Optimizing perfusion and volume in autologous breast reconstruction: dual-plane, conjoined and stacked flaps

Abstract

Microsurgical breast reconstruction has continued to evolve to improve outcomes and minimize complications. Dual-plane, conjoined and stacked flaps represent one aspect of this evolution in an effort to improve tissue perfusion and flap volume. Dual-plane flaps combine the superficial and deep circulation in abdominally-based free flaps to augment perfusion. Conjoined flaps use additional pedicles to supply multiple perforasomes combined in a single flap. Stacked flaps utilize separate flaps on individual pedicles to increase volume at a single recipient site. Multiple donor sites, pedicle configurations and recipient vessel choices have been described, primarily focusing on using the cranial and caudal internal mammary system as well as intra-flap anastomoses. Though more technically demanding, dual-plane, stacked and conjoined flaps allow for improvement in flap perfusion and volume, and are important tools for optimizing results in autologous breast reconstruction.

Keywords

Autologous / breast / microsurgery / stacked flap / conjoined flap / dual plane flap / DIEP

References

[1] Holmström H.The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report.Scand J Plast Reconstr Surg1979;13:423-27

[2] Eltahir Y,Dreise MM,Werker PMN.Which breast is the best?.Plast Reconstr Surg2015;135:43-50

[3] Jeevan R,Gulliver-Clarke C.Surgical determinants of patient-reported outcomes following postmastectomy reconstruction in women with breast cancer.Plast Reconstr Surg2017;139:1036e-45e

[4] Liu C,Momeni A.Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q.Breast Cancer Res Treat2014;146:117-26

[5] Pennington DG,Lam P.Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap.Ann Plast Surg1993;31:123-6; discussion 126

[6] Blondeel PN,Verstraete K.Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps.Plast Reconstr Surg2000;106:1295-9

[7] Sadik KW,Cohen A.Predictive value of SIEV caliber and superficial venous dominance in free DIEP flaps.J Reconstr Microsurg2013;29:57-61

[8] Galanis C,Koh J,Festekjian J.Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction.Plast Reconstr Surg2014;134:20-7

[9] Sbitany H,Piper M.The "Dual-plane" DIEP flap: measuring the effects of superficial arterial and venous flow augmentation on clinical outcomes.J Reconstr Microsurg2019;35:411-6

[10] Hembd A,Haddock NT.Abandoning the SIEA flap for the dual-plane DIEP reduces fat necrosis and flap failure.Plast Reconstr Surg2023;151:958-68

[11] Davies AJ,Colavitti G.The "Dual-plane" DIEP flap: measuring the effects of superficial arterial and venous flow augmentation on clinical outcomes.J Reconstr Microsurg2019;35:e1

[12] Chu CK,Lee ZH.Introduction of the L-PAP flap: bipedicled, conjoined, and stacked thigh-based flaps for autologous breast reconstruction.Plast Reconstr Surg2023;152:1005e-10e

[13] Hallock GG.Branch-based conjoined perforator flaps.Plast Reconstr Surg2008;121:1642-9

[14] Ali RS,Ramakrishnan V.Stacked free hemi-DIEP flaps: a method of autologous breast reconstruction in a patient with midline abdominal scarring.Br J Plast Surg2002;55:351-3

[15] Agarwal JP.Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction.Ann Plast Surg2007;58:359-63

[16] Beahm EK.The efficacy of bilateral lower abdominal free flaps for unilateral breast reconstruction.Plast Reconstr Surg2007;120:41-54

[17] Hamdi M,Van Landuyt K,Monstrey S.Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast.J Plast Reconstr Aesthet Surg2007;60:904-12; discussion 913

[18] Chang EI.Dual-pedicle flap for unilateral autologous breast reconstruction revisited: evolution and optimization of flap design over 15 years.Plast Reconstr Surg2016;137:1372-80

[19] Koolen PG,Lin SJ,Greenspun DT.Bipedicle-conjoined perforator flaps in breast reconstruction.J Surg Res2015;197:256-64

[20] Seth AK,Sultan SM,Erhard HA.Unilateral autologous breast reconstruction with bi-pedicled, conjoined deep inferior epigastric perforator flaps.J Reconstr Microsurg2019;35:145-55

[21] Salibian AA,Frey JD.Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction.Microsurgery2021;41:240-9

[22] Uda H,Sarukawa S.Abdominal morbidity after single- versus double-pedicled deep inferior epigastric perforator flap use.J Plast Reconstr Aesthet Surg2016;69:1178-83

[23] Rosa J, Sherif RD, Torina PJ, Harmaty MA. Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction.J Plast Reconstr Aesthet Surg2017;70:47-53

[24] Blondeel PN,Depypere H,Van Landuyt K.Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle.Plast Reconstr Surg2009;123:455-62

[25] Patel NG,Chow WT.Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping.Gland Surg2016;5:115-21

[26] Beugels J,Tuinder SMH.The stacked hemiabdominal extended perforator flap for autologous breast reconstruction.Plast Reconstr Surg2018;142:1424-34

[27] Ciudad P,Orfaniotis G.The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction.Microsurgery2016;36:359-66

[28] Haddock NT,Gassman A.Stacked profunda artery perforator flap for breast reconstruction in failed or unavailable deep inferior epigastric perforator flap.Plast Reconstr Surg2019;143:488e-94e

[29] Salibian AA,Bekisz JM.A systematic review and meta-analysis of microvascular stacked and conjoined-flap breast reconstruction.J Reconstr Microsurg2021;37:631-42

[30] Haddock NT.Modern approaches to alternative flap-based breast reconstruction: stacked flaps.Clin Plast Surg2023;50:325-35

[31] DellaCroce FJ,Trahan C.Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years.Plast Reconstr Surg2011;127:1093-9

[32] Dellacroce FJ.Reply: alternative method for volume improvement in autologous breast reconstruction.Plastic and Reconstructive Surgery2011;128:778e-9e

[33] Dayan JH.Lower extremity free flaps for breast reconstruction.Plast Reconstr Surg2017;140:77S-86S

[34] Allen RJ,Ahn CY.Breast reconstruction with the profunda artery perforator flap.Plast Reconstr Surg2012;129:16e-23e

[35] Stalder MW,Allen RJ.Using the retrograde internal mammary system for stacked perforator flap breast reconstruction: 71 breast reconstructions in 53 consecutive patients.Plast Reconstr Surg2016;137:265e-77e

[36] Tessler O,Bartow MJ.Stacked lateral thigh perforator flap as a novel option for autologous breast reconstruction.Plast Reconstr Surg2019;143:1601-4

[37] DellaCroce FJ,Trahan C.Body lift perforator flap breast reconstruction: a review of 100 flaps in 25 cases.Plast Reconstr Surg2012;129:551-61

[38] Haddock NT,Teotia SS.Simultaneous circumferential body lift and four-flap breast reconstruction using deep inferior epigastric perforator and lumbar artery perforator flaps.Plast Reconstr Surg2021;147:936e-9e

[39] Mayo JL,Sadeghi A.Four-flap breast reconstruction: bilateral stacked diep and pap flaps.Plast Reconstr Surg Glob Open2015;3:e383 PMCID:PMC4457246

[40] Evgeniou E,Haddock NT.Asymmetric four-flap breast reconstruction with DIEP flaps and PAP flaps.Plast Reconstr Surg2022;150:1236e-9e

[41] Follmar KE,Manahan MA,Rad AN.Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction.Plast Reconstr Surg2011;127:34-40

[42] Teotia SS,Jayaraman AP,Haddock NT.Revisiting anastomosis to the retrograde internal mammary system in stacked free flap breast reconstruction: an algorithmic approach to recipient-site selection.Plast Reconstr Surg2020;145:880-7

[43] Venturi ML,Chevray PM.Comparison of flow rates in the antegrade and retrograde internal mammary vein for free flap breast reconstruction.Microsurgery2011;31:596-602

[44] Kerr-Valentic MA,Agarwal JP.The retrograde limb of the internal mammary vein: an additional outflow option in DIEP flap breast reconstruction.Plast Reconstr Surg2009;124:717-21

[45] Li S,Li Y.[Clinical study of the hemodynamics of both ends (proximal and distal) of internal mammary artery and its following-up].Zhonghua Zheng Xing Wai Ke Za Zhi2002;18:140-142

[46] Berrino P,Adami M.The “parasite” TRAM flap for autogenous tissue breast reconstruction in patients with vertical midabdominal scars.Ann Plast Surg1999;43:119-26

[47] Martinez CA,Secchi-Del Rio R.Bilateral outpatient breast reconstruction with stacked DIEP and vertical PAP flaps.Plast Reconstr Surg Glob Open2021;9:e3878 PMCID:PMC8522876

[48] Muto M,Tsunoda Y.Lateral thoracic vessel as a recipient vessel in immediate breast reconstruction after nipple/skin-sparing mastectomy: experience with 270 flaps.Plast Reconstr Surg2023;151:1157-67

[49] Opsomer D,Benmeridja L,Noel W.Bilateral DIEP flap breast reconstruction to a single set of internal mammary vessels: technique, safety, and outcomes after 250 flaps.Plast Reconstr Surg2019;144:554e-64e