Uh, once again, thank you very much for the invitation of being here and um.
I have, um, I'm a temporary consultant for establishment labs and um I've been asked to.
Say something about the lumber flap, so the lumber flap.
We have been using it quite a lot recently in the last couple of years.
I think it's now 567 years perhaps.
So it's actually my colleague and friend Kunalon who introduced the flap in our
department. It has been described as a case report several
years ago by the. And um it's a very interesting flap that can be
used as an alternative in autologous uh breast reconstruction.
So the standard approach is a deep flap.
And the lumbar flap is actually removed from the left and the region and is based on the
perfraus L3 and L4, and they emerge through the torquo lumbar fascia at the lateral
border of the rectus pina muscle.
So it's approximately at 7.5 centimetres from the midline.
So one of the advantages of the lumbar flap is that the anatomy is quite consistent.
The perfects have a diameter of approximately 1.8.
2.2 millimetres and another advantage of the lumbar flap is that you can actually include
the cual nerves to uh restore sensation in the breast.
So, um, it's taken from the left and the region and uh mainly the tissue bulk overlying
the muscle is part of the flap.
So and what's important to realise is that's a septocutaneous perforator that emerges the
torcal lumbar fascia in between the erectus spina muscle and the cadratus lumbora muscle.
And the craneal nerve is one of the first structures you will encounter during your
dissection. So it, it, it appears, it perforates the fascia
immediately from the perforator.
Now, um There has been some kind of discussion. You use NSA or a lumbar slap.
I like to use the lumbar flap in patients who have some kind of tissue bulk in that love
handle region. An S gap flap, we are still using the SAP flap,
but I like to use the S gap flap in patients with some laxity like on the on the right side,
and she has a flattened love handle region, so it will be difficult to have some tissue bug to
reconstruct the breast.
Because the thing is, often in those patients with um a firm gluteal region,
the SAP uh often creates some step of deformity. That's why the lumbar flap,
uh very nice advantages, a very nice shape of the breast.
Now, and you will be surprised even in skinny patients, uh,
ideal patients or candidates or the typical skinny pear shaped patients,
and you will be surprised how much tissue you can remove from the left handed region in those
patients to reconstruct a large volume breast and um before,
just as in a deep flap, before we perform a lumbar flap,
we always do a preoperative CT examination and the CT will show you.
The course of the perforated, the quality of the perforated,
the diameter of the perforator, and what's important to realise is the radiologist,
he will um uh locate the perforator at approximately 7 to 8 centimetres,
but that's from a bird's eye view. So in a lumber flap,
your dissection, you start on the hill, so you're running down the hill.
So the erectusspina muscle has a um a convex shape.
So the actual distance from the midline.
To the point where the perforator per fascia will be 9 centimetres.
So when we start doing those dissections initially we were scared because we were
dissecting and after 78 centimetres we we didn't see anything,
but it's actually lower.
You go right to the lateral border of the erectus spina muscle.
And another thing is when you do your dissection, I will show it later,
you will actually encounter two fascias because the two fascias coming together to the
torcolumbar fascia comes together from the quadratus lumbora muscle and the erectus pini
muscle. So that's something I'm gonna show you later on.
So a CT angio should be done, I think, because we also have some patients that shows some
vascular anomalies with the with the intercostal arteries.
So it's quite, it's a, it's a very.
Um, um, it's very advisable to perform this examination.
The steps um through the learning curve because there is a learning curve,
uh, we have some tips and tricks, you know, what what should be done initially we have been
doing those flaps in the lateral from in the lateral position with the patient lateral uh
placed in later position so that section was done from lateral to medial.
The problem with the dissection from lateral to medial is that in the lateral part of the flap
you have quite a lot of tissue blocks so surgical exposure is very challenging.
So that's why I started to do my dissections from medial to lateral because in the medial
part you don't have that much tissue, so exposure is,
is, is easier.
And so I start my, um, the procedure with the patient prone position.
I do a a two stage procedure. I know that couldn't.
He likes to do the the three-stage procedure. I do the two-stage procedure,
yeah, so even some time.
And it has no influence on the ischemia time of the flap,
because, and also, I mean, it's, it's safer for your interposition graph because your
interposition graphs will be harvested um at the moment that your flap is harvested,
so you can connect it immediately.
That's something that we can talk about later.
So prone position dissection from medial to lateral.
So we make the design of the flap with the with the patient in a standing position.
Once she's asleep we turn on the belly and then we actually will confirm.
The location of the of the we will confirm the strength of the perfect with the Doppler.
We will, um, you can actually point and this is the Claudio.
Claudio showed me that at the perfect grows and he says,
Why are you doing all those efforts with the Doppler?
You know, there's there's one point. You take your finger and you can feel the
dimple. Where the erectusspina muscle crosses the iliac
crest muscle, and that's where L4 actually perfects the torical lumbar fascia.
But you can with the Doppler, you have a nice signal.
You can also Doppler L3 if you want, so you can include both perhaes.
With the patient prone position, you will see that you will be able to lower the design of
the flap. One of the disadvantages of the lumbar flap is
that you have a visible scar above the yellow crest over time.
After 3 or 4 years, you see that the scar is actually getting,
it's, it's becoming a bit lower 23 centimetres.
So incision prone position media lateralization, you incise the flap completely initially it's
very important to have a nice surgical exposure, a wide surgical exposure.
So don't work in a hole.
Don't start like a partial incision on the medial side and try to look for the perfect in
inside the flap completely.
And create that conic shape of the flap. So what you do is an angle dissection.
You go an angle dissection mainly towards the inferior parts of the flap because what you
want, you want to include.
The gluteal fat that's overlying on top of the gluteus me muscles because
that fat has a very nice consistency. It's fat that has large lobels,
so it's very soft and very pliable fat. So initially you go to the subcutaneous fat pad,
which is a bit more rigid. So and then you can choose,
you can you can you can you can use that lower part for upper polefulness or lower polefulness
that's something that will be shown.
But this is the fat that you need. It's the fat overlying the lutee medium muscle.
So you shouldn't stop your dissection.
You should stop your dissection when you see the muscle.
So you can actually scoop out that fat.
Initially it will create some deformity at the donor site,
but you will see a couple of months later the deformity will become.
So, uh, in the, um, after that you created the flap, you created the shape,
then you change position and you go to the contralateral part and you start to a section
from medial to lateral. So that's important.
You go mel to lateral and the 1st 7. 8 centimetres are just straightforward.
You don't need microscope. You don't need loops.
You go straightforward. There's no danger that you will actually harm
the perforator. You use the iliac crest as a reference line,
so the margin of the iliac crest, just follow it with your finger.
You go 78 centimetres dissection and then what you do,
um, I use the microscope, uh, I use a microscope because it gives you a very nice
view. On your dissection.
Once you have 78 centimetres dissection, I use the microscope.
Also position wise, it's good for your spine because with the loops you're actually actually
bending over the whole time. So the microscope gives you some confidence in
dissecting out.
First of all, you will encounter the cloneal nerve, and once you see the cloneal nerve,
you go slowly, you incise that torcolumbar fascia and then slowly you can dissect out to
perforate. The ulian nerve is very easy to dissect out.
You can actually harvest quite a lot of length of the nerve,
often 67 centimetres that can be harvested, and you can actually include different lunar nerves
so you can use a graph from one nerve to another to lengthen the nerve and anas move it
to the intercostal nerve.
So dissection is straightforward. It's like a standard dissection,
nerve, nerve.
The perfectf will be lateral to the nerve. So once you see the clonal nerve,
then you know the perfectfator will be there. So there is no,
you don't need to get nerves. He will be there.
You follow iliac crest. You have the clonal nerves,
and then slowly you continue the section and you will now enter the lateral border of the
erectus pena muscle, but you incised the torical lumbar fascia.
Then it's a standard dissection, um, with, um, dissecting out the,
the, the perforators.
So, um, you go slowly, I think hemostas is very important in this area.
So this is part of the clinian nerve that is dissected out,
um, and which is uh straightforward.
This is what I wanted to show you when you start doing these flaps,
you become a bit, you know, it's it's.
It's, it looks like the anatomy is a bit difficult initially because #1 is your first
incision in the in the fascia.
So if you incise this in front of the clean nerve, your second incision,
it will dissect and what you will see is suddenly you will see another fascia showing up
and that's that that's the other fascia that's actually going around the lateral part of the
reussinnaus. So you have to incise that fascia a second time
to actually visualise the perforator.
One of those steps that are very important, it's the use of an interposition graft.
So our first choice is the deep epigastic vessel, and it is very important,
and that's the reason why I think we lost two flaps.
It's very important to transect your your graft very, very distally
underneath the rectus abdominal muscles. So, uh,
and I will explain to you why, because um it's easier.
to remove part of the graft then to add because of the mismatch in diameter
can occur with the with the pedicle.
We move the flap with the vascular graft while other people are preparing the mastectomy site
to a side table, and then we perform the microsurgical anastomosis between the graft and
the pedicle using an elo 0O suture.
So you see the two liar nerves and um the graft sutured to the pedicle and then you can
play around. You have often you have the L3,
you have the L4 per ratus, you can uh anastomos two veins,
um, um, and then for example, what's also important is the anastomosis of the artery.
In, in general, I just go back.
In general, the vein ostomosis is not a problem. The artery should be done carefully and
normally when you anastomo an artery, the last stitch is almost always done like blindly.
You shouldn't do that in this case. So what I do,
my last 4 stitches for my last 4 arterial stitches.
I leave them open and I, I, I, um, I, I tied one knot and then I rinse.
I tie the other knot and then I rinse because every time you rinse you will avert the edges
of the artery and you will also rinse out some small debris because um it should be really
clean and well done because the revision of that anastomosis always,
I mean it's always impossible or it's not done so um.
That's an image, an interoperative picture of uh a nerve anastomosis because the lengthening
of the pedicle flap inset is very easy and you can also anastomos um the nerve.
So for example, in this case I wanted to create upper pole volume,
so the the the lower part of the inferior part of the flap with the gluteal fat overlying the
gluteus medias muscle is positioned in the upper pole,
but you can see because we have been lengthening the pedicle of the flap,
you can see that the flap inet is straightforward, is easy.
There is no traction.
There is also no mismatch between, for example, the perforator and the memory vessels and um
you know and it's it's it's just loose everything is loose you can play around with
the shape and um um so you see also that the conical shape of the flap immediately
gives you that nice breast shape.
For example, for example, this patient, she had a deep flap in the past,
um, then they did a reconstruction with autismus dorsi muscle and an implant that
ruptured, so she came to our department. She says,
you know, um, I want to get rid of the implant. What can I do?
So, um, there was one epigastric artery left as a graft,
so we took a lumbar flap.
This is the flap, and you'll be surprised the amount of tissue that can be taken in that
region and you look at the shape. The shape has already a nice conic shape of a
breast, and you know you can you can fill it up.
It's really nice to see how that fat actually will shape your breast.
It's the immediate postoperative result and then it's after you know.
With a lumber flap, I think it's also very advisable and important not to.
Incorporate too much skin, uh, so always be sure that you have a tension free closure and
this is mainly to, for example, in secondary reconstructions where you can actually preserve
that inferior part of the original skin envelope.
This is the donor site.
And then another case is a young patient who had an implant on the on the left,
on the right side with the radiation therapy, we did a lumbar flap just to show you how it
looks two weeks after the operation. You have a look at the shape.
The shape already is very, it's very it's very aesthetically pleasing,
so it's a nice shape already yes she has.
So this is um 2 weeks ago I did my case number 100, and this is her.
So it's a bilateral case. She had a circumferential abdominalplasty in
the past. She came to the oh she was sent over by a
colleague. He said, you know, she, she needs a
prophylactic mastectomy and uh and and and a reconstruction.
What, what would you do? So, um, so it's an ideal candidate for a lumbar
flack. She has a nice excess of tissue and on top of
that you can actually extend the excision of the abdominalplasty towards the back of the
patient. So I did the.
And now I have to think I did the.
The right breast 6 weeks ago and the left breast 2 weeks ago,
so this is now 2 weeks after her uh her her final reconstruction.
If we do a bilateral cases, we always respect an interval of at least 6 weeks,
but in this case we did 3 weeks, but normally you should wait 6 weeks.
Another case with a very bad positioning of the mastectomy scars.
She had radiation therapy. She also had on top of that radiation of the
sternal region because of a Hodgkin lymphoma, so she had a bilateral lumbar flap,
and this is her shortly after the operation.
And this is after a nipple tattoo.
Unfortunately she has some hypertrophic scars, but you know,
look at the shape, the shape of the breast already is nice with a nice uh upper pole.
One of the first cases we did is a typical pear shaped patient.
These are the ideal candidates.
Um, they wanted to um uh reconstruct her with implants.
She came for a second opinion.
And we did a lumber flap, and these are the donor sites at the long term.
This is 2 years post-op um and you know I think it's quite acceptable.
Also there's no contu. She's a physician.
She also came from another hospital. We also they advised her to put an implant.
She came for a second opinion.
So what we did, what, what did we do? We did a bilateral lumbar.
We preserved the native skin envelope, so we were very conservative with the skin inclusion
in the flap, and you can see you can actually resect everything and you just use it for
nipple reconstruction.
So the skin that you see here is just the native skin,
so you can expand it and you can create a nice result.
Another case, a secondary case and then a primary prophylactic case on the left side and
then the donor side. This case also came, uh,
she says, you know, I had a bilateral reconstruction with implants.
My surgeons told me that it will heal the exposed implants.
I just have to wait. I say, you know, OK, we better do something.
We removed everything.
She had uh uh abdominoplasty in the past, circumferential abdominoplasty,
so we did a CT scan.
And she still had her lumbar perforated, so we could use the existing scar,
so we didn't have to create an additional scar.
So, uh, and also in this case, we did a bilateral uh lumber and you know.
The projection of the breast is nice. The shape is nice.
The lower pole expansion is nice, and this is just also she recently had a 2.
It's a secondary and primary case and have a look at this is the donor site,
you know, it's a visible scar, I know, but at the long term,
4 or 5 years later, you will see the scar will descend but will never become lower than the
iliac crest of course.
So, um, it's now, um, we just finished like 100 cases.
Um, I had, I did 30 bilaterals. I had One failure on one side,
probably due to the mismatch in the artery, and then we had together with Koon we did one
bilateral in one in one session, but I think it's not advisable to do and we lost that one
and so it was strange because technically everything went well,
but afterwards she had some clotting disease so she had a protein C deficiency.
We did 40 union, one failure. It's an obese patient,
so probably the weight of the flap was actually compromising the small anastomosis.
So now what we do, we make a small incision in the pectoralis muscle actually to stabilise the
vessel and to prevent too much pressure. And then one failure is puffed up last
day at day 4 also an arterial failure.
Uh, a day before she had a history of radiotherapy.
I don't know if that has something to do with it, but 5% now we have failure rates.
I have been doing now 20 lumbers this year until now we should touch wood.
I didn't have any, so there is like a learning curve, you know,
technically it is doable as long as you follow.
Uh, specific steps.
So, uh, be careful, you know, and this is the case where I lost the right side.
It's a bilateral case, so the, the left side is a lumbar flap,
and then, you know, I had to solve it with a hybrid reconstruction on the right side.
So all the candidates for lumbar flaps were patients with insufficient abdominal tissue.
Uh, patients who had previous abdominal plastic procedures had poor abdominal perforators.
Patients who had uh previous deep flap on the other side and now had breast cancer on the
contralateral site had recurrence in the deep flap, so the deep flap has to be removed and
needed a new reconstruction.
Uh, or for example, in this case, a failed deep flap or with,
with uh partial necrosis where we removed everything and did a a lumbar flap breast
reconstruction. The advantages of this flap, I think is shape
and volume. You can restore sensation in the breast.
We haven't seen any partial necrosis in all the flaps.
We also see less secondary corrections needed to shape the flap into second stage.
The only The problem is the scar is visible in the in the in the left handle region just above
the crest and they do have you know some some sensory loss in that region but it it actually
recovers quite so but they stay with the sensory loss of about 12 centimetres below the
scar and all of them 100% they develop seroma, all the patients,
they all have seroma, but seroma.
It's not a problem. You know, most of them, you punch them twice or
3 times and it's it's solved. So, nobody complained about sum,
but all of them 100% has roma.
To conclude, so this is a general overview prone position.
Dissection from media to lateral into position graft taken very distally
because then you have some you know some reserve.
Do you anastomosis on a side table. You can do a nerve anastomosis and then turn
the patient to stage to perform uh the final uh reconstruction.
Thank you very much.
So, For the final Our co-chair shall give us his final words
what he thinks yeah, it's going to be very, very fast,
you know, it's, it's nice it's nice to be friend of,
uh, of Jan and Marlin because always they put me very strange,
you know, presentation or just smothering very strange thing,
and I asked to, to John what what do you want here?
On my hands, he said, uh, talk about something that is only working your hands.
I said I cannot talk about anything because Nothing only works in my hands,
you know, I can tell a little bit what I am.
Doing from my beginning, this is in the 90s when I did my,
my training in Spain and here in this wonderful country in uh in the UK and at that time I
was full of, you know, enthusiasts and, and wishes and.
And you know I was learning visiting many surgeons at that time it was not so easy like
now there was no internet. I, I, I remembered I need to write my my
letters and then asking and, and waiting for the reply,
but you know I learned something and the first thing that I learned was reconciive
microsurgery.
I put a lot of energy learning this.
Why? Because it was the best way to transfer tissue.
And you know, uh, at that time it was also something challenging and,
and you know I did all kind of reconstruction had a net lower limb,
breast, you know, um, genital, but in the last, in the last probably 15 years I've been focused
more in these fields in reconstructive breast surgery, breast aesthetic,
and lymphedema and lipedema surgery and um.
I start my journey not wanting to be a rich man like Patrick.
I just wanted to be just a good surgeon, a good surgeon, and,
and that was my dream. This is why all, all the journeys start,
you know, you need to have a dream and and it's good.
Some people want to have a dream to be a rich man, but I wanted to be a good surgeon.
And, and I think more or less is what uh I, I, I get.
I can, I can do good reconstructive surgery with all kinds of techniques and I'm,
I am very happy with my results nearly I can tell you that no one patient in my hands has
been missing a breast reconstruction, something better, something not perfect,
but you know I can do it.
Then Is uh Aesthetic surgery, OK, I do more or
less when I see the results of the people, not the ones that they show on the,
on the presentations, the, the real results after two years.
I can tell you that more or less I get the same results, you know,
maybe not so good like Patrick, but you know, not bad.
People don't complain. The people come back here.
When I saw what I, I, I get what I got on lymphedema surgery,
something that not many people believe, you know, 15 years ago nowadays we can help a lot
of people and I can tell you that in secondary lymphedema, we can get the results,
you know, improvement over 70% in nearly all patients, primary lymphema still we need to
work. And I try to understand this very boring field
that is the Lipedema.
Lipedema now is a kind of trendy topic in Europe, and I can see that even in other places
and I say boring because I all my life I hate liposuction.
I never do liposuction, you know, when a patient came,
you know, for a liposuction, I sent to Patrick, I sent to Charles,
you know, the big guys. I never do liposuction.
This is extremely boring.
But you know I do liposuction for lymphedema patients and I can tell you that I understood a
little bit that lipedema is more than aesthetic is painful,
it's a lot of things is a kind of massive liposuction that normally the people,
they have a lot of problems, sero mass, you know, problems with the skin,
and again we have a technique that we can get nice results,
very reliable and very, very few, few complications.
And at the end, why you can get all of these dreams, you know,
all of these things we can get main mainly ambitious because you need to be ambitious.
I hate when the people say no, you know I put only implant under the skin because my patient
what the volume. Oh no, because my patient was all,
it's not true. You need to be ambitious.
It's like it's like uh like what I said, you know, all the patients want the perfection.
doesn't matter if it's 40 with 72. It doesn't matter who,
where do you come from, and you need to be ambitious, but you need to be specially honest,
honest with you and honest with your patience.
And the most important thing that you need to put in everything that you do.
I you need you need you need to put passion passion in your work only if you put dedication
and passion you can achieve nice results and this is why London Bress meeting and Barcelona
press meeting is a great meeting. Why?
Because Jan Marlen and I, we put a lot of passion and this is why we are here and we want
to be for many years with you in London and in Barcelona.
Thank you very much.
Thank you very much.
For this end of the London press beating 2023.
I hope you enjoyed it. I definitely I enjoyed myself.
Um, yes, I'm very tired.
It was a very intensive programme, but not only because I'm tired because of the programme
because this guy here wanted to have some sightseeing in the middle of the night through
London and that killed me off.
Um, From my point of view, for sure, I need to say a few thank yous to,
to, to the people who put this hard work into it, um,
at the very first is um obviously.
As always, we are guests of the Royal College of Physicians,
not surgeons, and that they give us the space that we can be in here and I think I'm still
very happy that we are in this great venue with a team working from the AV team,
from the backs, um, catering, that they really provide us with these excellent days to be here.
And as well, obviously this meeting would not be possible with all these sponsors and
exhibitors.
For them it's getting tougher and tougher as the number of meetings are going up and
therefore they have to spread their time across many different places and so.
I think we have to be grateful that they are here and I think we always show them that by
going to them, talking to them, and the and the exhibitors who are standing here day for day,
the whole day to be just chatting for a few minutes, I think we need to appreciate that.
So thank you very much to all of them that they support this meeting.
They support education for us.
Then obviously there is the team who of MA Healthcare who does put this together.
Charlie and his team, yes, there was a change in the midst of the whole meeting organisation
suddenly, um, Lisa, who many of you have known, decided I'm done.
I said what, you're gonna go to competition? No, no,
no, no, no, no, I'm opening a shop.
I just saw yesterday a picture that she's somewhere in south of England selling apples
and pears and bananas.
Totally something different.
But yes, but she did hand over to from Lisa to Charlie and um we were both a bit nervous
initially said oh god Charlie, what does he know what he's gonna be doing but um I think
Charlie and his team, they did an amazing job they pulled through and they really put an
amazing show together and I really. Thank you again for that.