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Fisher et al. Plast Aesthet Res 2024;11:36 https://dx.doi.org/10.20517/2347-9264.2024.53 Page 5 of 13

Compromising the spinal cord blood supply by accidentally injuring a spinal artery may cause ischemia and
devastating complications. The artery of Ademkiewicz arises between T8 and L1 and is avoided with proper
[24]
perforator selection .

PREOPERATIVE PLANNING
Women who have sufficient fatty tissue in the lumbar area are candidates for LAP flap reconstruction.
[18]
Pinch test and physical exam are used to assess the donor site for adequacy of soft tissue and for the
degree of laxity in the lower back and buttock, which is essential to allow closure of the donor site with
appropriate tension and contour. Patients who have sufficient tissue in the “love handle” are considered for
LAP reconstruction. Soft tissue volume and laxity necessary for closure should be assessed clinically by the
surgeon in the same way they would assess a patient for a cosmetic lower body lift contouring procedure. As
a rule of thumb, patients whose anatomy would allow them to theoretically be a candidate for a posterior
body lift with excision of lover back tissue are potential candidates for LAP flap harvest. The lumbar region
and upper gluteal fat are harvested based on the surgeon’s clinical assessment such that a tension-free
closure can be achieved while also aesthetically lifting the buttock, accentuating lumbar lordosis, and
narrowing the waistline. The volume and shape of the flap obtained and thus the reconstructed breast vary
greatly with patient body habitus. The authors believe that secondary deformity at donor sites should be
avoided at all costs in the breast reconstruction population, as poor donor sites for free flap reconstruction
serve to shift the defect from one area of the body to another. This is not ideal in any patient but resonates
especially for patients who undergo elective prophylactic mastectomies and are seeking increased quality of
health and life with their reconstructive outcomes [25,26] . If aesthetic principles are followed when harvesting
donor tissue, the donor site will have an ideal outcome.

The skin island of the LAP flap is generally not more than about 7 cm in its maximal vertical dimension;
however, in some cases, up to 12 cm of vertical skin island height can be obtained at the center of the ellipse
[Figure 3]. The skin island of the flap will inherently be located over the lower 1/3rd of the flap, thus
limiting the extent to which LAP flaps can be utilized for patients who require skin envelope restoration.
The limitations of skin island surface area and position must be carefully considered preoperatively; this is
especially the case for patients who have previously been irradiated, for those undergoing purely delayed
reconstruction, and for those who otherwise have significant skin-envelope restoration requirements.

Special consideration is given to the use of grafts in bilateral cases in those patients who have inadequate
abdominal soft tissue for bilateral reconstruction but for whom a 3- or 4-zone abdominal flap would
provide adequate tissue for unilateral breast reconstruction. For such patients, our preference is to use DIEP
grafts ipsilateral to the breast being reconstructed first. When the second breast is reconstructed, the use of
the contralateral TD graft preserves the ability to harvest abdominal tissue based on the DIEP pedicle on
one side of the abdomen, with or without additional vessels (including the superior epigastric or superficial
inferior epigastric) from the side from which the DIE vessels were already used. In the event of failure of the
second side, this scenario preserves the ipsilateral latissimus/TD system and 3- or 4-zone abdominal
perforator flap. The surgeon should be mindful to try to preserve as many potential secondary options as
possible when selecting grafts.

Although the senior author performs other free flap breast reconstruction on patients with known
hypercoagulable conditions, we presently consider hypercoagulable conditions such as Factor V Leiden,
Protein C and S deficiencies, etc., as strong relative contraindications to LAP flap surgery. Prior spine
surgery in the lumbar area is not an absolute contraindication, but a detailed surgical history and discussion
with a spine surgeon are prudent ahead of these procedures for patients with such a history. We also
recommend the use of preoperative magnetic resonance angiogram (MRA) to map perforator anatomy.