Commentary on: Breast Reconstruction With Simultaneous Bilateral Lumbar Artery Perforator Flaps Improves Waistline Definition and Buttock Projection
Year: 2023
Type: editorial
Abstract: See the Original Article here. Congratulations are due to Drs Teotia, Haddock, and co-authors for their well-executed study focusing on the aesthetic results of the lumbar artery perforator (LAP) flap donor site in 50 patients (100 flaps).1 The holy grail of autologous breast reconstruction remains an ample donor site that is quick and easy to harvest with a long adequate caliber pedicle while minimizing donor site morbidity and optimizing aesthetic results. Today, the deep inferior epigastric artery (DIEP) flap remains the primary choice for microsurgical breast reconstruction, but some patients are not candidates due to an inadequate abdominal donor site. Although several secondary flap donor sites from the thigh, buttocks, and back in various stacked configurations have been proposed, each has its own specific advantages and disadvantages.2 The transverse upper gracilis and profunda artery perforator flaps are reliable with long pedicles and have a nicely hidden donor site, but only relatively smaller volumes of tissue are available. The lateral thigh perforator flap can provide ample volume but has a rather inconspicuous donor scar. The superior gluteal artery perforator (SGAP) and inferior gluteal artery perforator are considered the most technically complex dissections which require positional changes and have been reported to distort the donor sites.3 Recently, the LAP flap has been championed as a useful alternative with favorable donor site aesthetics. However, the authors acknowledge the significant challenges of needing a composite vascular graft for length as well as positional changes. The combination of these obstacles has limited the popularity of the LAP flap for common use. A reported benefit of this flap has been the accentuation of donor site concavity in the lumbosacral region, resulting in an aesthetic improvement in waistline and gluteal definition. The authors' favorable outcome is not unexpected as it mimics the popular Brazilian butt lift procedure, which often includes aggressive liposuction of this same lower lumbar region or a circumferential body lift to narrow the waistline and accentuate the lumbosacral angle while improving gluteal projection. Creating an acute lumbosacral angle accentuates the waistline and upper gluteal volume, which is currently a very popular aesthetic. Often, candidates for these alternative flaps have lower BMI or smaller body habitus and already have a generally favorable body aesthetics. The cases described by Haddock and Teotia show how the scar design neatly mimics a lower body or circumferential body lift. The scar is still relatively high and visible from a posterior view in comparison to abdominal or inner-thigh–based flaps. In comparison, the SGAP can result in an unflattering flattening of the superior gluteal contour. However, refinements in SGAP flap design have been reported to address these issues and there are many microsurgeons (including myself) who still prefer the SGAP or other thigh-based flaps over the LAP. The authors surveyed patients postoperatively to confirm patient satisfaction. However, the response rate was rather low at 15 (30%) and it is difficult to extrapolate based on such a small number. In a similar study, Blondeel and co-workers reported a 54.5% response rate with the BREAST-Q questionnaire for patients comparing DIEP, LAP, and SGAP flaps in 417 women.4 In contrast, their study found lower or less favorable scores in the patients who received LAP flaps. Clearly there remains some variation in technique and flap designs which may account for the contradictory results. This study by Haddock would be more interesting if the results were rated by plastic surgeons and compared to other donor sites including thigh-based flaps. Also, in this case series, all patients underwent bilateral reconstruction and therefore there was no donor site asymmetry due to unilateral flap harvest. Unilateral patients often need a secondary symmetrizing procedure with liposuction and/or direct excision to allow for clothing to fit properly. Although most of their patients noted either improvement or no change in their donor site, it would be useful have a better understanding why 20% (waistline) and 6.7% (buttock appearance) of the surveyed patients felt they had worsened to better understand how to avoid this unfavorable outcome. I commend the authors for their calculation of the waist-hip ratios to demonstrate objective improvement in these patients and for validating their findings with patient-reported outcomes. As we continue to refine donor site aesthetics, validating our results is critical to understanding outcomes and choosing the right flap for the right patient. The LAP flap is a solid option for patients with limited donor sites due to previous surgery or low BMI and excess volume in the “love handles” region. However, there remain significant technical challenges with dissection of the pedicle for the LAP flap that will likely continue to limit its popularity for widespread use. As with any plastic surgical consultation prior to recommending a particular procedure, ultimately each surgeon must carefully address the patient concerns, have insight into their own technical prowess, and assess each donor site when evaluating patients for non–abdominally based autologous reconstruction. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article.
Source: Aesthetic Surgery Journal
DOI: 10.1093/asj/sjad335
Author: Angela Cheng
Institution: Emory University
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4387965241