The transverse lumbar perforator flap: An anatomic and clinical study

Abstract

Background and aims: Lumbosacral defects are complex reconstructive problems requiring tension-free vascularised soft tissue reconstruction in patients who often have comorbidities. In an area prone to recurrent tissue breakdown, both free and islanded flaps risk complete failure. Cadaveric studies have demonstrated the consistency of lumbar perforators, yet ipsilateral lumbar perforator flaps have modest reconstructive potential owing to geometric limitations. An axial pattern lumbar perforator flap based on a contralateral lumbar perforator may surmount these problems; however, it has only been described in a small clinical and cadaveric study previously.

Methods: An anatomical study was performed in the consecutive patients undergoing computed tomographic angiography (CTA) of the trunk, assessing the presence and location of lumbar artery perforators. The use of midline or contralateral lumbar artery perforators in the lumbar perforator flap was assessed in the reconstruction of lumbosacral defects.

Results: A total of 102 patients with 102 lumbosacral defects have been managed with the use of contralaterally based transverse lumbar perforator flaps over a period of 20 years. In 96 patients, the defects requiring reconstruction followed debridement of a pressure ulcer, with seven cases following debridement of pilonidal sinuses and one following abdominoperineal resection. There were 65 men and 37 women, with a mean follow-up of 1.5 years. Necrosis of the tip of the flap occurred in 3%, with no cases of complete flap loss. Recurrence occurred in two cases (both sacral pressure sores). All recurrences and/or necrosis were managed with flap advancement or skin grafts. All the donor sites were closed directly.

Conclusion: The contralateral-based transverse lumbar perforator flap is a simple, reliable, versatile and, in some cases, reusable choice in the management of lumbosacral defects. Flap dimensions of 24 × 15 cm can be based on one lumbar perforator.

Keywords: Cadaveric study; Computed tomographic angiography; Lumbosacral defect; Perforator flap; Sacral sore.