Microsurgical breast reconstruction options after abdominoplasty: lumbar artery perforator (LAP) versus profunda artery perforator (PAP)

Authors: Teotia SS, Troia TC, Kim LJ, Haddock NT

Affiliation: Department of Plastic Surgery, University of Texas Southwestern Medical Center Journal: Plastic and Reconstructive Surgery – Global Open, December 2025 PMID: 41377927

Key takeways

• In patients with prior abdominoplasty (n=39), LAP was used more often than PAP and yielded higher BREAST-Q satisfaction across most domains.

• Overall flap-related complication rates were similar between prior-abdominoplasty and no-abdominoplasty cohorts despite higher BMI and comorbidities in the former.

• Within the prior-abdominoplasty subgroup, LAP had markedly higher postoperative satisfaction with breasts, psychosocial well-being, and chest physical well-being than PAP; sexual well-being trended higher.

• LAP bilateral cases took longer operative time than PAP.

Background

After abdominoplasty, the abdomen is frequently unavailable for deep inferior epigastric perforator (DIEP) flaps. Surgeons must pivot to alternative donor sites. The LAP and PAP flaps are leading second-line options, but direct comparative data in the specific context of prior abdominoplasty are limited.

Objective

Compare outcomes and patient-reported satisfaction (BREAST-Q) of LAP versus PAP autologous breast reconstruction in patients with a history of full abdominoplasty.

Methods

• Design: Retrospective single-institution cohort (2011–2023); Level of Evidence III.

• Population: All microsurgical breast reconstructions (n=264); subset with prior full abdominoplasty (n=39) analyzed against those without (n=225). Mini-abdominoplasty or liposuction-only patients were excluded.

• Flap selection: Individualized; no rigid algorithm (patient anatomy/preferences).

• Exposures: LAP vs PAP flaps within the prior-abdominoplasty subgroup.

• Endpoints: Postoperative complications (fat necrosis, infection, seroma, hematoma, wound issues, flap loss) and BREAST-Q domains (satisfaction with breasts; psychosocial; physical well-being: chest; sexual well-being). Responses at standard intervals were included regardless of timing.

• Statistics: χ² for categorical variables; independent-samples t test for continuous variables; α=0.05.

Results

Cohort characteristics

• Prior-abdominoplasty patients were older and had higher BMI and more hypertension/diabetes than those without abdominoplasty.

• Despite higher risk profiles, any flap complication was similar between groups.

Flap usage and configuration (prior-abdominoplasty subgroup)

• LAP favored over PAP after 2018.

• Configurations: bilateral LAP (n=18), unilateral LAP (n=6), bilateral PAP (n=11), unilateral PAP (n=2), plus small stacked combinations.

Operative time

• Bilateral LAP mean 516.6 ± 84.9 minutes vs bilateral PAP 365.2 ± 101.8 minutes (longer for LAP).

Complications (prior-abdominoplasty vs no-abdominoplasty)

• Any flap complication: 38.5% vs 32.4% (NS).

• Specific events (fat necrosis, infection, seroma, hematoma, flap loss) were not significantly different; breast wound dehiscence trended higher with prior abdominoplasty.

BREAST-Q (prior-abdominoplasty LAP vs PAP)

• Satisfaction with breasts: 74.6 (LAP) vs 45.8 (PAP) [P < 0.001].

• Psychosocial well-being: 77.6 vs 54.0 [P < 0.001].

• Physical well-being—chest: 88.0 vs 51.0 [P < 0.001].

• Sexual well-being: 59.8 vs 47.4 [P = 0.942].

Conclusion

For patients with prior abdominoplasty seeking autologous reconstruction, LAP provides higher patient-reported satisfaction than PAP with comparable complication rates, at the expense of longer operative time. LAP should be strongly considered as a primary alternative donor site in this scenario.

Strengths

• Focused, clinically relevant subgroup (post-abdominoplasty) where DIEP is unavailable.

• Inclusion of BREAST-Q adds patient-centered perspective.

Limitations

• Retrospective design without standardized flap-selection algorithm → High potential for selection bias.

• BREAST-Q limited to responders; timing heterogeneous.

• Single institution; learning-curve effects likely (LAP adoption after 2018) and may influence operative time and outcomes.

• Modest abdominoplasty subgroup sample (power constraints for complication comparisons and sexual well-being domain).

Clinical Relevance

• Counseling: In post-abdominoplasty patients, particularly those with truncal adiposity, LAP may yield superior satisfaction and chest comfort compared with PAP.

• Trade-offs: Expect longer OR time with LAP; plan resources accordingly. Complication profiles are similar, supporting shared decision-making driven by anatomy, desired volume/shape, and scar preferences.

• Planning: Given equivalent safety signals, prioritize donor site matching to volume and contour goals; discuss scar visibility (LAP: back/flank; PAP: posterior thigh) but emphasize that breast shape/volume may dominate satisfaction.

Critiques and questions

• Selection bias: Without a prespecified algorithm, were PAPs chosen for patients with poorer lumbar perforators or less truncal adiposity, inherently disadvantaging PAP satisfaction? A prospective algorithmic comparison would help.

• Volume/contour hypothesis: The authors suggest LAP’s volume/contour advantages drive higher satisfaction in higher-BMI/truncal adiposity phenotypes. Future work should quantify delivered flap volume, projection, and breast anthropometrics to validate mechanisms.