60 Lumbar Artery Perforator Flap



10.1055/b-0040-176826

60 Lumbar Artery Perforator Flap

Frank J. DellaCroce


Summary


The lumbar artery perforator flap is a difficult but viable option in breast reconstruction. It tends to be a lower tier flap choice due to its technical difficulty and short pedicle. Its appeal results from the large fatty volume often found in this donor site but is typically used only when other options in the form of the upper medial thigh or buttock have been exhausted or are not available.




Key Teaching Points




  • Preoperative imaging is helpful.



  • This is a difficult flap to raise.



  • The pedicle is short—2 to 3 cm and may require arterial/venous grafting to extend.



  • The vein is frequently much larger than the artery.



  • Fat necrosis is common if flap harvest is taken too laterally around the flank.



60.1 Anatomy



60.1.1 Surface Anatomy



Landmarks

The lumbar area, defined by the lumbar spinal bodies, from the midline to the midaxillary line.



Composition

Fasciocutaneous.



Size

Size is 15 × 24 cm maximally. As with most flaps of the back, in most patients, primary closure can be obtained with a width of 10 cm or less. In patients with skin laxity, this can be greater.



60.1.2 Arterial Anatomy



Dominant Pedicle

Lumbar perforating arteries.




  • Regional source: Aorta (L1–L4); iliolumbar arteries (L5).



  • Length: 2 cm.



  • Diameter: 1 mm.



  • Location: Perforators from the upper three lumbar vertebral bodies run between the erector spinae and the quadratus lumborum muscles. The last two pairs of perforators run in front of the quadratus lumborum muscles just lateral to the erector spinae musculature. Each lumbar artery gives off a perforating vessel. The second and fourth perforators generally are the largest.



60.1.3 Venous Anatomy


Accompanying venae comitantes with the perforators.



Nerve Supply


Sensory

Superior cluneal nerves (L1–L3) (▶Fig. 60.1).

Fig. 60.1 Dominant pedicle: lumbar perforating arteries (L1–L5). (From Zenn M, Jones G. Reconstructive Surgery. New York, NY: Thieme Medical Publishers; 2012)


60.1.4 Vascular Anatomy


See ▶Fig. 60.2.

Fig. 60.2 (a) Arterial system and (b) artery and bone are shown in these posterior views of three-dimensional reconstructions of the pelvic region from a human cadaver angiographic injection specimen (1, lumbar artery; 2, superior gluteal artery). (c) Interior view and (d) angiogram of the soft tissues of the gluteal region (L3 and L4), third and fourth lumbar arterial perforators; 1, anterior branch of the fourth lumbar arterial perforator; 2, posterior branch of the fourth lumbar arterial perforator; 3, ascending branch of the superior gluteal artery; IGA, inferior gluteal artery; SGA, superior gluteal artery; green arrow, anterior superior iliac spine; red arrow, greater trochanter; blue arrow, gluteal fold). (From Zenn M, Jones G. Reconstructive Surgery. New York, NY: Thieme Medical Publishers; 2012)


60.2 Indications


The flap is a third- or fourth-tier option in breast reconstruction. It is used when the abdomen, upper medial thighs, or gluteal regions have been exhausted or are unavailable or unsuitable.



Surgical Plan




  • Preoperative planning.



  • Flap design and markings.



  • Patient positioning.



  • Flap dissection.



  • Pedicle dissection.



  • Flap inset.



  • Donor site closure.



60.3 Surgical Technique



60.3.1 Planning


Doppler examination, cross-referenced with angiography (computed tomography angiography [CTA]/magnetic resonance imaging angiography [MRA]), provides accurate determination of the location of the lumbar perforators (▶Fig. 60.3).

Fig. 60.3 CT angiography demonstrating the course of the lumbar perforator into the overlying soft tissue. (From From Zenn M, Jones G. Reconstructive Surgery. New York, NY: Thieme Medical Publishers; 2012)


60.3.2 Design and Markings


Lumbar artery perforators are first localized using Doppler ultrasound. The flap design then encompasses this Doppler point. The margins of the flap can run from midline to midaxillary line, depending on the reconstructive need. Elliptical patterns are most common, since they aid in closure (▶Fig. 60.4). The skin pattern and associated bevel of the underlying fat may be tailored accordingly (▶Fig. 60.5).

Fig. 60.4 Lumbar flap design for third and fourth perforators. (From Zenn M, Jones G. Reconstructive Surgery. New York, NY: Thieme Medical Publishers; 2012)
Fig. 60.5 Preoperative markings for bilateral lumbar perforator free flaps with associated Doppler signal points. (From Zenn M, Jones G. Reconstructive Surgery. New York, NY: Thieme Medical Publishers; 2012)

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Jun 25, 2020 | Posted by in Reconstructive surgery | Comments Off on 60 Lumbar Artery Perforator Flap
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