Surgery Spotlight: Lumbar Artery Perforator Flap Breast Reconstruction-Surgery Spotlight: Lumbar Artery Perforator Flap Breast Reconstruction

Surgery Spotlight: Lumbar Artery Perforator Flap Breast Reconstruction

Video Transcription

Hi there, my name is Kunrat van Landaerts, I'm an associate professor at the University of Ghent and we're going to do today a primary breast reconstruction in a 49-year-old patient  who already had a deep flap and we opted and we discussed with the patient that we would do a lumbar perforated flap.  She was diagnosed with breast cancer in 2006, at that point she got a lumpectomy and sentinel node I suppose.  Afterwards she got radiotherapy, chemotherapy, unfortunately she had a recurrence in 2009. In 2009 she got mastectomy and lymphadenectomy and then afterwards she discovered that she  was BRCA positive and now the question is to do a preventive subcutaneous mastectomy on the other side together with an overectomy and immediate reconstruction.  The options for the immediate otologist reconstruction obviously are limited, but I think she is  a reasonably good or rather good candidate for a lumbar flap, although most of the time I would do my lumbar flaps like bilateral flaps in the BRCA patients, but unfortunately  she already had it. One of the issues in the BRCA patients is whether we're going to spare the nipples or  we're not going to spare the nipples and this is essentially an oncological question in the first place.  If you remove the nipples she has less, obviously less breast tissue left, but on the other hand the risk is rather limited, so a lot of patients opt to keep their nipples.  On the other hand there is also a technical problem or a technical issue. If we have to lift the breast too much then it becomes difficult to spare the nipple and  on the other hand if she has a bilateral reconstruction sometimes the aesthetic result is better if we remove the nipple.  So in this case the patient opted for removing of the nipple, that was the issue. So this is the deep flap, she didn't have her nipple reconstruction yet, which makes  it slightly easier for us. At this point of the procedure we're going to not do any reshaping options, this will be for the last operation within three to six months.  At this point we're just going to do a subcutaneous mastectomy, removing of nipple areola. So let me have a little look, we make a drawing of the sub-mammary crease, we try to have  our sub-mammary crease almost the same, you see this one maybe needs a little bit of tucking  in, she will need a little bit of ptosis correction but we're going to remove the whole nipple areola complex and we do a small extension on the inferior pole, we just draw the line  of the mastectomy. Then we're also going to mark, this is a scar from a previous intervention, we're going  to mark a small incision if we want to take epigastric artery interposition graft. We found out through the previous report of the operation that it was an ipsilateral unipedical  deep flap she got, so we could see it also on the CT scan, the epigastric artery and vein on the left side are spared. So the intervention will be left side to left side.  As you can see through the patient shape, she has a lot of tissue over here, so what we're going to do, essentially this is the tissue that we want to take and also we scoop  a little bit from underneath, so this patient obviously has enough tissue to do this flap.  We make a drawing of the midline, we try to access the iliac crest, which is about here.  And then we mark it afterwards, but you will see that most of the time the perforator will  be at the edge of the spine musculature, which will be about 8 centimetres from the midline,  so we think that the perforator will be somewhere over here, but we'll mark it afterwards and we'll doppler her when she's on her side.  We'll mark one side in this case, we try to get on top of the buttock, but keep the scar as low as possible and we mark the skin island.  Obviously the skin island can't be as big with this flap as it can be with the deep flap, but this will be about the position of the skin island, maybe we'll change it  a little bit when she's on her side, in order to try to keep the incision as low as possible but on top of the buttock, and then we make some markings for closure, so that we have  a nice closure. A lot of attention has to be paid to the closure thing, and then most of the tissue of the  flap will be over here, that will be the part where we bevel, on top we'll bevel a little bit, and then we try to do, at the end of the intervention, we'll try to do kind of  a vest over pan closure, so she will have kind of a hip lift on this side, and because we're only going to do it on one side, she will obviously need some secondary corrections  in this case probably liposuction on the other side. If we do a bilateral one, we opt to do it in two separate interventions, because it's  a little bit time consuming due to the fact that we have to turn the patient, but we would mark already this side in advance, and then put an upside tape on top of that so that  we can keep it for the next intervention. The thing is that with the CT scan of a deep flap, it's rather nice because you have a  topographic location of the CT scan, you have the XY axis is already there around the umbilicus,  over here it's a little bit more difficult, in the beginning we applied a wire to make the position, nowadays he makes his Y axis on the top of the iliac crest, which is not  always obvious to feel, but in this case it's about here, 8.87, so for the L3. So you see this is not that far from the cross that I marked in the beginning, this will  be the point that we would presume the perforator to be, and then we'll check it when she's  on the side to do the Doppler, when she's asleep we'll put her on the side for the Doppler.  Now she's going to lie on the back, sometimes we do this procedure with the patient on the side from the beginning, but because she needs the mastectomy, overectomy, we're going to  do the first procedure lying on the back, and then we'll turn her on the side. This preoperative CT scan of the patient, differently to the normal CT scans we do for  the deep flap, is that the patient is this time positioned on the belly in the CT scan, so this is the, she's lying on her belly, this is the perforator that we're going to  take, this is the L3 perforator, and they marked the top of the iliac crest as their Y axis, and then we can position, he measured the exit point of the perforator over there,  which to him is about 8.8 cm from the midline, and normally we would scroll up and down, with this machine it's a little bit difficult, but we're going to scroll up a little bit  and then I'll come down, just to show you the difference, perforators, the kidneys showing up, so we're going to come down, so this is the first lumbar perforator, or the second  lumbar perforator, coming down, scooping down, you can already see the perforator on the right side, this is a left breast reconstruction, we do ipsilateral perforators, and this is  the perforator that we need, and as you can see, this perforator is very close to the iliac crest, it comes down, but it goes downwards on top of the iliac crest, it's one of the  biggest perforators that you can see around, always like this, and then it has a lot of connections also with the first ASGAP perforators, so you can already see the outline of the  gluteus medius, gluteus maximus coming up here, this is a septal perforator, and there we have the first ASGAP perforators coming.  As you can see also, there is a very large paniculus adiposus over here, we're going to scroll up again a little bit, these are the ASGAP perforators, one intramuscular perforator,  this is one of the septal perforators, we scroll up again, and this is the territory  of our perforator, you see, still you can see the size of the paniculus adiposus, and  even in the skinny patient, this is not really a skinny patient, but even in the skinny patients you almost always have enough tissue to do a bilateral breast reconstruction.  In this case, because she already has the scar, and she already had the deep flap, we're not going to think twice, and we're going to take an interposition graph from the beginning,  so if we really need it, we don't have to go in for a second time, open up the fascia,  where are we, there we are, that's the spot.  So we open up the fascia at the lateral border of the rectus abdominis muscle, should realise at this point there are two fascias, two blades, so closure wise,  you have to close both of them, otherwise you will develop hernia, also over here we have nerves, you see, we try to spare this nerve, although probably it's going to be difficult.  Do you want me to turn it down a bit?  With the Heparin solution.  Mark the distal ends, the proximal ends. It's not the length of the thing which is important. It's more the size match that we're looking for.  So we're going to close this up, turn the patient on the sides and then proceed with the flap harvesting. We positioned the patient in lateral decubitus.  We positioned her so that we can break her open a little bit and close her again. This is going to be... You see, when you position them in the lateral decubitus,  the position of the iliac crest tends to be a little bit lower, so maybe we could slightly lower our incision a little bit. Now we're going to Doppler her.  This was the point which was measured by the CT. We're going to see if the blood pressure is all right. What's the blood pressure? Too low. Could you heighten it a little bit?  We're going to see if we can Doppler the perforator and then go ahead. I like to position her in a sideway position.  I know that Philip Londale, I think, does them in ventral decubitus, but the sideway position helps you because while you're developing the flap,  it falls towards you and it gives you a better or an easier approach, I think.  You hear it?  You hear it? So that's where we Dopplered it. It's almost on the point where we marked it. So the question is do you really have to do the CT scan? We like to do the CT scan.  It gives you more visual information on the perforator, but you could do it with a Doppler also. You really could do it. It is fairly, anatomically it's fairly stable.  You see this is the edge of the, even in this patient who is a little bit sturdier, you can still see that this is the edge of her spine musculature,  and it will be really on top of the iliac crest and where the spine, at the lateral border of the spine musculature. Okay?  So this will probably give us the opportunity to slightly lower our marking or incision line and do it more like that, and then we do,  because we don't need an extremely big skin island in this patient. I don't think the flap is really very good for secondary cases where you need a lot of skin.  The same holds true for the ASGAP. The skin is a little bit tough, but this will give her a reasonable thigh lift and should be all right.  During the dissection, the flap will fold towards me, which will give me a nicer exposition, I think. The main bulk of the flap is on the lower side,  and there you have the soft, in comparison to the ASGAP, this fat is also more pliable and softer. On top, it will be also thinner than on the bottom,  so it doesn't give you the typical shelving of the ASGAP flap. Do you have a pen?  You have to leave a reasonable thickness over here in order to avoid a depression.  But this is the area where you want to get your main bulk.  We did our primary incision.  We undermined the flap a little bit around, and in the meantime, I also identified the position of the iliac crest, which is there, you see?  And sometimes it's a bit difficult to really find it on the outside.  There are a couple of nerves here, a few nerves at the anterior border of the iliac crest, that you try to spare. And now we're going to organize ourselves  to do the dissection of the flap, okay? Well, we're going for the perforator over here. It's behind here. This is the thoracolumbar fascia.  The problem with these perforators is that they are quite involved. You see, we have little ones over here, and they're quite involved into the thoracolumbar fascia.  So you think there's nothing here, but then suddenly, when you look at the flap, you see that there is a lot of tissue.  So you think there's nothing here, but then suddenly, when you open it up, they distend, or when you cut them, they start bleeding quite profusely.  So we have to be a little bit careful. And this is kind of the crucial moment of the dissection, because you have to open up this thoracolumbar fascia  in order to find the perforator.  And sometimes they just pop up, and sometimes they hide until the last moment.  I'm going to open this up.  Well, the dissection is normally not that difficult in this one.  You know, because the pedicle is that extremely small, it is kind of difficult.  I'm not quite sure this is really the perforator yet, because it's so small and on the CT scan it seems so promising. On the other hand, you can see here, this is the iliac crest.  You can see here it diving down underneath, which would be the connection with the deep circumflex, because most of the time they do connect with the deep circumflex.  And then you have all them tiny side branches going through the muscle with the clip, which normally tend to be really bigger.  It's kind of strange that it's a bit deceiving in this case, if we really have the right perforator. Well, it will get a little bit bigger, but it's a bit like the SCIA,  that normally you would see it and then you think, wow, such a big, nice perforator. And that one also doesn't become bigger. But this one is really small.  But we're in the right position. This is the spine musculature. So it becomes slightly bigger, you can see over there, but really, really, really, really painfully small.  We're going to open it up a little bit more to give us some more exposition.  OK. So we developed the little one, the lower most one, which was supposed to be the biggest one, but it's extremely small.  You won't believe me, but this is the smallest I've ever seen. So the upper one is better. It's also small, also pretty small. At least slightly better.  But we have a small problem on there, that we have a small bleeding on it. I think we can manage that. Other stuff.  So maybe we should do it with this one, because I doubt I'm going to be able to do an anastomosis on the... No, my name is not Kashima. But this one would do, I think.  I should be able to do an anastomosis on that one. So we'll try to free that one a little bit more. I think we have a little hole in the vein there, that we should take care of.  That's alright. We'll leave it for a while and try to raise the flap a little bit further and see if it's alright.  I was lured by the little one, but this was probably the main branch, which looks like a nice one, but it goes completely deep there, so I missed it.  I think I missed it here, so we will have to do it with the little ones, because this one goes in there and doesn't seem to have a connection to the depth here.  We will have to do the anastomosis on the small ones.  We are going to first free our perforator and cut it.  The flap still seems to be alright.  Another flap.  We are going to weigh it.  800.  Looks alright.  In order not to have too much depression over here, what we do now is we are going to do  a slide vest over pant. Give us a pen.  He can sleep if he wants.  Too much misery in my head.  Extreme attention has to be paid to the closure, because if you don't pay attention, there's a risk of seroma formation.  While they're finishing the closure, we're going to do the interposition graft on a side table.  Can I remove the spools?  Yes, you can remove the spools.  L2. The L3 was very, very small, as you could see.  I think we missed it, because it went immediately down. It really went down behind the iliac crest.  So, as you can see, the artery is about 1 mm here. It's not much.  It should be feasible. Liquimin is kind of a heparin solution.  Okay, let's take the graft, the blue dot is proximal, we're supposed to have two veins here so we can do a dual venous anastomosis, contrary to what most people would do I suppose  anastomosis, with the clip we're going to put the artery to the artery and the veins to the veins, here we are, one artery, two veins, I'm going to cut the artery slightly  shorter and we can start, see there is a reasonable size match even.  SFX  I'm leaving nicely, you see?  I think the flap looks alright. You see, the color is good. It's a bit hyperimic, but that's normal.  With this flap, first of all you have plenty of volume, but then again, you don't have the shelving that is usually associated with the S-GAP flap.  You know, she has a nice contour on top, because you put the volume underneath and you push it a little bit underneath.  The only thing is, if you use an interposition graft, you have to be careful. I just tried to rearrange the pedicle, because the pedicle is too long.  So the interposition graft is not about the pedicle length, I think. It has to do with the discrepancy between the vessels. Okay, we're going to close it up. Thanks a lot.  www.ottobock.com

Video Summary

Associate Professor Kunrat van Landaerts from the University of Ghent discusses a breast reconstruction procedure for a 49-year-old patient with a history of breast cancer and BRCA positivity. She previously underwent a lumpectomy, mastectomy, and had recurrences of cancer. The patient opted for a preventive subcutaneous mastectomy, oophorectomy, and immediate reconstruction using a lumbar perforator flap, as she already had a deep inferior epigastric perforator (DIEP) flap. The procedure involves careful marking, Doppler ultrasound for locating the perforator, and a CT scan for visual guidance. The team focuses on achieving a balance between the aesthetic outcome and the technical complexities, such as sparing or removing nipples. The lumbar flap offers sufficient tissue for reconstruction, with careful attention to closure to avoid complications like hernias. The process includes harvesting a perforator, connecting interposition grafts, and ensuring proper vascularization of the tissue. The patient, following surgery, achieves a aesthetically pleasing outcome while reconstructing one breast.

Asset Caption

In this video, Koenraad Van Landuyt, MD, PhD performs a lumbar artery perforator flap breast reconstruction on a 49-year-old patient. The patient has previously undergone a lumpectomy and sentinel lymph node biopsy. After a recurrence of cancer, a mastectomy and DIEP flap was performed. Now, after testing positive for the BRCA gene, the patient will undergo a preventive subcutaneous mastectomy as well as an ovariectomy followed by immediate breast reconstruction.

Surgeon Koenraad Van Landuyt, MD, PhD

Disclosure All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Breast

Koenraad Van Landuyt MD PhD; Memben

breast reconstruction

lumbar perforator flap

BRCA positivity

preventive mastectomy

vascularization

aesthetic outcome