Stacked and conjoined flaps

Introduction

When available tissue from a single donor area is inadequate to achieve an aesthetically balanced result, stacked or conjoined multi-pedicle flaps from a single or multiple donor area(s) can provide a fully autologous-only breast reconstruction. In unilateral cases, the most common option is the stacked or conjoined bipedicled deep inferior epigastric perforator (DIEP) flap supplied by two anatomically distinct vascular pedicles. Raising both sides of the abdomen on at least one perforator on each side permits all zones to be harvested, providing ample skin and fat for a unilateral breast reconstruction. In bilateral breast reconstructions, a combination of flaps from different anatomical areas, such as DIEP flap, profunda artery perforator (PAP) flap, transverse upper gracilis (TUG) flap, lumbar artery perforator (LAP) flap, and inferior and superior gluteal artery perforator (IGAP/SGAP) flap can be used in the form of a four-flap reconstruction to provide a volume appropriate breast reconstruction.

Radiation deficits that create an imbalance of chest wall soft tissue and skin availability benefit the most from a multi-flap breast reconstruction, which affords an opportunity to improve and perhaps even reverse radiation-related changes to the upper anterior thoracic region, including the breast form. We are strong advocates of multi-flap procedures in appropriately selected healthy patients and have utilized over 800 such individual flaps that are part of either conjoined or stacked flaps in a 10-year span from 2012 to 2022 involving our co-surgery team. Our experience has resulted in combinations of various flaps that include at least dual-pedicle conjoined DIEP/SIEA flaps, DIEP and PAP flaps, stacked PAP flaps, DIEP and LAP flaps, LAP and PAP flaps, and uncommonly used other flaps such as lateral thigh flap (LTP), along with various other subsets of multi-flaps in order to achieve a permanent autologous-only reconstruction.

Patient selection and preoperative assessment

Candidates for stacked flaps are patients who desire a completely autologous reconstruction and do not have an adequate single donor site to recreate a body-appropriate breast. Patients are assessed regarding their general and psychological health and other comorbidities, history of previous surgery to the abdominal, lumbar and thigh areas, which may have compromised the available perforators, and examined for available donor tissue and skin laxity from a single or multiple area(s). The risks of the operation are discussed with the patient. These include donor site morbidity from multiple sites, flap failure and attempted salvage, wound complications, seroma, hematoma and infection, pulmonary embolism and deep vein thrombosis. The incidence of the majority of these complications, except for deep venous thrombosis, is not higher in stacked flap reconstructions when compared with single flap breast reconstructions in our early experience.

Prior to committing to a specific target donor area, computed tomographic angiography (CTA) is used to evaluate and select perforator and pedicle anatomy preoperatively. The CTA typically includes the abdomen, lumbar and thigh areas to assess perforators on all available donor sites. Our practice has evolved to embrace the DIEP, PAP, LAP and LTP flaps and their combinations in stacked flaps, and we have moved away from TUG, IGAP and SGAP flaps.

Surgical technique