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Page 2 of 17 Garoosi et al. Plast Aesthet Res 2024;11:42 https://dx.doi.org/10.20517/2347-9264.2024.57

INTRODUCTION
The evolution of breast reconstruction techniques has significantly advanced over the years, offering women
undergoing mastectomy for breast cancer or other conditions a range of options for restoring breast shape,
symmetry and possibly sensation. Among these, autologous breast reconstruction, which uses the patient’s
own tissue to recreate the breast mound, has gained prominence for its ability to achieve natural-looking
[1]
results with possible resensitization . Studies have shown that autologous breast reconstruction, including
microsurgical abdominal-based free flaps, tends to result in high levels of patient satisfaction and quality of
[2-4]
life .

The history of autologous breast reconstruction is marked by continuous innovation and refinement. A
pivotal development in this field was the introduction of the deep inferior epigastric perforator (DIEP) free
flap, which involves the transfer of skin and fat from the lower abdomen to the chest without sacrificing the
underlying abdominal muscles [1,5,6] . This technique has been lauded for its effectiveness in mimicking the
natural breast while preserving abdominal strength .
[6]

Building on the success of DIEP free flaps, the stacked DIEP free flaps represent a further evolution in flap-
based breast reconstruction. This advanced technique involves utilizing two hemiabdominal DIEP free
flaps, either as conjoined/bipedicled flaps or two separate flaps, to create a more substantial breast mound,
and they are particularly beneficial for patients requiring larger volume unilateral reconstructions or those
with limited hemiabdominal donor tissue availability [7-10] .

Several variations of the stacked DIEP flap exist, such as the conjoined or bipedicled DIEP flap, where one
flap from the abdominal donor site is harvested with two separate blood supplies for unilateral breast
reconstruction. Another approach involves stacking two separate flaps harvested from the same or distinct
areas of the abdomen, each with its own blood supply. The extended hemiflap represents another variation,
wherein a single DIEP flap is extended beyond the hemiabdomen to utilize a larger portion of the
abdominal tissue supplied by one hemiabdominal perforator group. The use of conjoined/bipedicled flaps,
two separate flaps, or the extended hemiflap highlights the flexibility and adaptability of these modern
breast reconstruction techniques [Figure 1] [7,9-11] .

The stacked DIEP free flap approach has opened new doors in reconstructive surgery, offering solutions for
complex cases where traditional methods might not suffice. By providing a tailored, autologous tissue
reconstruction, the stacked DIEP flap technique underscores the modern ethos of patient-centered care in
breast reconstruction, striving to meet the diverse needs and aesthetic goals of individuals undergoing this
life-changing procedure.

CONSIDERATIONS FOR STACKED FLAP BREAST RECONSTRUCTION
Indications for surgery
The use of stacked flap techniques, particularly the stacked DIEP free flap, is indicated in autologous
unilateral breast reconstruction when a single hemiabdominal flap is insufficient to achieve the desired
breast volume or shape [10,12] . This scenario is common in patients who desire autologous reconstruction but
have low body mass index (BMI) and, thus, limited abdominal donor tissue volume [Example 1] [7,13] . The
stacked DIEP flap is also useful in patients with larger native breast sizes where maximizing volume and
symmetry is crucial, and in patients who prefer to avoid implants due to concerns about implant-related
complications or personal preference [6,7,10,14] . Additional breast volume or breast skin obtained during a
stacked DIEP flap facilitates future revision surgeries and allows for more predictable and straightforward
outcomes, such as in future breast mastopexy or reduction procedures [10,13] . Additionally, it can preclude the