Page 26 - Read Online

Fisher et al. Plast Aesthet Res 2024;11:36 https://dx.doi.org/10.20517/2347-9264.2024.53 Page 7 of 13

Figure 4. LAP flap markings. LAP: Lumbar artery perforator.

equivalent to the sub rectus muscular segment of these vessels from their origins off the external iliac up to
the point where they enter the undersurface of the muscle or until the arterial vessel diameter tapers to
approximately 1 mm. For TD AV grafts, the length is from the origin at the subscapular artery until the
arterial diameter tapers to 1 mm. The graft donor site is temporarily closed with a sterile occlusive dressing
and the patient is repositioned into either lateral decubitus or prone position.

Interposition AV grafts from the deep inferior epigastric system are obtained through a small lower
abdominal incision near the pubic hairline. After incising the skin and dissecting down to the rectus fascia,
the muscular fascia is incised longitudinally at the lateral border of the rectus sheath parallel to the fascial
fibers. The lateral border of the rectus muscle is reflected medially and the deep inferior epigastric pedicle is
exposed where it lies in the sub-muscular position [Figure 5A]. The lateral motor nerves should be carefully
protected and maintained. The deep inferior artery and its venae comitantes are dissected free of the
enveloping fat to the desired length.

TD AV grafts can also be used if the deep inferior epigastric vessels are not preferred or available.
Consideration should be given to using the TD system contralateral to the breast being reconstructed to
maintain ipsilateral TD and latissimus flap viability in case of a LAP flap failure. The TD vessels can be
exposed just beyond the anterior border of the latissimus dorsi with the patient in either prone or lateral
position. The TD pedicle is exposed on the undersurface of the latissimus muscle and dissected into the
axilla superiorly and to the takeoff of the serratus branch inferiorly. Ligation and harvest of these grafts are
deferred until completion of the LAP flap harvest [Figure 5B].

LAP flap elevation
The ipsilateral lumbar region is used as the donor site for breast reconstruction in the majority of cases, as
our preferred recipient vessels are the internal mammary artery and vein(s). An ipsilateral flap will be
rotated 180 degrees after harvest, so the anatomically inferior aspect of the flap will become the sloping
upper pole of the reconstructed breast. The surgeon must thus capture sufficient gluteal soft tissue, inferior
to the inferior border of the skin island, to achieve the desired breast shape.