*Purpose: Left-lobe grafts are underused for adult liver transplantation in the United States. Better strategy is needed to expand the use of left lobe in both deceased split (DST) and living donor transplantation (LDT).

*Methods: Retrospective review of 80 LDT and 68 DST performed between 2004 and 2017 in the single institution. The study period was divided to before and after 2010, when a novel triple hepatic vein outflow technique was introduced and inflow modulation was converted from portocaval shunt to splenectomy.

*Results: Left-lobe utilization in LDT was well with 40% during the overall study period, and that of DST was increased from 0% to 27% in the later period. Selecting smaller recipients for left-lobe DST enabled to have a decent graft-to-recipient weight ratio (GRWR). Compared to DST, LDT using left-lobe was performed with a significantly lower median GRWR (0.79 vs. 1.24), and higher portal flow (150 vs. 106 mL/100gLW), with more frequent inflow modulation (56% vs. 7%). In the later period, the occurrence of small-for-size syndrome successfully diminished, and left-lobe graft survival became equivalent to those of right lobe-grafts.

*Conclusions: The successful outcome of left-lobe grafts can be achieved with optimized outflow and inflow modulation in LDT and judicious donor recipient pairing in DST.

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