameter, the path of the lumbar pedicle, and the thickness of tissues available for transfer.Results:One hundred five lumbar perforating vessels were analyzed on 60 posterior hemi-bodies, of which 86% came from the third and fourth lumbar arteries. The average location was situated 7.4 cm from the midline and in a 6-cm vertical wide area. The position of the lumbar perforator was independent of body mass index, abdominal circumference, and subject size. Our results, compared to previous studies, show no difference in this position between men and women.Conclusions:The LAP flap is useful for regional reconstructions and as a free flap for both women and men. We provide male-specific tracking values for the dissection of lumbar perforating vessels. Dominant perforators were found to be situated in a wide region of 4 cm × 6 cm in the lumbosacral region at 7.4 cm from the midline.

Use of the Propeller Lumbar Perforator Flap: A Series of 32 Cases.

Introduction:Lumbosacral substance defect is a challenge in reconstructive surgery because few coverage solutions are available in this anatomical region. Lumbar artery perforator flaps (LAPs) have been progressively developed and make it possible to solve very complex situations. We report a multicenter study on LAP performed to treat medium and low lumbar defects of various etiologies, to highlight the versatility of this flap as well as its robustness and reproducibility.Methods:Between 2012 and 2019, 32 LAPs were performed in the Toulouse and Strasbourg University hospitals. Etiologies of the defects encountered were diverse: chronic wounds following neurosurgery, oncodermatology, burn sequelae, and ballistic injury. All LAPs were used in their pedicled form, turned as propeller, and combined or not with other flaps.Results:We treated 31 patients with 32 LAPs. Average flap size was 14.3 cm (range 8–26) × 6.5 cm (range 5–10), and average arc of rotation was 131.3 degrees (range 70–180 degrees). Only 4 patients (12.9%) presented partial necrosis, but required no other covering procedure because secondary healing was sufficient. No coverage failure was reported. Average follow-up duration was 9.7 months (range 1–18).Conclusions:In the case of lumbosacral defects of various etiologies, propeller LAP is a reliable and efficient surgical procedure, offering the advantage of low donor site morbidity. The reconstructive surgeon should propose this technique to patients as a first-line option where surgery is indicated.

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

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 compared with other flaps because of the quality of the lumbar fat and the gluteal extension. Between October of 2010 and June of 2017, a total of 100 lumbar artery perforator free flap breast reconstructions were performed in 72 patients. Patient demographics, indications, flap specifics, and complications were reviewed retrospectively. 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/m. The authors report 43 preventive mastectomies for elevated cancer risk with subsequent immediate reconstruction, 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. 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. Therapeutic, IV.

Unilateral Bipedicled Subcostal and Lumbar Arteries Perforator Flap for Reconstruction of Large Myelomeningocele Defects

Background: A plenty of options have been described forreconstruction of large myelomeningocele defects. We reportedour experience of using bipedicled subcostal and lumbararteries perforator flap.Material and Methods: During a period of 31 months 23neonates with large myelomeningocele defects were reconstructedwith unilateral bipedicled subcostal and lumbar arteryperforator flaps. We did not report any total flap loss.Results: Only one flap suffered distal necrosis that becomeswell after debridement and re-suturing. All donor siteswere closed primary.Conclusion: Our study confirmed reliability of bipedicledsubcostal and lumbar artery perforator flaps in reconstructionof large myelomeningocle defects.

Myelomeningocele closure by unilateral lumbar artery perforator flap: Experience with thirty-eight patients.

Repair of large soft tissue defects in meningomyelocele is difficult and its morbidity is high. By applying unilateral lumbar artery perforator transposition flap for closing these defects, we aimed to investigate effects on the repair procedure, duration of surgery and recovery period, with the rates of bleeding and morbidity. Our report was conducted in 38 patients between the years 2013 and 2017. All soft tissue defects were repaired with unilateral lumbar artery perforator flap (LAPF) in meningomyelocele. Fourteen patients were female and 24 patients were male. The youngest patient was a 5.5 month premature female baby and weighing 570 g. The oldest was weighing 3,700 g and at 1.5 months old. Mean flap size was 32 ± 29.4 cm2 (ranged: 4 × 3-8 × 7 cm2 ). The mean rotation angle was 126.7° (ranged: 90°-170°). Flap positions were separated as 9 (23%) thoracodorsal and 29 (77%) lumbosacral. None of the patients had flap necrosis, infection, or hematoma. The operation took 23 ± 5.3 minutes on average and bleeding was minimal as 16 cc. All patients were discharged within around 9 ± 2 days. The follow-up period of the patient ranged from 4 to 21 months. Flap survival was at the rate of 100%. There was no flap or postoperative complications. Final outcome for all patients were assessed as complete healing. All patients recovered fast with minimal blood lose, and satisfied the outcomes. As a result, unilateral lumbar perforator flap can be performed successfully in every center. This report suggests using LAPF for reconstruction of meningomyelocele by surgeons as a safe and reliable option, allowing surgeons strong results.

Reconstruction mammaire autologue par lambeau perforant lombaire

Even though DIEP-SIEA flaps or latissimus dorsi musculocutaneous flap are the most frequently used, a wide variety of flaps have been described for autologous breast reconstruction. Concerning the choice of donor-site, the aim is to prevent and to limit the morbidity. That is why the donor-site should be carefully chosen, according to the morphology of the patient. Lumbar artery perforator flap (LAP) is an option for breast reconstruction, but it is not well known and its use is limited. This study summarizes the authors' early experience with free LAP flap for breast reconstruction. Three patients underwent immediate or delayed autologous breast reconstruction using a LAP flap. No vascular by pass was required to lengthen the pedicle. No partial or complete flap necrosis has been reported. There was no surgical donor-site complication. Mean operative time was 7hours. LAP flap can be considered as a good option for autologous breast reconstruction, especially in patients with unfavorable abdominal donor-site, and impossibility to use a DIEP flap.

Lumbar artery perforators: an anatomical study based on computed tomographic angiography imaging

Background: The free lumbar artery perforator flap has recently been introduced as a potentially valuable option for autologous breast reconstruction in a subset of patients. Up to date, few anatomical studies, exploring the lumbar region as a donor site for perforator- based flaps, have been conducted.Methods: An anatomical study of the position of the dominant lumbar artery perforator was performed, using the preoperative computed tomographic angiography images of 24 autologous breast reconstruction patients. In total, 61 dominant perforators were determined, 28 on the left and 33 on the right side. A radiologist defined the position of the perforator as coordinates in an xy-grid.Results: Dominant perforators were shown to originate from the lumbar arteries at the level of lumbar vertebrae three or four. Remarkably, approximately 85% of these lumbar artery perforators enter the skin at 7–10 cm lateral from the midline (mean left 8.6 cm, right 8.2 cm).Conclusion: This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.

Lumbar Artery Perforator Flap: An Anatomical Study Using Multidetector Computed Tomographic Scan and Surgical Pearls for Breast Reconstruction.

Breast reconstruction with the lumbar artery perforator flap is indicated in patients with unfavorable abdominal donor site. In addition to their clinical experience with lumbar artery perforator free flap breast reconstruction, the authors present an anatomical study of the origin and course of the perforators. Images of multidetector computerized tomography scans were used to visualize the location of the dominant lumbar artery perforator in 20 patients. The medical files of the authors' patients who underwent lumbar artery perforator flap breast reconstruction were also analyzed. Multidetector computed tomographic imaging in 20 female patients with a mean age of 47 years revealed an equal number of dominant perforators (10 left and 10 right); 60 percent were third lumbar artery perforators, 30 percent were fourth, and the remaining were second. The dominant perforators were mainly located 42.6 mm from the y axis at their origin at the transverse process, and 69.5 mm when emerging in the subcutaneous tissue. Six patients had nine successful lumbar artery perforator flaps for breast reconstruction. Average operative time was 270 minutes. Due to shortness of pedicle and mismatching between diameter of lumbar artery and internal mammary artery, vascular bypass (harvested from the deep inferior epigastric vessels) was required in 50 percent of the cases. The major complication at the donor site was seroma (80 percent). The lumbar artery perforator has a constant anatomical location. The free lumbar artery perforator flap provides an ample amount of tissue for breast reconstruction; however, its major disadvantages are the small artery diameter, shortness of the pedicle, and high seroma rate at the donor site. Therapeutic, IV.

The dog-ear flap as an alternative for breast reconstruction in patients who have already undergone a DIEAP flap

Breast reconstruction in patients who have previously undergone deep inferior epigastric artery perforator flap (DIEAP) reconstruction or abdominoplasty is often challenging. Depending on patients' body habitus, several second-choice flaps have been described such as the transverse upper gracilis (TUG) flap, profundus femoris artery perforator (PFAP) flap, superior gluteal artery perforator (SGAP) flap, and lumbar artery perforator (LAP) flap. Patients who have undergone a DIEAP flap reconstruction or abdominoplasty occasionally present with dog ears on both sides of the abdominal scar. The adipose tissue and skin of these dog ears are supplied by perforators of the deep circumflex iliac artery (DCIA). The DCIA flap was first described in 1979 by Taylor. We introduce this abdominal "dog-ear" flap for autologous breast reconstruction.

Early experience with the free lumbar artery perforator flap for breast reconstruction

Autologous breast reconstruction has become a progressively more popular method of breast reconstruction. A wide variety of perforator flaps have been described and subsequently refined to decrease donor-site morbidity. Recently, the lumbar artery perforator (LAP) flap has been reported as an option for autologous breast reconstruction. This study summarises the prospectively gathered data of 35 free LAP flaps for breast reconstruction in 28 patients. The mean follow-up was 18 months. The internal mammary artery and the venae comitantes were used as recipient vessels in all reconstructions. In 80% of the reconstructions (28 flaps), an interposition graft was used. Six flaps (17%) had to be revised for venous thrombosis. Two of the revised flaps (5.7%) could not be salvaged, and total flap necrosis occurred. The mean operating time was 6 h and 15 min, 6 h and 39 min when an interposition graft was used and 5 h and 23 min when no interposition graft was necessary. The LAP flap should be considered as a further alternative for breast reconstruction in patients in whom a deep inferior epigastric artery perforator (DIEAP) flap is not possible or not desirable. Shaping of this flap is easier compared to any other flaps due to the quality of the lumbar fat and the gluteal extension. An interposition graft is frequently used to facilitate anastomosis, either to lengthen the pedicle or to resolve size mismatch. This is a disadvantage of the LAP flap.

Application of Lumbar Artery Perforator Flap for Reconstruction of Back Ulcer: Clinical Study with Computed Tomographic Angiography

Application of Lumbar Artery Perforator Flap for Reconstruction of Back Ulcer: Clinical Study with Computed Tomographic Angiography

Preexpanded Perforator Flaps of the Dorsolateral Trunk in Pediatric Patients

Contractures and broad scars of the axilla, anterior chest wall, and neck have detrimental effects on functional, physical, and psychological development of children. Perforator flaps have already been shown to be reliable options for the reconstruction of contractures, but there have been no reports demonstrating the value of preexpanded perforator flaps of the dorsolateral trunk region in the treatment of extensive contractures and scars of pediatric patients. The purpose of this study was to demonstrate these techniques by a case series formed of pediatric patients with broad scars and contractures of the anterior chest wall, axilla, neck, and breasts. Seven pediatric patients (mean age, 11.6 years) who were treated by preexpanded perforator flaps are presented. By this means, clinical experience regarding the intercostal artery perforator, thoracodorsal artery perforator, circumflex scapular artery perforator, and lumbar artery perforator flaps was shared. Flaps as large as 21 × 11 cm could be successfully transferred in pediatric patients. Broad scar tissues were resurfaced with broad flaps carrying similar characteristics with the uninjured anterior chest wall and neck skin in six of the authors' patients. In one patient with partial necrosis, a full-thickness skin graft was used for the residual defect. The mean duration of postoperative (after flap transfer) follow-up was 17.2 months. The preexpanded thoracodorsal artery perforator, intercostal artery perforator, and circumflex scapular artery perforator flaps are useful and effective reconstructive options for the treatment of scars and contractures of the anterior chest wall, axilla, neck, and breast in pediatric patients. : Therapeutic, IV.

Closure of Large Myelomeningocele by Lumbar Artery Perforator Flaps

Closure of Large Myelomeningocele by Lumbar Artery Perforator Flaps