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Farajzadeh et al. Plast Aesthet Res 2024;11:32 https://dx.doi.org/10.20517/2347-9264.2024.24 Page 7 of 11

Figure 5. Stacked PAP flaps in a patient with prior bilateral mastectomy as well as a history of circumferential body lift with severe left
chest wall radiation. A: A large proximal branch of one flap (blue background) is utilized as recipients for the second flap. B: Left stacked
PAP reconstruction and right tissue expander placement in first stage of delayed reconstruction.

[39]
the upper pole, mimicking the shape of a mastectomy specimen . Recently, studies have advocated for
asymmetric four-flap reconstructions in cases of bilateral reconstruction, utilizing a conjoined bipedicled
DIEP on the side requiring additional skin resurfacing and stacked PAP flaps on the contralateral side [39,40] .

RECIPIENT VESSELS
Recipient vessels are a critical consideration when planning stacked and conjoined flaps, given the need for
additional anastomoses. The most commonly used vessels in a systematic review of 2,006 flaps were the
[29]
cranial and caudal internal mammary (IM) vessels [Figure 6] . A 2011 study by Stalder et al. showed that
the anterograde and retrograde IMAs are adequate to perfuse a flap with a reported 97.5% success rate .
[35]
Their study also showed that the retrograde IM mean arterial pressure (MAP) is 74%-78% that of the
anterograde [28,35] . If sizeable IM perforators are identified, these can also be utilized for secondary
anastomoses [Figure 7] . A recent study by Teotia et al. examining anastomotic configurations in stacked
[41]
flaps revealed a higher rate of postoperative venous compromise in caudal IM anastomoses, though this was
attributed to vessel lie . The caudal IM vein, however, has been demonstrated as a reliable means of
[42]
outflow in multiple studies, and regression analysis of recipient vessels in a systematic review of stacked and
conjoined flaps demonstrated that choice of recipient vessel was not associated with an increased risk of
anastomotic complications [29,35,43-45] .The use of intra-flap anastomoses is also common. Multiple options exist
based on the needed vessel caliber, including the use of large branches in DIEP or PAP pedicles or the
cranial runoff in DIEP flaps. This technique has been described for multiple different flap types, including
sole SIEV venous outflow augmentation, conjoined abdominal flaps, stacked DIEP/GAP flaps, stacked PAP
reconstruction, and bilateral stacked DIEP/PAP flap reconstruction with high success rates [11,37,46,47] . With
intra-flap secondary anastomoses, it is important to remember that vascular issues in the primary pedicle
would result in potential compromise of both flaps.

If the IM vessels are not suitable for use, additional options include the ipsilateral subscapular (SC) system
comprising thoracodorsal or serratus vessels [28,35] . Utilization of the lateral thoracic vessels has also been
described . Finally, the contralateral IM vessels can also be used through a subcutaneous tunnel across the
[48]
sternum .
[49]
CONCLUSION
Modern autologous reconstruction has evolved toward the goal of improving aesthetic outcomes and