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24 The Lumbar Artery Perforator Flap: ATrue Alternative inAutologous Breast Reconstruction
239
dissection that goes too deep will increase the risk of
nerve root damage, and an intraoperative bleeding will be
too difcult to handle.
6. Try to avoid a dissection too laterally to avoid damage to
the iliohypogastric nerve.
Whenever feasible, especially in slender patients, one
should identify the descending branch of the iliohypogastric nerve to avoid postoperative discomfort in the lateral
part of the buttock region or upper thigh region.
7. Include the fat overlying the gluteus medius muscle.
The fat overlying the gluteus medius has an ideal con-
sistency to shape the breast. It is moldable and has a softer
consistency compared to subcutaneous fat.
8. The vascular interposition graft is anastomosed to the
perforator on a side table (Fig.24.24).
a
A crucial step that requires attention is the anastomosis
between the perforator and the interposition graft. An Ethilon
10/0 suture is used to anastomose the artery and vein. Often a
second vein can be anastomosed. This anastomosis should be
perfect as it will be challenging to add additional sutures once
the vascular clamps are released on the recipient vessels.
24.7 Clinical Scenario
Case 1
Post-bariatric 48-year-old patient with a history of gastric
bypass surgery and a circumferential abdominoplasty procedure. One year later she had a prophylactic bilateral mastectomy
with immediate implant-based reconstruction. She developed
an infection of the right implant and both implants were removed
with the insertion of new implants. She had a recurrence of the
infection on the right side with wound dehiscence and was
referred to our department for a second opinion (Fig.24.25).
b
Fig. 24.24 (a, b) It is mandatory to lengthen the perforator with an
interposition graft. The anastomoses are done on a side table with a
10/0 Ethilon suture. Lengthening the perforator avoids traction on the
anastomosis with the recipient vessels and facilitates ap inset
Fig. 24.25 History of bilateral mastectomy with complicated implantbased reconstruction. She presented at our outpatient with implant
exposure, footprint deformity, and excessive scarring. She had a history
of gastric bypass surgery and circumferential abdominoplasty
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Fig. 24.26 Angio-CT scan examination revealed acceptable and nonscarred lumbar artery perforators to perform a LAP ap breast reconstruction procedure
F. B. J. L. Stillaert et al.
Fig. 24.27 The LAP ap was chosen to avoid additional scarring, and
we used the existing scars of the circumferential abdominoplasty
procedure
Her angio-CT scan showed well-developed lumbar artery
perforators (Fig. 24.26). To avoid additional scarring, we
Fig. 24.28 Postoperative view at 2 years with bilateral LAP ap
reconstruction and an additional implant of 185 mL. Restoration of
breast projection, breast volume, footprint, and symmetry
opted to use the existing scars in the lower back region and
choose a LAP ap to reconstruct both breasts (Fig.24.27).
The weight of the right and left LAP ap was 395 gr and 365
gr, respectively.
Postoperatively the patient requested for additional volume, and an additional silicon ergonomic implant was
inserted of 185mL (Fig.24.28).
Case 2
A 34-year-old patient diagnosed with BRCA1 mutation.
History of right breast cancer with mastectomy and prophylactic left mastectomy (Fig.24.3). She refused a reconstruction with implants and came to our department for a second
opinion. She is an ideal candidate for a breast reconstruction
with a bilateral LAP procedure (Fig. 24.4). The angio-CT
scan examination revealed acceptable lumbar artery perforators to perform the breast reconstruction (Fig.24.5). She is
seen 2years postoperatively (Fig.24.29).
24 The Lumbar Artery Perforator Flap: ATrue Alternative inAutologous Breast Reconstruction
Pitfalls
• Harvest the interposition graft as distal as possible
to match vessel diameter.
• Include the fat overlying the gluteus medius
muscle.
• Avoid damage to the iliohypogastric nerve that
crosses the lateral border of the iliac crest.
• Do not proceed the perforator dissection too deep to
avoid nerve damage or uncontrolled bleeding; as
long as the artery diameter is sufcient you should
stop the dissection.
• Try to limit the size of the skin island in order to
perform a tension-free closure of the donor site.
24.9 Selected Readings
• de Weerd L, Elvenes OP, Strandenes E, Weum
S.Autologous breast reconstruction with a free lumbar
artery perforator ap. Br J Plast Surg. 2003;56(2):
180–3.
• Opsomer D, Stillaert F, Blondeel P, Van Landuyt K.The
Lumbar artery perforator ap in autologous breast reconstruction: initial experience with 100 cases. Plast Reconstr
Surg. 2018;142(1):1e–8e.
• Sommeling CE, Colebunders B, Pardon HE, Stillaert FB,
Blondeel PN, van Landuyt K.Lumbar artery perforators:
Fig. 24.29 View on the donor site of a bilateral LAP breast reconstruction (patient presented in Fig.24.3)
24.8 Pearls andPitfalls
Pearls
• Dissection in prone position not lateral decubitus
position.
• Dissection from medial to lateral.
• Harvest the deep epigastric inferior vessels as an
interposition graft (alternatives are thoracodorsal
vessels or descending branch of the lateral circumex femoral artery/vein).
• Include the cluneal nerve to restore sensation.
• Use the operating microscope to dissect the
perforators.
an anatomical study based on computed tomographic
angiography imaging. Acta Chir Belg. 2017;117(4):
223–6.
• Peters KT, Blondeel PN, Lobo F, van Landuyt K. Early
experience with the free lumbar artery perforator ap for
breast reconstruction. J Plast Reconstr Aesthet Surg.
2015;68(8):1112–9.
• Offman SL, Geddes CR, Tang M, Morris SF.The vascular
basis of perforator aps based on the source arteries of the
lateral lumbar region. Plast Reconstr Surg. 2005;115:
1651–9.
References
1. de Weerd L, Elvenes OP, Strandenes E, Weum S.Autologous breast
reconstruction with a free lumbar artery perforator ap. Br J Plast
Surg. 2003 Mar;56(2):180–3.
2. Hamdi M, Craggs B, Brussaard C, Seidenstueker K, Hendrickx
B, Zeltzer A. Lumbar artery perforator ap: an anatomical
241
242
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F. B. J. L. Stillaert et al.
study using multidetector computed tomographic scan and surgical pearls for breast reconstruction. Plast Reconstr Surg.
2016;138(2):343–52.
3. Lui KW, Hu S, Ahmad N, Tang M.Three-dimensional angiography
of the superior gluteal artery and lumbar artery perforator ap. Plast
Reconstr Surg. 2009;123:79–86.
4. Offman SL, Geddes CR, Tang M, Morris SF.The vascular basis of
perforator aps based on the source arteries of the lateral lumbar
region. Plast Reconstr Surg. 2005;115:1651–9.
5. Kato H, Hasegawa M, Takada T, Torii S.The lumbar artery perforator based island ap: anatomical study and case reports. Br J Plast
Surg. 1999;52:541–6.
Right Gastroepiploic Artery:
Omental Flap
VladimirAnikin andKatherinede Rome
25
25.1 Introduction
The greater omentum is a well-vascularized fatty apron,
coined the “abdominal policeman” in 1906 by the surgeon
Rutherford Morrison (1). Its use as a ap has evolved with
time, ever since its rst described use in the protection of
intestinal anastomosis in 1888. The rst free omental ap
was performed by McLean and Buncke in 1972 where a
large scalp defect was reconstructed with omentum and covering skin graft (2). This greatly expanded its potential indications for recipient sites which were previously limited by
pedicle length.
The omentum has unique properties which convey specic advantages to its use as a ap. It has the ability to promote neo-angiogenesis and tissue healing in regions to which
it is applied, a critical benet to ischemic and inamed tissues. Studies have demonstrated the omentum to be a rich
source of growth factors, inammatory mediators, and pluripotent stem cells (3). Another favorable characteristic is its
high lymphoedema absorptive capacity and amorphous
structure, easily able to ll cavity defects.
The indications for free or pedicled omental aps are vast.
Common recipient sites include head and neck defects,
locally advanced breast cancer, prevention of lymphoedema
in radical lymph node dissections, and treatment of deep sternal wound infections. It is also important to note a number of
important relative contraindications for the use of the omen-
V. Anikin (*)
Department of Thoracic Surgery, Hareeld Hospital, Royal
Brompton and Hareeld Hospital NHS Foundation Trust,
London, UK
Department of Oncology and Reconstructive Surgery, Sechenov
First Moscow State Medical University, Moscow, Russia
e-mail: v.anikin@rbht.nhs.uk
K. de Rome
Department of Thoracic Surgery, Hareeld Hospital, Royal
Brompton and Hareeld Hospital NHS Foundation Trust,
London, UK
tum, for instance, previous major abdominal operations, portal hypertension, and a history of gastric outlet obstruction.
25.2 Anatomy
The omentum is a double layer of the peritoneum, attached
to the greater curvature of the stomach and transverse colon,
hanging to cover the contents of the abdominal cavity. Its
blood supply is derived from the branches of celiac trunk,
namely, the right and left gastroepiploic arteries (Fig.25.1).
The right gastroepiploic artery is typically dominant compared to the left and is the largest terminal branch of the gastroduodenal artery (GDA). The gastroepiploic veins
accompany the gastroepiploic arteries and drain into the portal system.
The GDA arises from the common hepatic artery in 75%
of cases; it may also branch from the right or left hepatic
artery and can rarely arise from the superior mesenteric
artery. It runs posterior to the proximal duodenum, along the
lower margin of the pylorus, and then along the greater curvature of the stomach between the layers of the omentum as
the right gastroepiploic artery (RGEA). Its termination is
variable; most commonly it terminates at the middle of the
gastric curvature; however, in 30% of patients, there is a
well-developed continuous arcade with the left artery. There
are several gastric and omental branches arising from the
gastroepiploic arcade. The omental branches course inferiorly providing the omentum with its arterial supply and
forming secondary anterior and posterior arcades. The right
gastroepiploic vein (RGEV) runs parallel to the RGEA along
the greater curvature of the stomach joining the superior
mesenteric vein near its junction with the splenic vein.
Anatomical studies have demonstrated a variation in size
of the RGEA along its course. The diameter varies from
3.0mm at origin to 1.5 mm at middle of the greater curvature. Its ow rate also varies considerably between patients,
with an average of 55.78ml/min (4). This corresponds to a
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_25
243
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V. Anikin and K. de Rome
shown to be an effective tool in the assessment of the anatomical properties of the RGEA (7). It can ensure suitability
for its use as a ap prior to mini laparotomy is performed.
Alternative ultrasonographic evaluation of the GEA is also
feasible (8). Pulsatile ow and diameter can be recorded
from upper median views of the abdomen, negating the need
for IV contrast when contraindicated.
25.4 Flap Design andMarkings
Flap design and arterial supply are determined by distance to
the recipient site. If the pedicled ap does not have sufcient
length to reach the site via the right gastroepiploic artery and
primary arcade, the ap can be lengthened further. This is
done through division of the primary arcade and use of the
secondary arcade. The feeding arcade can be further skeletonized to aid delivery of the ap. Delivery route must also
be taken into consideration preoperatively; a window may be
made in the diaphragm for this purpose but must be of sufcient size to prevent torsion or compression of the pedicle.
Fig. 25.1 Anatomical overview of anatomy of the greater omentum
(Courtesy of Marcie Bunalade, 2020, All rights retained)
greater ow rate than other commonly used aps, for example, the latissimus dorsi ap based on the thoracodorsal
artery with an estimated in situ ow rate of 16.6ml/min (5).
25.3 Preoperative Investigation
To date it has not been possible to calculate omental volume
from preoperative investigations. Anatomical studies in
cadavers have demonstrated considerable variation in its size
with average dimensions of 34cm wide by 24cm in length
(6). The omental ap size, however, correlates roughly with
patient’s height and weight but not signicantly enough to
accurately predict ap volume. The best predictor of omental
volume is total body fat content, and obese individuals will
have excessive volumes when compared to a malnourished
cachectic patient. Some groups have suggested the use of a
diagnostic laparoscopy prior to reconstruction in order to
gauge omental volume and any conicting abdominal pathology such as signicant adhesions from prior surgery or
trauma.
Preoperative evaluation of the omental blood supply is
recommended if easily accessible. CT angiography has been
25.5 Core Surgical Techniques inFlap
Dissection
An upper midline laparotomy is a standard access for the
greater omentum. Previous abdominal surgeries or disease
may have resulted in adhesions which need to be divided and
taken down before the omentum can be fully assessed.
Integrity and blood ow through the omentum can be
assessed through manual pulse check or with a handheld
Doppler probe.
Mobilization of the omentum from the transverse colon is
rst achieved through dissection along the avascular embryonic fusion plane; care is taken to avoid damage to middle
colic arterial branches. This dissection is aided by cephalad
retraction of the omentum with countertraction on the transverse colon (Fig.25.2). The omentum can then be delivered
through the midline incision to aid planning of the size of the
graft.
The left gastroepiploic artery and vein are commonly
ligated near the spleen, if basing the ap blood supply on the
dominant right gastroepiploic artery. However, in some situations, e.g., left-sided chest wall defects, excessive stretch on
the right-sided pedicle may dictate the use of the left gastroepiploic artery instead. The omentum is carefully dissected
from the stomach along the greater curvature in a left to right
direction, dividing tributaries between the arcade and gastric
wall (Fig.25.3). We prefer to divide these vessels with ligation rather than use powered instruments to avoid thermal
injury to the arcade. The arcade is mobilized to the level of
the pylorus. An optional running stitch along the greater cur-
25 Right Gastroepiploic Artery: Omental Flap
245
Fig. 25.2 Separation of the greater omentum from the transverse colon
(Courtesy of Marcie Bunalade, 2020, All rights retained)
vature is recommended to peritonize the denuded area and
provide additional security to ligated stumps.
The omentum can now be assessed as to whether it will
reach the desired recipient site. If this is not possible, the
pedicled omental ap can be lengthened through the division
of the anterior epiploic arteries basing the blood supply on
the secondary anterior and posterior omental arcades
(Fig. 25.4). Passing the omentum through the laparotomy
wound should be avoided, for target sites within the thorax
creation of a window in the anterior diaphragm can be created to allow passage of the ap (Fig.25.5). A free omental
ap is possible for remote coverage. In these instances, the
right gastroepiploic artery and vein are carefully denuded
under magnication. Once the recipient site is ready, the vascular pedicle can be divided between ligatures and reanastomosed at the distant site. Following transposition, the
ap can be secured along its perimeter with absorbable interrupted or a running stitch.
Although open harvesting of the omental ap is described
above, it is important to mention laparoscopic harvesting of
the omental ap (LHOF) which was rst described by Costa
Fig. 25.3 Mobilization of the greater omentum from the stomach
(Courtesy of Marcie Bunalade, 2020, All rights retained)
Fig. 25.4 Elongation of the pedicled greater omentum ap (Courtesy
of Marcie Bunalade, 2020, All rights retained)
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V. Anikin and K. de Rome
Fig. 25.5 (a, b) Delivery of pedicled omental ap to recipient site (Courtesy of Marcie Bunalade, 2020, All rights retained)
in 1998. It has since become a popular technique in breast
reconstructive surgery with evidence supporting its safety
and success rates (9). Laparoscopic harvesting signicantly
reduces donor site morbidity, with no midline scar and reduction in adhesions and incisional hernias rates, and therefore
may be preferable if the requisite laparoscopic skills are
available to the harvesting team.
25.6 Flap Raise: AStep-by-Step Guide
Step 2 The greater omentum is then separated from the
transverse colon along embryologic fusion plane. In this way
the omentum is fully mobilized and graft size can be planned.
Step 3 If basing the ap off of the dominant right gastroepiploic artery, the left can be ligated near the spleen. The
greater omentum is then dissected from the stomach along
the greater curvature preserving gastroepiploic arcade.
Step 4 The pedicled ap can be lengthened by dividing
anterior epiploic arteries and maintaining its blood supply
through secondary anterior and posterior omental arcades.
Step 1 Upper midline incision is made or less commonly a
transverse incision over epigastric quadrant. Adhesions are
taken down and omentum carefully separated from the
abdominal wall. Its blood supply via the right and left gastroepiploic arteries can be assessed with a handheld Doppler
probe.
Blood supply maintained through rst two omental branches
from the primary arcade.
Step 5 Greater omentum ap can be delivered through a
window in the anterior portion of the diaphragm into thoracic cavity to avoid risk of hernias. The omental ap is
25 Right Gastroepiploic Artery: Omental Flap
247
secured with an absorbable interrupted or running stitch
around its perimeter, with additional stitches to secure the
pedicle taking care not to damage the feeding vessels.
25.7 Clinical Scenario: TheUse
oftheGreater Omentum inDeep
Sternal Wound Infections (DSWI)
andNonunion oftheSternum
Deep sternal wound infections (DSWI) are a rare (1%) but
devastating complication of cardiac surgery. The use of the
greater omentum as a salvage ap in DSWI is well described
in the literature. We include here the case of a 64-year-old
patient with chronic sternal nonunion and infection following coronary artery bypass surgery. The patient required
bilateral internal mammary arteries for grafting which limited the options for sternal reconstruction with a pectoralis or
rectus ap. He underwent sternal xation with insertion of
titanium StraTos bars (MedXpert, Germany) and an overlying pedicled omental ap (in Fig.25.6) to promote healing.
He made a complete and uneventful recovery, with no evidence of further infection of instability.
Fig. 25.6 An omental ap placed over titanium StraTos bars for
chronic sternal nonunion
25.8 Pearls andPitfalls
Pearls
• The omentum’s unique angiogenic and immunological properties can promote wound healing even
in hostile recipient sites with prior radiation exposure and infection.
• Perioperative antibiotics are deemed necessary in
omental aps due to transfer of fat tissue which
increases risk of infection.
• Heparinization of patients for 5 days to preserve
ap microcirculation in free aps is recommended.
• When dividing small gastric branches, it may be
advisable to use traditional ties and ligation over
electrocautery to prevent inadvertent damage to the
primary arcade.
• Postoperative use of portable Doppler sonography
is particularly useful as a ap monitoring tool.
Pitfalls
• It is advisable to avoid use of the omentum in previous abdominal surgery or disease.
• Be mindful of omental atrophy (can be up to 50% in
3months) when considering the size of ap required
for the defect.
• The omentum is considered a “salvage ap” by
many given the perceived donor site morbidity
associated with harvesting.
• Common intra-abdominal complications following
omental harvesting include ventral incisional hernias, gastric outlet obstruction, and intra-abdominal
abscess formation; these may be reduced with laparoscopic harvesting technique.
• Free transfer of the omentum enables denitive closure of the peritoneal cavity, which can reduce
abdominal complications.
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V. Anikin and K. de Rome
25.9 Selected Reading
• Rutherford Morrison in 1906. British Journal of Surgery
Br Med J. 1906;1:76.
• Term “abdominal policeman” when referring to the
omentum rst used in 1906. He likened the structure to a
jellysh taking care of “whatever mischief is brewing.”
• McLean DH, Buncke HJJ.Autotransplant of omentum to
a large scalp defect, with microsurgical revascularization.
Plastic Reconstruct Surg. 1972;49(3):268–74.
• First successful free transfer of greater omentum ap to a
distant site.
• Vernik J, Singh AK.Omentum: power to heal and regenerate. Int J Artif Organs. 2007;30(2):95–9.
• Review article on the unique properties of the omentum
and its application to surgical practice.
• Tavilla G, Jackimovicz J, Berreklouw E.Intraoperative
blood ow measurement of the right gastroepiploic artery
using pulsed Doppler echocardiography. Ann Thorac
Surg. 1997;64(2):426–31.
• The average ow rate through RGEA calculated in bypass
grafting as 55ml/min (where no postoperative ischemic
events occurred).
• Lorenzetti F, Giordano S, Tukiainen E. Intraoperative
hemodynamic evaluation of the latissimus dorsi muscle
ap: a prospective study. J Reconstr Microsurg.
2012;28(4):273–8.
• Study investigating the hemodynamic changes in the
donor vessel of the free latissimus dorsi ap before and
after denervation in free ap transfer.
• Das SK.Assessment of the size of the human omentum.
Acta Anatomica. 1981;110(2):108–12.
• Extensive study on human omentum size in 200 cadavers
and 100 laparotomies – highlighting rough correlation
with height and weight of patient, but not signicant
enough to enable predication of omental volume.
• Settembre N, Bouziane Z, Mandry D, Braun M, Malikov
S. The omental free ap and ow-through ap: preoperative evaluation of right gastro-omental artery on
multidetector computed tomography. Abdomin Radiol.
2020.
• This recent study has provided evidence for the preopera-
tive use of CT angiography in the assessment of RGEA
blood ow.
• Minakawa M, Fukuda I, Wada M.Preoperative Evaluation
of the Right Gastroepiploic Artery Using Abdominal
Ultrasonography. 1131–3.
• This study demonstrated signicant positive correlation
between abdominal ultrasonographical evaluation of the
RGEA diameter and postoperative angiography following use of the RGEA in bypass grafting.
• Zaha H, Abe N, Sagawa N, Unesoko M.Oncoplastic surgery with omental ap reconstruction: a study of 200
cases. Breast Cancer Res Treat. 2017;162(2):267–74.
• Assessment of safety and long-term complication rate in
200 patients with laparoscopic harvesting of the omental
ap (LHOF)– 99% were successful, however 12% insufcient ap volume.
Acknowledgments We thank Marciano Bunalade (Hareeld Hospital)
for providing the illustrations for this chapter.
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