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Garoosi et al. Plast Aesthet Res 2024;11:42 https://dx.doi.org/10.20517/2347-9264.2024.57 Page 7 of 17

[27]
extension of the flap pedicle (one pedicle draining into the second pedicle) . Preoperative imaging aids in
identifying viable options for anastomoses, and intra-operative confirmation of vessel flow is mandatory
[Figure 2] [19,28] . The decision between using a single or double vascular pedicle depends on the flap’s volume
and the patient’s vascular anatomy. Intraoperatively, ICG-A can help confirm vessel patency and flap
perfusion [10,24-26] .

3. Risk Assessment and Management: Identify potential risks and complications, such as flap failure, donor
site morbidity, and aesthetic concerns. Develop strategies to minimize these risks [1,8,16,21,29] .

4. Patient Counseling and Informed Consent: Discuss the procedure’s details, benefits, risks, expected
outcomes, and recovery process. Obtain informed consent after ensuring the patient’s understanding of the
procedure.

5. Team Coordination and Resource Allocation: Ensure the availability of a skilled microsurgical team and
necessary resources, including operating room facilities and postoperative care arrangements .
[10]

6. Customization and Flexibility: Adapt the surgical plan to each patient’s unique needs, maintaining
flexibility to modify the approach intraoperatively as needed.

In-depth preoperative planning for stacked flap breast reconstruction is essential to address the complex
needs of patients seeking autologous breast reconstruction. By carefully evaluating each aspect of the
patient’s case and planning the surgical approach, surgeons can optimize the chances of successful
outcomes and patient satisfaction.

RELEVANT VASCULAR ANATOMY [19,28,30,31]
The vascular anatomy of the DIEP flap is integral in the successful execution of stacked flap breast
reconstruction. The DIEP flap primarily relies on the deep inferior epigastric artery (DIEA) and its
perforators, which typically emerge through the rectus abdominis muscle and supply the overlying skin and
subcutaneous tissue. This artery is a direct continuation of the external iliac artery, branching off just above
the inguinal ligament [28,30] .

At the donor site of conjoined/bipedicled DIEP flaps, perforator(s) from both the left and right DIEA are
utilized, supplying different perforasomes within one flap. In contrast, with the separated stacked flap, each
flap has its own individual pedicle and associated perforator(s). At the recipient site, the cranial and caudal
internal mammary arteries, a branch of the subclavian artery, and veins are most commonly used [28,30,31] .

An understanding of the vascular territory of the DIEA is essential for harvesting DIEP flaps. This includes
recognizing the variations in the number, location, and size of the perforators. The choice of perforators
significantly influences the design and viability of the flap. Sometimes, dissection of multiple perforators on
both sides of the abdomen may be needed. The vascular anatomy must be assessed preoperatively, often
using imaging techniques like CT angiography, to map the course and caliber of these perforators and plan
the flap harvest accordingly .
[19]
Moreover, a thorough understanding of the vascular anatomy reduces the risk of flap ischemia and ensures
optimal flap perfusion. It also allows for strategic planning in cases where variations in the vascular anatomy
are present, which is not uncommon. Intraoperative ICG-A can provide real-time perfusion assessment and