Expert Commentary Lumbar Perforator Flap

60 Lumbar Artery Perforator Flap

Frank Dellacroce

Summary
The lumbar artery perforator flap is a difficult but viable option in breast reconstruction. It tends to be a flap of last resort due to its difficulty and short pedicle. It is used only when other options in the form of the upper medial thigh or buttock have been exhausted or are not available.

Keywords: lumbar artery, perforator flap, breast reconstruction

Key Teaching Points

• Preoperative imaging is helpful.
• This is a difficult flap to raise.
• The pedicle is short – 2 to 3 cm.
• The vein is frequently much larger than the artery.
• Fat necrosis is common if flap harvest is taken too laterally around the flank.

60.1 Anatomy

60.1.1 Surface Anatomy

Landmarks
The lumbar area, defined by the lumbar spinal bodies, from the midline to the midaxillary line.

Composition
Fasciocutaneous

Size
Size is 15 x 24 cm maximally. As with most flaps of the back, in most patients, primary closure can be obtained with a width of 10 cm or less. In patients with skin laxity, this can be greater.

60.1.2 Arterial Anatomy

Dominant Pedicle

Lumbar perforating arteries.
Regional source: Aorta (L1-L4); iliolumbar arteries (L5).
Length: 2 cm.
Diameter: 1 mm.
Location: Perforators from the upper three lumbar vertebral bodies run between the erector spinae and the quadratus lumborum muscles. The last two pairs of perforators run in front of the quadratus lumborum muscles just lateral to the erector spinae musculature. Each lumbar artery gives off a perforating vessel. The second and fourth ferforators generally are the largest.

DellaCroce FJ. Reconstructive Surgery: Anatomy, Technique, and Clinical Applications. 2012; pp 686.