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Page 2 of 10 Tuinder et al. Plast Aesthet Res 2024;11:38 https://dx.doi.org/10.20517/2347-9264.2024.40

INTRODUCTION
The deep inferior epigastric artery perforator (DIEP) flap is considered the first choice in microvascular
[1]
autologous breast reconstruction worldwide . There is an increasing number of women choosing a breast
reconstruction after their mastectomy and accordingly, the number of challenges in autologous breast
[2]
reconstruction rises . One of these challenges is the DIEP flap being regularly deemed suboptimal or
unsuitable in women with a history of abdominoplasty, abdominal scars, or a lack of sufficient abdominal
tissue for the desired breast volume . In such cases, flaps from alternative donor sites are considered viable
[3]
options.

Among others, examples of these alternative flaps are the profunda artery perforator (PAP) flap, the
[3]
diagonal upper gracilis (DUG) flap, and the lateral thigh perforator (LTP) flap . The LTP flap is harvested,
as the name says, from the lateral thigh. Initially, the LTP flap was described as a myocutaneous flap and
[4,5]
used for reconstruction of defects in the lower body . In 1990, Elliot et al. first described the use of the
lateral thigh as a donor site for free flap breast reconstruction with a tensor fascia latae myocutanoeous free
flap, which was later refined to a perforator flap by Kind and Foster .
[6,7]

The investigation and identification of septocutaneous perforators have led to the introduction of the
septocutaneous TFL flap for breast reconstruction by Tuinder et al. in 2014 . The septocutaneous TFL flap
[8]
was later renamed the LTP flap, based on an idea of Linda Truluck Perry, to make the name more
understandable for patients [9-12] . In this technical note, we will discuss the LTP flap with important clinical
considerations, preoperative planning, relevant anatomy, operative technique, postoperative considerations,
and clinical outcomes.

CLINICAL CONSIDERATIONS
The LTP flap is seen as an alternative to the DIEP flap for autologous breast reconstruction. Reconstruction
with an LTP flap may be considered for breast reconstruction when a DIEP flap is not possible, not
recommended, or upon patient preference. The indications are, therefore, dependent on the clinical
considerations and expertise of the plastic surgeon.

There are several absolute and relative contraindications for the LTP flap. The absolute contraindications
are a lack of sufficient thigh tissue or a medical history that could compromise the eventual blood supply to
the free flap, such as a history of surgery or injury on the thigh region. Relative contraindications for the
LTP flap are comparable to those for other microvascular free flap reconstructions. Examples of these are
comorbidities possibly influencing blood flow to and from the flap, such as cardiovascular disease, smoking,
obesity, and hypercoagulability by any cause. Another relative contraindication is previous liposuction of
the lateral thigh, as it may have harmed the local vasculature. Radiological imaging of the perforators
through computed tomography angiography or magnetic resonance angiography examination is advised
and can contribute to insights into the availability and quality of perforators at the level of the lateral thigh.

The ideal patient for an LTP flap has a so-called pear-shaped body contour. However, it is a feasible donor
site for a much larger number of women than only these. One of the main advantages of the LTP flap is that
many women, regardless of their body contour, have sufficient tissue in the lateral thigh area to utilize for
safely harvesting the LTP flap.

PREOPERATIVE PLANNING
A decent preoperative physical examination is important to estimate the amount of tissue available for
reconstruction of the breast. At the lateral thigh, the widely used ‘pinch test’ is used for estimation of the