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Page 4 of 16 Shaaban et al. Plast Aesthet Res 2023;10:12 https://dx.doi.org/10.20517/2347-9264.2022.91

LD flaps
The LD flap is a pedicled flap and is one of the best options for immediate or delayed breast reconstruction.
While the LD is relatively easy to harvest compared to other donor tissues, it is limited by a relatively small
tissue volume provided by the flap. One approach to achieve larger volumes is a more aggressive extended
LD flap technique which involves harvesting the subcutaneous tissue with the skin paddle, though this
carries a higher risk of seroma, contour deformities, and lumbar hernia and is restricted to patients with
higher BMI [50-54] . Therefore, LD flaps often require augmentation with an implant to achieve satisfactory
aesthetic outcomes [55,56] . Despite its widespread use, the risk associated with implant-based reconstruction
after LD flap is relatively high, including capsular contracture, implant displacement and rupture, infection,
and the possibility of repeating the procedure to exchange the implant after its expected end-of lifetime [56,57] .

[58]
Because of the high vascularity of LD flaps , they are well suited for adjunct fat grafting to improve the
resulting appearance and symmetry [9,49,59,60] . Volumes reported in several studies ranged between 90.5-425
mL [51,56,61,62] . The timing of fat grafting with regard to flap procedures does not appear to affect flap survival,
as Zhu et al. showed that all flaps survived regardless of the timing of grafting with no fat-grafting-related
complications except for one patient that had undergone radiotherapy and needed additional fat
grafting [51,63] . Further, Santanelli di Pompeo et al. demonstrated that immediate intraoperative fat grafting
with LD flap surgery was successful with no effect on the outcome or complications and offered direct
[58]
visualization of fat injection to avoid flap injury . When used in delayed grafting, fat is grafted into all
possible recipient sites, including the LD skin paddle, LD muscle caudal to skin paddle, pectoralis major
muscle, serratus muscles, mastectomy skin flaps, and thoracoabdominal advancement flaps. In immediate
reconstruction, fat grafting and LD flaps may be used after tumor removal with fat injected only into the LD
skin paddle and the LD muscle caudal to the skin paddle or after prophylactic mastectomy with fat grafting
into the previously mentioned sites as well as the pectoralis major, serratus muscles, and the non-
undermined portion of the mastectomy skin flaps. Thus, adjunct fat grafting for LD flaps is a favorable
alternative to implant-based reconstruction with fewer complications and is expected to minimize
[51]
radiation-induced tissue damage . The determination of the relative superiority of one flap over another,
when considering various comparator variables, is inherently subjective in nature. The ultimate decision on
flap choice can be made on a more individualized basis based on patient and surgeon preference and
[51]
available tissue donor sites .

Transverse rectus abdominis muscle (TRAM) flaps
Originally introduced by Dr. Carl R. Hartrampf to reconstruct the breast using part of the transverse rectus
abdominis muscle either pedicled or as a free flap, TRAM flaps often provide larger volume than LD.
Alternatively, the DIEP flap spares the abdominal muscle and uses only the skin, fat, and blood vessels. Ideal
candidates for TRAM flaps are non-smoking patients that have undergone a single or double mastectomy
and have enough excess tissue to reconstruct a whole breast in addition to the general criteria of flap
reconstruction including no comorbidities and good overall health condition. A limitation of TRAM flaps is
the development of contour irregularities, mostly the superior portion of the breast, that can be corrected
with immediate or delayed fat grafting. Because mammary vessels, the dominant vascular pedicle to TRAM
flaps may incur trauma during flap harvest, it is generally advised to graft smaller volumes of fat than in
double-pedicled or free TRAM flaps, which likely have enhanced flap vascularity and perhaps superior graft
survival [64,65] .

Challenges inherent to adjunct fat grafting use
Implant and flap-based reconstruction with fat grafting can be challenging because of the unpredictability of
fat retention and the possible need for multiple sessions to achieve satisfactory results [6,11,59] . Additional
challenges include volume limitations in the amount injected in a healthy chest wall or previously irradiated