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Tuinder et al. Plast Aesthet Res 2024;11:38 https://dx.doi.org/10.20517/2347-9264.2024.40 Page 5 of 10

muscle toward the posterior septum, which is located between the TFL muscle and the gluteus medius
muscle. The perforators, often numerous, emerge through the septum toward the superficial subcutaneous
tissue underlying the flap skin. The aforementioned posterior septum is easily identified and distinguished
from the fascia of the gluteus medius muscle, as the former is very thin and translucent enough to be able to
see the TFL muscle fibers underneath, while the latter is thick and much whiter. After opening the posterior
septum in a longitudinal fashion, the septocutaneous perforators can be followed between the TFL and
gluteus medius muscle. Figure 3 shows a schematic representation of the harvesting of the LTP flap after
opening the posterior septum, where the perforators can be seen emerging from behind the posterior
septum between the TFL muscle and gluteus medius muscle. The most cranially located perforator with the
largest caliber is chosen. Careful dissection of the chosen perforator follows. A small cuff of fascia is taken
surrounding the perforator, preventing unnecessary harm to it. The perforator is bluntly dissected until its
origin at the ascending branch of the lateral circumflex femoral artery. Meanwhile, muscular branches are
carefully ligated when encountered. The pedicle is clipped at its maximum length. The dissection is
completed toward the lateral side of the flap and again, incisions are made without beveling. The flap is now
ready for transplantation.

Anastomosis and flap inset
When the flap has been harvested, an end-to-end anastomosis is made to the internal mammary vessels.
The venous anastomosis is made with a coupler device. Avoiding kinking and compression of the pedicle
during flap inset is important, because this occurs more easily with septocutaneous perforators, as these are
less flexible than musculocutaneous perforators. Ideally, the flap is positioned perpendicular to the thoracic
wall to reduce the risk of pedicle compression.

The recipient site is closed after locating the arterial Doppler and marking it on the skin paddle of the flap.
The donor site is closed after caudal undermining, with quilting sutures used to securely approximate the
subcutaneous tissue to the underlying fascia. To correct inconsistencies and increase donor site aesthetics,
liposuction can be performed to minimize contour defects. The fat tissue acquired can be used for lipofilling
of the upper pole of the breast to optimize the breast shape. This can also be done in a secondary surgery.
One suction drain is placed at the donor site and one at the recipient site. The drains at the donor site will
be kept in place for several weeks and often until the patient’s discharge at the outpatient clinic. Having the
suction drains in situ for an extended amount of time is important to prevent seroma formation.

Nerve coaptation
The flap can be converted into a sensate autologous breast reconstruction by taking a donor nerve during
flap dissection. The donor nerve is a branch of the LFCN or a branch of the anterior cutaneous branch of
the femoral nerve and can be identified at the anterior border of the flap, cranially to the septocutaneous
perforator. For the recipient nerve, we advise using the anterior cutaneous branch of the third intercostal
nerve [18,19] . The donor and recipient nerves are directly coapted end-to-end with 9-0 nylon sutures followed
by a drop of tissue glue.

Flap variations
The LTP flap on itself can be harvested as a conjoined or stacked flap for more volume, such as in
[20]
combination with the PAP flap as an L-PAP flap . Stacked LTP flaps can be oriented obliquely along the
junction between the hip and the upper thigh, in line with the earlier described preoperative markings, with
the posterior limit lying along the gluteal crease. The bipedicled L-PAP contains the vascularization of both
the LTP and the PAP flap and the design includes the midposterior thigh by performing a near-
circumferential thigh lift. Both pedicles have to be prepared and the flap can be harvested subsequently. The
pedicles can be anastomosed to the internal mammary vessels in an anterograde and retrograde manner for