Application of Lumbar Artery Perforator Flap for Reconstruction of Back Ulcer: Clinical Study with Computed Tomographic Angiography

Abstract

Un-healing and centrally located defect on back area, it is sometimes a challenge for the reconstructive surgeon. Although skin grafts are considered as the first choice for reconstruction of large skin defect on the back region, it is not always helpful but vascularized flaps provide a superior functional and aesthetic outcome. The present study was designed to investigate the clinical anatomy of the lumbar artery perforator flap to reconstruct back ulcer. Materials and Methods: Clinical anatomy study was undertaken using computed tomographic angiographic analysis. We identified the courses of lumbar arteries and its perforators, measured pedicle length by layers. The location of the perforator vessel was charted against anatomical landmarks. Results: The pedicle lengths of the third and fourth lumbar artery perforator reached a mean of 27.8 mm and 37.1 mm respectively from superficial fascia to deep fascia. The fourth perforator was more laterally located than the third perforator and less than 1 cm above the iliac crest. A case in which the fourth lumbar artery perforator was used as flap pedicle is described. Conclusion: For the reconstruction of central defect on the back area, the lumbar artery perforator flap coverage may be a good alternative option. Computed tomographic angiography can easily identify the course and location of lumbar artery perforators and can be helpful to elevate the flap successfully.

The Lumbar Artery Perforator Flap

“…4,[7][8][9][10][11][12]15 The observed variation in previously published work is likely due to the various methods used to collect data including cadaveric dissection techniques, 2D angiography, 3D angiography, and preoperative is is the first study of its kind to use 3D angiography and MIMICS software to characterize the LAs though the creation of 3D models of the microvasculature and to combine results from multiple cadavers. Using this technique, we have determined that perforators arising from the LAs pierce the thoracodorsal fascia in a predictable fashion.…”

“…This flap can be used as a pedicled flap to reconstruct soft tissue defects in the lumbosacral region [2][3][4][5] including closure of myelomeningocele, a complex congenital malformations of the central nervous system, exposed spine, and other soft tissue defects in the back. 6,7 As a free flap, the LA perforator flap is a possible option for use in autologous breast reconstruction. 8 Although there have been a number of reports on the use of the LA perforator (LAP) flap for closure of lumbosacral defects and breast reconstruction, 8 there have been few anatomical studies to document the anatomy of the LA perforators.…”

Modern techniques and alternative flaps in microsurgical breast reconstruction

“…The lumbar artery perforator (LAP) flap was first described in the literature by Kroll and Rosenfeld in 1988 as a new type of flap based on unnamed perforators arising near the midline of the lower back region. Since that time, additional studies have demonstrated the presence of perforators arising from four‐paired lumbar arteries, around which pedicled or free fasciocutaneous flaps can be designed . The first report of using the LAP flap in autologous breast reconstruction was described in 2003 by de Weerd, et al Since that time, Peters et al, and Seth and Greenspun have both reported on their early experience with the LAP flap for autologous breast reconstruction, outlining their technique and overall outcomes.…”