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Tuinder et al. Plast Aesthet Res 2024;11:38 https://dx.doi.org/10.20517/2347-9264.2024.40 Page 7 of 10

same patients. The incidence of these was significantly reduced after the implementation of improvements,
which we will discuss further.

With over a decade of experience using the LTP flap, we have encountered various pitfalls and made several
surgical refinements. First, we have decreased our maximum flap width from 9 to 6 cm. We started with a
larger flap width to ensure the inclusion of the perforator in the skin island, but with a decrease in flap
width, we saw an accompanying decrease in the risk of wound dehiscence at the donor site. As mentioned
earlier, the pinch test is suboptimal for deciding flap width at the lateral thigh and decreasing our flap width
by adhering to the maximum of 6 cm has decreased the likelihood of these donor site complications. The
second paramount improvement is the introduction of quilting sutures at the donor site. Achieving dead
space management and approximating the subcutaneous tissue to the fascia has drastically decreased the
risk of postoperative seroma. Additionally, quilting sutures reduce the closing tension on the donor site.
Third, we have refined aesthetic outcomes through several techniques, such as liposuction of the
contralateral side in unilateral cases, reducing contour defects distal to the donor site with liposuction,
lipofilling at the pectoralis major muscle to increase upper pole volume, and perpendicular dissection
[15]
instead of beveling during flap harvest . Although satisfied with their reconstructive outcomes, scars at the
donor site may impact a patient’s satisfaction with the donor site area and are visible when wearing
[21]
conventional underwear [Figure 4]. The average flap weight for the LTP flap is approximately 330-350
grams [15,19,22] .

As mentioned before, the LTP flap can be accompanied by a nerve coaptation to increase the postoperative
return of breast sensation. LTP flaps with nerve coaptation have better sensation in both the native and the
flap skin at a median follow-up of 16 months . To make this more concrete, after LTP flap breast
[19]
reconstruction and sensation measurements with the Semmes-Weinstein monofilaments, innervated native
skin was found to recover to diminished light touch thresholds, while non-innervated native skin recovered
to diminished protective sensation. Innervated flap skin recovered to diminished protective sensation, while
non-innervated flap skin kept a postoperative loss of protective sensation. Nerve coaptation seems to
stimulate nerve regrowth and sprouting of nerve fibers in both the flap skin, as the nerve is coapted to the
flap, but also to the native skin, where no nerve is directly coapted.

SUMMARY WITH KEY POINTS
1. The LTP flap is a viable option for microvascular autologous breast reconstruction in patients who are
not eligible for or do not wish a DIEP flap.

2. Adequate preoperative markings and perforator mapping with radiological imaging are essential for well-
prepared surgery.

3. The septocutaneous perforators lie in the posterior septum between the TFL muscle and the gluteus
medius muscle.

4. Avoid kinking and compression of the pedicle during flap inset, as septocutaneous perforators are more
prone to this happening.

5. Perpendicular incision instead of beveling during flap harvest is essential to reduce contour deformities at
the donor site.