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Page 2 of 11 Farajzadeh et al. Plast Aesthet Res 2024;11:32 https://dx.doi.org/10.20517/2347-9264.2024.24

[2-4]
satisfaction and superior aesthetic outcomes . With the advent of perforator-based techniques, an
armament of flap donor site options have expanded reconstructive options for patients, including the
abdominally-based deep inferior epigastric artery perforator (DIEP) and superficial inferior epigastric artery
(SIEA) flaps; thigh-based profunda artery perforator (PAP) and lateral thigh perforator (LTP) flaps; and
lower back/buttock-based superior gluteal artery perforator (SGAP), inferior gluteal artery perforator
(IGAP), and lumbar artery perforator (LAP) flaps.

In an effort to improve tissue perfusion and optimize flap volume, particularly in situations of a discrepancy
between desired breast size and donor tissue availability, multi-pedicled and multiple flap techniques have
been developed. Pennington et al. first described a conjoined transverse rectus abdominis myocutaneous
[5]
(TRAM) flap with intra-flap anastomosis to augment zone IV perfusion in 1993 . Today, multiple
variations of this technique are used to maximize donor tissue perfusion and volume. Dual-plane flaps most
commonly refer to the abdominal donor site where both the deep and superficial systems are harvested.
Conjoined flaps utilize multiple pedicles supplying different perforasomes within a single flap. Stacked flaps
involve multiple separate flaps that are transferred to the same recipient site for additional volume.
Nomenclature does vary significantly in the literature and “stacked” flaps have also been referred to as what
some would consider traditional bipedicled flaps.

These techniques can be challenging due to the need for additional flap dissection, numerous anastomoses,
multiple pedicles that can affect lie as well as more tedious flap inset and shaping. However, in cases of
compromised donor sites, a discrepancy between volume of tissue and area of perfusion and a need for
increased overall reconstruction size compared to the availability of donor tissue, these procedures can be
invaluable tools to deliver an ideal breast reconstruction. The purpose of this paper is to present a narrative
review and discussion of autologous breast reconstruction techniques for optimizing flap perfusion and
breast volume.

Dual-Plane abdominal flaps
The variability in the perfusion of the abdomen between the deep and superficial systems is not a new
concept. The concern for a superficial dominant flap, however, has primarily been focused on venous
drainage and the importance of the superficial inferior epigastric vein (SIEV). Blondeel et al. first described
[6]
the importance of augmenting venous outflow in congested flaps with a large SIEV in 2000 . Since then, the
use of additional superficial venous outflow in DIEP flaps has become common practice for addressing
intrinsic congestion. While SIEV caliber has been suggested to not correlate with a dominant superficial
venous system, approaches have focused on algorithmically preserving the SIEV if flap congestion is noted
despite an undamaged and patent deep venous system .
[7,8]

The modern “dual plane DIEP”(DP-DIEP) describes an abdominally based perforator flap where the
superficial inferior epigastric artery (SIEA) and/or SIEV [Figure 1] is utilized in addition to the deep system
to perfuse a flap [9,10] . A retrospective cohort study by Sbitany et al. compared 25 DP-DIEP flaps utilizing the
SIEA/V with 35 traditional DIEP flaps, and demonstrated a lower rate of fat necrosis in flaps augmented
[9]
with superficial perfusion . Other authors have argued that hypoperfusion remains solely a venous outflow
problem, as originally described, that is improved with SIEV augmentation, without an arterial
component . While the need for venous outflow augmentation is indeed most prevalent, the utility of
[11]
augmenting superficial inflow is likely to be multifactorial and continues to be elucidated.

Deciding to utilize the superficial system to augment both arterial and venous outflow is multifactorial and
depends not only on the size of the SIEA, but the amount of tissue harvested in relation to the number, size,