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Page 6 of 13 Fisher et al. Plast Aesthet Res 2024;11:36 https://dx.doi.org/10.20517/2347-9264.2024.53

Figure 3. Skin island oriented on lower 1/3 of a 28 cm × 7 cm LAP flap. LAP: Lumbar artery perforator.

OPERATIVE TECHNIQUE
While it is possible to perform this procedure without a position change if one performs the entire
procedure with the patient in the lateral decubitus position (as has been previously described and then
[23]
abandoned by others ), we prefer to optimize every step of the procedure and thus always begin with the
patient in the supine position to prepare the recipient site vessels. LAP flap reconstruction, therefore,
involves repositioning the patient one or more times during the case.

Our preferred operative sequence is as follows.

Marking
The ipsilateral lumbar region is used for breast reconstruction. The LAP flap is bordered anteriorly by the
anterior superior iliac spine (ASIS) and posteriorly by the midline. The flap’s vertical alignment must be
adjusted to position the selected perforator(s) beneath the skin island. The vertical height of the skin island
is determined through a pinch test, and the skin island is configured in an elliptical shape. Markings are
made over the upper gluteal fat to guide the non-anatomic dissection that will shape the upper two-thirds of
the reconstructed breast, primarily from gluteal fat incorporated into the flap [Figure 4].

Recipient site preparation
Recipient vessels are dissected following mastectomy or, in the case of delayed reconstruction, after the
breast pocket has been dissected and prepared. The internal mammary vessels are the preferred recipients
for lumbar flap reconstruction. Preparing the recipient site before flap harvest minimizes ischemia time for
the flap(s). Thoracodorsal (TD) vessels can also serve as recipients; however, modifications to the method of
reconstruction described herein are suggested to best align the vascular pedicle and shape the breast when
connecting to recipients at the lateral chest wall; specifically, a contralateral, rather than an ipsilateral
lumbar donor site should be considered if the TD vessels will be used as recipients. Once the recipient site is
prepared, the chest is closed temporarily with a sterile occlusive dressing.

AV graft harvest
Interposition grafts, when harvested from the abdominal wall, can also be prepared during this initial stage
of the reconstruction. To prevent unnecessary ischemia time for the grafts, we prefer to dissect, but not
ligate, the desired length of vessels at this stage of the procedure. The length of the DIE grafts obtained is