Autologous breast reconstruction using lumbar artery perforator flaps
Akhil K. Seth, MD1, David T. Greenspun, MD2.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Greenwich Hospital, Greenwich, CT, USA.
The abdominal donor site remains the gold standard for autologous, free flap breast reconstruction. However, for women in whom the abdomen is unavailable or insufficient, several other perforator-based flaps have been described. In particular, the lumbar artery perforator (LAP) flap can provide adequate tissue for breast reconstruction with an aesthetically appealing donor site for patients who have a relative excess of fatty tissue over the flanks and lower back, colloquially known as the "love handle". This study summarizes our experience with using free LAP flaps for autologous breast reconstruction, a flap for which little has been published.
Consecutive patients undergoing autologous breast reconstruction with LAP flaps were retrospectively reviewed. Microvascular anastomoses were performed directly between the flap pedicle and the anterograde internal mammary (IM) vessels, or using bridging arteriovenous grafts harvested from the deep inferior epigastric artery and vein. Clinical characteristics and outcomes were recorded.
Seven patients underwent autologous breast reconstruction with 10 LAP flaps in an immediate (n=5) or delayed (n=5) setting. Average age was 47.9 ± 4.4 years, with a median follow-up of 52.5 months. Three (30%) flaps received pre-reconstruction radiation therapy. All patients had preoperative abdominal imaging using magnetic resonance angiography. Reasons for not using the abdomen included inadequate tissue for breast reconstruction (n=5, 50%) and unavailable abdominal flaps because of prior surgery (n=5, 50%). Three patients underwent bilateral reconstructions: two in a staged fashion and one as bilateral simultaneous. The majority of flaps (n=8, 80%) were harvested in lateral decubitus. The four most recent flaps utilized arteriovenous grafts. There were no total or partial flap losses and no significant fat necrosis. All patients reported satisfaction with their reconstructive symmetry and final aesthetic results at the breasts and donor site.
Our study, the largest reported in the United States, demonstrates that autologous breast reconstruction with LAP flaps is safe and reliable in patients that have an insufficient or unavailable abdominal donor site. The LAP flap can provide adequate soft tissue for breast reconstruction with a particularly aesthetic donor site, making it an appealing alternative to other non-abdominal perforator flaps. Our growing experience has allowed for refinements in technique aimed at improving safety, efficiency and reliability, including meticulous flap harvest to minimize donor site morbidity, arteriovenous grafts to improve pedicle length and size match, and the staging of bilateral reconstructions. Continued work with the LAP flap will help establish it as a useful tool for the reconstructive microsurgeon.
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