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Page 8 of 13 Fisher et al. Plast Aesthet Res 2024;11:36 https://dx.doi.org/10.20517/2347-9264.2024.53

Figure 5. AV graft exposure and harvest. AV: Arteriovenous.

The skin paddle markings are incised, and the superior incision is deepened using cautery to dissect through
the subcutaneous fat to the level of the underlying fascia. Very little beveling is done along this border of the
flap. The inferior border of the skin island is deepened with the cautery, and significant beveling below the
skin of the buttock is done to capture a considerable amount of gluteal fat into the flap [Figure 6]. This
allows the surgeon to “sculpt” the flap into the necessary shape for breast reconstruction. The surgeon must
include gluteal fat into the flap as this soft tissue will form the upper one-half to two-thirds of the
reconstructed breast.

The posterior midline is an area where the surgeon should take caution with dissection to avoid
undercutting the flap and to avoid a hollowed-out appearance at the donor site.

Once the peripheral borders of the flap have been developed, the flap is elevated from the medial to lateral if
the patient is in prone position, or from lateral to medial if the patient is in the lateral decubitus position.
The lumbar perforators are identified as they emerge through the glistening white thoracolumbar fascia
[Figure 7].

Once the desired perforator(s) are identified, the thoracolumbar fascia is incised to gain the exposure
needed to dissect the lumbar perforator(s). The vessels are followed retrograde in the septal plane between
the quadratus lumborum and erector spinae muscles until a depth corresponding with an imaginary line
passing through the tips of the transverse processes of the vertebral bodies [Figure 7]. Importantly,
dissection is terminated at the level of the tip of the vertebral transverse process associated with the pedicle
to protect the dorsal sensory ganglion and deeper vasculature. Dissection anterior to the tip of the
transverse process, in our view, is dangerous given the relationship of the vessels to the dorsal sensory
ganglia and the potential for bleeding in an area where gaining control of bleeding could cause significant
morbidity. The vascular pedicle is typically 2-4 cm in length once the pedicle is ligated at this level. L5
perforator dissection is particularly tedious as these particular vessels need to be freed from the densely
adherent periosteum of the pelvic margin; utmost care must be taken to prevent bleeding from branches
that course down into the pelvis. Completion of flap harvest is achieved following division of the vascular
pedicle by dividing the remaining soft tissue attachments on the undersurface of the flap with the cautery.