Over the past three decades, major advances have been made in the field of autologous breast reconstruction. Since its introduction in 1994, the deep inferior epigastric artery perforator (DIEP) flap has become one of the most frequently used free flaps for autologous breast reconstruction and is the first choice in many centers.1,2 However, the abdomen may not be suitable as a donor site in every patient. In patients with insufficient subcutaneous abdominal tissue, abdominal scarring (e.g., previous abdominoplasty), and/or insufficient abdominal perforators, alternative donor sites have to be considered.3,4 Another indication for using an alternate donor site other than the abdomen can be related to patient preference.
Numerous other flaps for autologous breast reconstruction have been introduced and refined over the years. The septocutaneous tensor fasciae latae flap,5 the septocutaneous gluteal artery perforator flap6 or superior gluteal artery perforator flap,7,8 the profunda artery perforator flap,9,10 the lumbar artery perforator flap,11 and the transverse upper gracilis flap12 are the most commonly suggested alternatives to the DIEP flap. Of these, the septocutaneous tensor fasciae latae flap has emerged as a good option for autologous breast reconstruction because the upper lateral thigh region, as a donor site, provides sufficient subcutaneous tissue to reconstruct a breast, even in very thin patients.3
The tensor fasciae latae flap was first described by Hill et al. and Nahai et al. in 1978 as both a pedicled and a free myocutaneous flap, primarily for the coverage of pressure sores, groin defects, and lower extremity reconstructions.13,14 For breast reconstruction, however, the tensor fasciae latae myocutaneous free flap was first reported by Elliott et al.15 in 1990 and was later refined to a perforator flap by Kind and Foster.16 More recently, septocutaneous perforators were identified in radiologic and anatomical studies, thereby facilitating the dissection of the pedicle and flap harvest, which has led to the introduction of the septocutaneous tensor fasciae latae flap for breast reconstruction by our group in 2012.5,17–19 The septocutaneous tensor fasciae latae flap based on the septocutaneous perforators in the posterior septum was later renamed the lateral thigh perforator flap, as proposed by Linda Truluck Perry, to simplify the name of the flap for better patient understanding. For the scope of this article, and for future publications, we will use the term lateral thigh perforator flap when referring to the septocutaneous tensor fasciae latae flap.
In a previous article, we presented a literature review on the lateral thigh perforator flap together with several specific radiologic considerations and our experience with our first five flaps.5 We performed our first lateral thigh perforator flap breast reconstruction in September of 2012. Our experience increased steadily over the following years and resulted in the introduction of several surgical refinements. The aim of this study was to analyze our experience with the lateral thigh perforator flap for autologous breast reconstruction and to present the surgical refinements that have been introduced over the past 4 years.
PATIENTS AND METHODS
In this prospective study, the medical records of all consecutive patients who underwent lateral thigh perforator flap breast reconstruction between September of 2012 and November of 2016 at three centers in Maastricht, The Netherlands, and in New York and New Orleans, were reviewed. The study was approved by the institutional review committee and was performed in accordance with the ethical standards of the Declaration of Helsinki. Informed consent was verbally obtained from all patients.
Patient demographics, risk factors, indications, operative details, length of hospital stay, follow-up length, complications, and reexplorations were recorded. It should be mentioned that some patient demographics, indications, and operative details were recorded only for patients of the Maastricht University Medical Center, as indicated in each table. Type of reconstruction, timing of reconstruction, and surgical outcomes were recorded for all three centers.
Complications were divided into recipient-site and donor-site complications. Recipient-site complications included total flap loss, partial flap loss, venous congestion requiring a return to the operating room, infection, hematoma, seroma, fat necrosis, and wound problems (wound dehiscence and/or skin necrosis). Donor-site complications included infection, hematoma, seroma, fat necrosis, and wound problems (wound dehiscence and/or skin necrosis). The length of follow-up was defined as the time between the patient’s last visit and the date of the operation.
Contrast-enhanced magnetic resonance angiographic images were acquired on a 1.5-T magnetic resonance imaging system (Intera; Philips Healthcare, Best, The Netherlands) with a SENSE body coil (Philips Healthcare). The contrast agent used was 15 ml of Gadovist (Bayer Schering Pharma, Berlin, Germany) administered intravenously, followed by 25 ml of normal saline using an electronic injector at 2 ml/second. A three-dimensional fat-suppressed ultra-fast gradient echo sequence was used, with the following parameters: echo time, 4 msec; repetition time, 8.4 msec; field of view, 380 to 304; and matrix, 400 to 320. The number and course of septocutaneous branches of the ascending branch of the lateral circumflex artery and maximal pedicle length were assessed systematically (Fig. 1).
A vertical line is drawn from the anterior superior iliac spine to the lateral border of the patella to indicate the anterior edge of the flap. A second, horizontal line is drawn from the height of the pubic bone perpendicular to the vertical line. The perforators can usually be identified at the level of the horizontal line, always laterally of the vertical line (Fig. 2). The distance from the midline can be measured on magnetic resonance angiographic images. A Doppler device is used to mark suitable septocutaneous perforators before surgery, guided by the magnetic resonance findings. The distance from the anterior superior iliac spine is registered. The perforators are located in the posterior septum between the tensor fasciae latae and gluteus medius muscles and are considered suitable when the length of the pedicle is at least 6 cm.5 The most cranially located perforator in the posterior septum with the largest caliber is chosen, because the height of the scar depends on the selection of the perforator. Next, a horizontal or oblique skin island is drawn around the perforator extending laterally to include as much subcutaneous tissue as possible within the flap (Fig. 3). The pinch test is used to mark the width of the flap. Flap dimensions range between 6 and 9 cm in width and 18 and 22 cm in length.
During surgery, the patient is in a supine position with the arms along the body. (See Video, Supplemental Digital Content 1, which demonstrates the surgical technique of lateral thigh perforator flap breast reconstruction, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C542.) Dissection of the flap and dissection of the internal mammary vessels with a rib-sparing approach (except for stacked reconstructions), preceded by mastectomy in cases of primary breast reconstruction, are performed simultaneously. In a bilateral reconstruction, even a three-team approach can be applied, with two teams harvesting the flap and one team performing the mastectomy or dissecting the recipient vessels. The dissection of the flap starts medially and continues laterally along the markings. The lateral femoral cutaneous nerve is identified at the anterior border of the flap, and care is taken to not damage the nerve. The dissection proceeds above the fascia of the tensor fasciae latae. The posterior septum is easy to identify because the fascia over the tensor fasciae latae muscle is very thin, showing the muscle fibers underneath, whereas the fascia over the gluteus medius muscle is very thick and white. The difference between the colors of both fasciae marks the posterior septum. The fascia covering the posterior septum is opened longitudinally for the total width of the flap and the septocutaneous perforators are identified (Fig. 4). A cuff of fascia is sometimes included with the flap to prevent damage to the perforator. Blunt dissection of the perforator is continued to its origin from the ascending branch of the lateral circumflex femoral artery while muscular branches are ligated. Then, the perforator is clipped and dissected (Fig. 5). The pedicle length usually varies between 6 and 8 cm. Generally, the left donor site is used to reconstruct the left breast and the right donor site is used to reconstruct the right breast.
An end-to-end anastomosis is performed to the internal mammary vessels. A coupler device is used to create the venous anastomosis. After flap inset, the recipient site is closed and the perforator arterial venous Doppler signal locations are marked. Before closure, the donor site is undermined caudally and several quilting sutures are placed to attach and approximate the subcutaneous tissue to the fascia (Fig. 6). (See Video, Supplemental Digital Content 2, which demonstrates the use of quilting sutures to close the donor site, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C543.) In addition, liposuction of the thigh region is performed to further minimize contour defects. The harvested fat tissue is used for subsequent fat grafting in the pectoralis major muscle to prevent volume deficit of the upper pole. A suction drain is placed at each individual flap and donor site. Common additional procedures such as dog-ear correction at the donor site and fat grafting are performed in a second operation.
As our experience with the lateral thigh perforator flap increased steadily over the years, several surgical refinements were introduced in the Maastricht University Medical Center to optimize the technique and results, and to minimize complications and contour defects. First, the flap width was limited from 9 cm to 6 cm. Initially, wider flaps were used to ensure that the perforator was included with the skin island, but these showed an increased risk of wound dehiscence of the donor site. Second, the most significant modification was the introduction of quilting sutures in September of 2015. From then on, three rows of quilting sutures were placed at the donor site to approximate the tissue and to prevent dead space. Other refinements included liposuction distally of the donor site to reduce contour defects, subsequent fat grafting in the pectoralis major muscle to augment the upper pole and, lastly, the donor site was no longer beveled.
Continuous variables are presented as means with standard deviations for normally distributed data or as medians with ranges for nonnormally distributed data. Categorical variables are presented as total numbers with percentages. The data analyses were conducted using IBM SPSS Version 23.0 for Windows (IBM Corp., Armonk, N.Y.).
Between September of 2012 and November of 2016, a total of 138 lateral thigh perforator flap breast reconstructions were performed in 86 consecutive patients with a median follow-up of 12 months (range, 2 to 54 months). Sixty-six patients (103 flaps) were operated on in Maastricht and 20 patients (35 flaps) were operated on in New York and New Orleans. The patient demographics are listed in Table 1. Mean patient age was 47.2 ± 10.3 years at the time of surgery. Median body mass index was 23.5 kg/m2 (range, 18.8 to 36.2 kg/m2). Preoperative magnetic resonance imaging was performed in all patients. Of the 138 lateral thigh perforator flap breast reconstructions, 44 were unilateral reconstructions in 39 patients, because five patients underwent unilateral reconstructions for both sides at different times. In addition, 36 bilateral reconstructions and 11 stacked unilateral reconstructions, using two lateral thigh perforator flaps to reconstruct one breast, were performed. Forty-seven reconstructions (37.0 percent) were tertiary, mostly because of complaints associated with tissue expanders or prostheses. The reason for mastectomy was prophylactic in 47.5 percent of the cases (n = 47), either because of genetic predisposition (n = 26) or without known genetic mutations (n = 21). Lastly, one patient underwent breast reconstruction for Poland syndrome.
Indications for Lateral Thigh Perforator Flap Breast Reconstruction
The indications for choosing a lateral thigh perforator flap over a DIEP flap breast reconstruction are shown in Table 2. The most common indication was having insufficient subcutaneous abdominal tissue [n = 39 (59.1 percent)]. Nine patients (13.6 percent) previously had a DIEP flap breast reconstruction, which either had (partially) failed (n = 2) or was already used for the contralateral breast (n = 7). In addition, seven patients (10.6 percent) previously had an abdominoplasty, whereas seven patients (10.6 percent) preferred a lateral thigh perforator flap breast reconstruction over the other donor-site options. Only one patient had better septocutaneous perforators than abdominal perforators as assessed by magnetic resonance angiographic analysis.
An overview of the operative details is provided in Table 3. The median operative times were 277 minutes (range, 196 to 561 minutes) and 451 minutes (range, 335 to 710 minutes) for the unilateral and bilateral lateral thigh perforator flap breast reconstructions, respectively. The median ischemia time was 45 minutes (range, 26 to 162 minutes) and the median flap weight was 348 g (range, 175 to 814 g). The coupler device was used for the venous anastomosis of 94 flaps (91.3 percent). The size of the coupler that was used for the anastomosis matched the perforator size closely and was 2.0 mm for the majority of the perforators [n = 66 (64.1 percent)]. Surgical refinements were introduced gradually: autologous fat grafting in the pectoralis major muscle was performed in 44 cases (44.4 percent), and quilting sutures were used to reduce dead space at the donor site in 55 cases (53.4 percent). Preoperative and postoperative photographs of patients who underwent lateral thigh perforator flap breast reconstruction are provided in Figure 7 and at the end of the video (see Video, Supplemental Digital Content 1, http://links.lww.com/PRS/C542).
Two total flap losses (1.4 percent) and one partial flap loss (0.7 percent) occurred. Five flaps (3.6 percent) developed venous congestion. Other recipient-site complications (Table 4) included infection (0.7 percent), hematoma (2.2 percent), seroma (2.9 percent), fat necrosis (2.9 percent), and wound problems (2.2 percent).
In addition, 11 flaps (8.0 percent) needed reexploration, of which four flaps (2.9 percent) required a revision of one or both anastomoses. All reexplorations resulted in viable flaps (Table 4).
Donor-site complications were observed more frequently (Table 4). Infection [n = 20 (14.5 percent)]; seroma [n = 21 (15.2 percent)]; and wound problems, predominantly wound dehiscence [n = 22 (15.9 percent)] of the donor site, were often observed in the same patients. In two cases (1.4 percent), a hematoma had to be treated. However, the incidence of donor-site complications was reduced significantly after the introduction of several surgical refinements, of which the use of quilting sutures and limitation of the flap width were the most important (Fig. 8). The incidence of wound problems decreased from 40.0 percent to 6.3 percent (p < 0.001), seroma decreased from 25.0 percent to 9.5 percent (p = 0.035), and infection decreased from 27.5 percent to 9.5 percent (p = 0.017).
The aim of this study was to analyze our experience with the lateral thigh perforator flap for autologous breast reconstruction and to present the surgical refinements that have been introduced during the study. The most common indication for lateral thigh perforator flap breast reconstruction was insufficient subcutaneous abdominal tissue followed by abdominal scarring and patient preference for a different donor site than the abdomen. The lateral thigh perforator flap was shown to be a reliable flap, with an overall success rate of 98.6 percent [n = 2 total flap losses (1.4 percent)]. Wound dehiscence, seroma, and infection of the donor site occurred more frequently. Nevertheless, the incidence of donor-site complications was reduced significantly after the introduction of several surgical refinements. The most significant of these refinements included the use of quilting sutures and reduction of the flap width. These modifications significantly helped to reduce the donor-site closing tension and the empty space between the subcutaneous tissue and fascia. In addition, the aesthetic results were improved by reducing donor-site contour defects and by fat grafting of the recipient site.
The majority of patients were satisfied with the donor site of the lateral thigh perforator flap after secondary correction to improve the contour and aesthetic results. This is supported by the fact that five patients underwent a second unilateral lateral thigh perforator flap breast reconstruction between 4 and 10 months after the first reconstruction. The lateral thigh perforator flap donor-site scar is acceptable, and patients usually have minimal contour deformity. Initially, the donor-site scar was designed as high as possible to make it easier to hide. Nevertheless, in our experience, the position of the scar is less important for patients than an improvement of the shape of the thighs. Preoperative imaging supported the identification of the most suitable septocutaneous perforators of the lateral circumflex femoral artery and facilitated the flap design and planning.5
A comparison among the lateral thigh perforator flap, the DIEP flap, and the most common alternatives for autologous breast reconstruction is presented in Table 5.1,6–12,20 During the entire lateral thigh perforator flap operation, the patient remains in a supine position, and a two- or even three-team approach can be used, which is a clear advantage compared with lumbar artery perforator, septocutaneous gluteal artery perforator, and superior gluteal artery perforator flap reconstructions. Likewise, the relative ease of dissection of septocutaneous perforators compared with intramuscular perforators is a considerable advantage. The perforators of the other flaps have a variable intramuscular course. Dissection of the lumbar artery perforator flap is particularly difficult because the dissection through the thoracolumbar fascia has to be performed carefully to avoid injury to the spinal nerves under the fascia. Although the diameters of the arteries and veins are comparable, the pedicle length differs significantly between flaps. The pedicle length of lateral thigh perforator flaps is shorter than that for DIEP flaps, but was always adequate for direct end-to-end anastomoses to the internal mammary vessels, and no grafts have to be used, such as those used in lumbar artery perforator flaps.11
When considered in thin patients, the amount of tissue harvested in lateral thigh perforator flaps is in our experience higher compared with the other donor sites in the same patient. The tissue of lateral thigh perforator flaps ensures good projection of the reconstructed breast, is more pliable than the tissue of superior gluteal artery perforator flaps, but is less pliable than in DIEP flaps based on the experience of the authors. In 11 cases when a unilateral lateral thigh perforator flap could not achieve the desired volume of the reconstructed breast, a stacked unilateral reconstruction was performed. In addition, as in profunda artery perforator flap and transverse upper gracilis flap reconstructions, autologous fat grafting can be used to achieve the desired volume.10,12 The reported overall success rates of all flaps differ significantly, with more total flap losses reported in the studies on superior gluteal artery perforator, lumbar artery perforator, and transverse upper gracilis flaps, although no definitive conclusions can be drawn because of the small sample sizes of the studies. Lastly, patients should be informed about the potential donor-site morbidity. Sensory discomfort is frequently reported after profunda artery perforator and transverse upper gracilis flap–based reconstruction, and may cause pain while sitting. Temporary paresthesia of the lateral thigh region is possible after lateral thigh perforator flap reconstruction, comparable to the numbness of the abdomen after a DIEP flap.
This study has demonstrated that the lateral thigh perforator flap is an excellent option for autologous breast reconstruction, yielding a low total flap loss rate and limited recipient-site complications. The introduction of several surgical refinements resulted in a significant reduction of donor-site complications. Advantages of the lateral thigh perforator flap include ease of septocutaneous perforator dissection, short operative time, and favorable tissue pliability and projection that are associated with overall good aesthetic results. For these reasons, the lateral thigh perforator flap is currently our second choice after the DIEP flap and provides an excellent alternative when the abdomen cannot be used as the donor site for autologous breast reconstruction.
The authors would like to thank Greet Mommen, medical illustrator of the Department of Anatomy and Embryology of the University of Maastricht, for providing the detailed illustrations; and Shai M. Rozen, M.D., associate professor in plastic surgery of the University of Texas Southwestern Medical Center in Dallas, Texas, for advice on the use of quilting sutures that reduced the donor-site complications significantly.
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