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Page 6 of 11 Farajzadeh et al. Plast Aesthet Res 2024;11:32 https://dx.doi.org/10.20517/2347-9264.2024.24

Figure 4. A: 35-year old female with a history of left total mastectomy and radiation planned for right prophylactic mastectomy. B: Left
ShAEP flap using medial DIEP perforators and SCIA/SCIV planned to resurface and restore volume to radiated left chest (A small right
DIEP flap for concomitant immediate right prophylactic mastectomy reconstruction was performed). C: 6-month postoperative photo
prior to nipple reconstruction and tattooing.

though alternative means of monitoring, including flow coupler and Doppler blood flow monitors, are
possible.

Some techniques preferentially call for splitting a conjoined flap into two independent stacked flaps .
[31]
DellaCroce et al. suggest that the folding of the bipedicled flap may actually compromise the shared blood
supply and that separation of the flaps allows for independent inset and enhanced ability to shape the
reconstruction . While conjoined flap do offer less maneuverability and flexibility for inset, multiple
[32]
techniques have been described to optimize shaping for both conjoined and stacked abdominally-based
flaps .
[25]

Multiple donor sites
Independent stacked flaps are most commonly used from multiple donor sites. In autologous breast
[33]
reconstruction, the lower extremity, particularly the medial thigh, is frequently utilized . Flaps harvested
from the medial thigh typically include the transverse upper gracilis (TUG), diagonal upper gracilis (DUG),
and PAP flap . The PAP flap was first described for breast reconstruction in 2012 and since then has
[33]
[34]
become the second or third choice for autologous breast reconstruction after DIEP . In cases where the
abdominal donor site is unavailable or insufficient, the stacked PAP flap provides ample skin and soft tissue
for unilateral reconstructions [Figure 5]. A retrospective series of 20 stacked PAP flaps by Haddock et al.
reported an average combined flap weight of 685.5 g . The long pedicle in the PAP flaps affords multiple
[28]
options for recipient vessels. Flaps are typically anastomosed to the cranial and caudal IM vessels, though
the thoracodorsal system or intra-flap anastomoses can also be utilized if necessary [28,35] . Stacked LTP flaps
[36]
have similarly been described to provide adequate skin and volume in unilateral reconstructions .

The use of multiple flaps per breast lends itself to many opportunities for improving volume in autologous
breast reconstruction. Several different configurations and donor sites for bilateral breast reconstruction
have been described with stacking flaps at each recipient site, performing “four-flap reconstructions”.
Dellacroce et al. described bilateral stacked DIEP and SGAP flaps with intra-flap anastomoses effectively
resulting in a body lift four-flap reconstruction . More recently, a similar configuration of stacked DIEP
[37]
and LAP flaps has also been described for a circumferential four-flap body lift reconstruction .
[38]

Four-flap reconstructions have classically utilized bilateral stacked DIEP and PAP flaps. In these cases, the
PAP flap typically restores the lower pole contour while the hemi-abdominal DIEP is rotated 90 degrees for