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Page 2 of 13 Fisher et al. Plast Aesthet Res 2024;11:36 https://dx.doi.org/10.20517/2347-9264.2024.53

[6]
Perforator-based flaps are the cornerstone of autologous breast reconstruction . The lumbar artery
perforator (LAP) flap is a perforator flap based on the deep lumbar artery perforators that arise from the
[7-9]
aorta, and course superficially to supply the skin and subcutaneous tissue of the lumbar region
[Figure 1]. This fasciocutanous flap is not associated with any functional defects and pain at the donor site is
de minimus as a result of the muscle-preserving approach. This highly versatile flap was first described as a
pedicled flap for loco-regional coverage of sacral pressure sores and midline back defects [10,11] . The LAP flap
was then described as a free flap for breast reconstruction by de Weerd et al. as an alternative for patients
[12]
with relative contraindications for abdominally-based flap breast reconstruction . In the years since de
Weerd’s publication, the LAP flap has slowly been gaining popularity, primarily as a “secondary” flap option
for breast reconstruction, typically utilized when the abdomen is not a sufficient or suitable option .
[12]

While abdominally-based free flaps are the most frequently used donor site for autologous breast
reconstruction, patients lacking sufficient abdominal tissue or with a history of abdominal surgery that
precludes the use of the abdominal donor site may require other flap options to achieve breast
restoration . While thigh-based flaps provide reliable outcomes and high patient satisfaction, they often
[13]
necessitate stacking of flaps to provide adequate tissue for breast reconstruction and donor scar placement
can be challenging [11,12] . Thigh-based flaps have also been shown to have high rates of wound healing
complications and unfavorable donor site aesthetics [14,15] . Trunk-based flaps such as the LAP flap are an
alternative option that can facilitate aesthetic breast reconstruction with superior results to thigh flaps at the
donor site. It is our thesis that donor sites for reconstructive surgery should mimic the principles of
aesthetic body contouring. The tissue utilized with a LAP flap is fairly analogous to that removed during a
lower body lift and, therefore, has the net effect of lifting the buttocks and narrowing the waistline [16,17] . For
this reason, we consider the LAP flap donor site preferable to horizontally based thigh and buttock flaps, as
the latter donor sites do not have corollaries in body contouring surgery. That said, the LAP flap, like the
superior gluteal artery perforator (SGAP) flap, is associated with higher flap failure rates than abdominally-
based and thigh-based flaps due to short vascular pedicles and increased complication rates, and this should
be considered and discussed with potential LAP candidates as part of the informed consent process [14-16] .

Taken together, the seminal studies reporting the LAP flap demonstrate that a flap with a skin island
measuring up to 12 cm × 27 cm and with adequate soft tissue volume to create a breast can be harvested on
a single perforator . In our experience, however, the maximal short-axis (“vertical height”) of the skin
[18]
ellipse should be limited to approximately 7-8 cm to avoid excessive tension on the donor site closure in
[18]
most patients. A sensory nerve can be harvested for neurotizing a LAP flap . The lobular structure of the
fat of the lumbar region makes it possible to reconstruct breasts with excellent projection and overall
contour, including a sloping upper pole . Drawbacks of this donor site include limited surface area of the
[17]
skin island and difficulty sculpting the skin island and flap itself due to the structural nature of the fat of the
donor site region .
[19]

CLINICAL CONSIDERATIONS
The LAP flap is a valuable tool for a reconstructive surgeon and the donor site is generally acceptable to
patients given that it mimics a posterior lower body lift, thereby narrowing the waist and lifting the
buttocks [17,18] . The LAP flap donor site provides fat that is organized into lobules that are firmer than those of
the abdominal wall, and thus provides for relatively greater projection than can typically be achieved with
an equivalent volume of abdominal soft tissue. A LAP flap can, and when used for breast reconstruction,
should be harvested with a shape that resembles an anatomic implant [Figure 2]. The surgeon must
recognize that the shape of the reconstructed breast is largely determined during the harvest of these flaps,
as the lumbar soft tissue is relatively firm and thus not amenable to the kind of folding and manipulation