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Page 4 of 17 Garoosi et al. Plast Aesthet Res 2024;11:42 https://dx.doi.org/10.20517/2347-9264.2024.57

need for secondary large-volume autologous fat grafting, which often faces high resorption rates and can
[15]
require multiple procedures to achieve the desired volume .
Additionally, the stacked flap approach offers an advantage for cases with substantial breast tissue loss and
skin deficit, especially following radiation or trauma. For radiated breasts, the approach ensures a more
reliable outcome, reducing the risk of complications associated with compromised tissue quality . It
[10]
addresses the need for both skin coverage and volume, providing a robust foundation that can better
accommodate the effects of radiation than alternatives like implants [Example 2]. Lastly, other autologous
donor sites, such as the deep circumflex iliac artery (DCIA) flap, can also be considered in conjunction with
the DIEP for these complex reconstructions [1,10] .

The timing of breast reconstruction is another crucial consideration in the surgical planning process.
Stacked DIEP flap breast reconstruction can be performed either immediately following mastectomy or in a
delayed fashion. Immediate reconstruction is often preferred as it allows for better aesthetic outcomes and
can be psychologically beneficial for the patient . However, delayed reconstruction might be necessary in
[2,3]
cases where adjuvant radiation is planned to reduce the risk of complications . The decision on timing
[1,5]
should be individualized based on the patient’s overall treatment plan and medical condition.

Patient selection
The stacked DIEP flap breast reconstruction is a complex, yet highly rewarding procedure for both the
patient and the surgeon. Like all autologous breast reconstructions, careful patient selection is critical in
achieving successful outcomes with stacked flap breast reconstruction. Ideal candidates for this procedure
are those in good general health with adequate donor sites for flap harvesting. Patients should be non-
smokers or willing to cease smoking, as smoking can significantly impair wound healing and flap
viability [1,5,6,16] .

Patients with significant comorbidities (such as diabetes, vascular disease, or obesity), a history of radiation
therapy, and those with previous abdominal surgeries may have an increased risk of complications [1,5,14] . For
instance, patients with a lower midline vertical scar are not typically candidates for conjoined flaps and will
require two separate hemiabdominal stacked flaps [17,18] . A thorough preoperative assessment including
medical history and physical examination, and a thorough preoperative planning including imaging studies,
such as CT angiography, are essential to evaluate the vascular anatomy and plan the surgery [1,5,19] .

In addition, patient expectations and aesthetic goals should be discussed in detail. Autologous
reconstruction using stacked flaps can provide a natural feel and appearance but requires a longer operative
time, more advanced microvascular expertise and recovery period for the patient compared to other
reconstruction methods [2,20,21] . Patients should be counseled about the extent of the surgery, potential risks,
and the recovery process to make an informed decision.

The choice of stacked flap technique will depend on individual patient factors and the surgeon’s expertise.
Techniques such as the conjoined/bipedicled DIEP flap, two separate hemiabdominal perforator free flaps,
and various combinations of these methods have been described in the literature, each with specific
indications and technical considerations.

PREOPERATIVE PLANNING FOR STACKED FLAP BREAST RECONSTRUCTION
Preoperative planning is a critical component in the success of stacked flap breast reconstruction. This
process involves a series of steps tailored to the patient’s specific needs, ensuring the best possible outcomes.