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Farajzadeh et al. Plast Aesthet Res 2024;11:32 https://dx.doi.org/10.20517/2347-9264.2024.24 Page 5 of 11

Figure 3. Conjoined or bipedicle DIEP flap for unilateral breast reconstruction. DIEP: deep inferior epigastric artery perforator.

Extended donor sites
The use of additional vessels based on adjacent known perforasomes has also expanded the volume
limitations of traditional flaps. The stacked hemiabdominal extended perforator (SHAEP) flap combines the
DIEP pedicle with more lateral pedicles to enable additional tissue harvest outside the zone of DIEP
perfusion . Multiple perforator combinations have been described, most commonly utilizing the DIEP and
[26]
[26]
deep inferior circumflex artery (DCIA) pedicles . Utilization of the lateral flank perfusion based on the
superficial circumflex system can also help recruit more skin and volume when needed [Figure 4].

The lower extremity has also been utilized for conjoined flaps. A 2023 study by Chu et al. described
[12]
harvesting PAP and LTP flaps as a conjoined “L-PAP flap” to optimize coning and projection . The flap
utilizes the medial, posterior, and lateral thigh tissues to improve reconstruction volume influenced by body
[12]
contouring thigh-lift procedures . Additional bipedicled designs in the lower extremity include
combinations of the gracilis and PAP flaps, though PAP perforators typically provide robust perfusion of
the medial thigh in isolation .
[27]

STACKED FLAPS
Stacked flaps typically consist of two physically separate flaps with isolated pedicles which are then
anastomosed independently [14,28-30] . The individual flaps are shaped and inset to obtain the desired breast
conus, volume, and footprint. The use of multiple flaps can help provide additional projection, overall
volume, and skin resurfacing, depending on the need.

Single donor site
When the abdomen is utilized as a single donor site, the vast majority of reports have utilized a conjoined or
bipedicled design. However, splitting the abdomen and stacking hemiabdominal flaps is also a reported
29
technique. In such cases, the flaps are often placed on top of each other with an unmonitored buried flap,
14