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Garoosi et al. Plast Aesthet Res 2024;11:42 https://dx.doi.org/10.20517/2347-9264.2024.57 Page 9 of 17

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surgeon with immediate autologous reconstruction .

2. Flap Harvesting
● Flap Selection: The choice of the flaps should take into account the patient’s anatomy, the patient’s
reconstruction needs (e.g., amount of skin deficit), the desired breast shape and size, surgeon preferences
and experience, as well as pedicle availability and overall flap perfusion. Based on the authors’ experience,
the preference is to use the conjoined flap whenever possible, since no additional incisions have to be made
and the perfusion across the midline is maintained between the two sides. However, the configuration of the
pedicles might not always allow the surgeon to proceed with this approach and separate stacked flaps should
be considered. In addition, separate stacked flaps need to be considered in cases where the patient’s
reconstructive needs and goals will not be met with the folding/coning of the conjoined flaps.
● Incision Planning: The upper abdominal transverse incision is completed first to ensure the main
perforators are included. Then, the lower abdominal transverse incision is completed after ensuring that the
patient’s abdominal donor site will be able to close at the lower incision mark. This is typically the opposite
sequence to that utilized in an abdominoplasty [1,30] .
● For a conjoined/bipedicled flap, the dissection is done from lateral to medial on both sides because there
is no infraumbilical vertical midline incision. For separate stacked flaps, an infraumbilical vertical midline
incision is made and the dissection is done from lateral to medial and from medial to lateral on both sides
[Figure 1] [12,32,33] .
● For an extended hemiflap, the dissection is first completed from lateral to medial on both sides in order to
identify the side with the best perforators to base the flap on, and then the contralateral perforators are
sacrificed to allow for a medial to lateral dissection in order to keep most of the lower abdominal tissue
intact. Additionally, the hemiflap can be based off the SIEA pedicle, as well as be extended laterally to
include the DCIA [11,18] .
● Once the perforators are identified, the rectus sheath is incised, and the dissection of the perforators and
the deep inferior epigastric vessels is completed in a standard fashion. It is important not to divide the
superior continuation of the deep inferior epigastric vessels at this point, as additional length might be
[33]
needed in case an intra-flap anastomosis is necessary (for bipedicled flaps) . Prior to harvesting of the flap,
SPY (ICG-A) angiography can be used to confirm adequate flap perfusion and design. Areas with reduced
perfusion can be excised to reduce the risk of wound healing complications and fat necrosis [24-26] .
● The SIEV should be preserved if present as it can become beneficial for additional venous outflow [1,7,30] .

3. Stacking Procedure
● Flap Design: Depending on the patient’s anatomy and volume requirements, either harvest two separate
DIEP flaps from each hemiabdomen or shape a single large flap to achieve the desired volume [Figure 1].
● Bipedicled Flap Approach: In a bipedicled approach, each pedicle should have an independent blood
supply and reach the recipient site without tension. Sometimes, an intra-flap anastomosis is completed with
one of the pedicles; thus, only one pedicle is left for the anastomosis to the recipient site [Figure 2]. The
flaps can be folded in a symmetric or asymmetric manner to meet the tissue needs at the recipient site.
Folding will also be dependent on the locations of the perforators [7,32,34] .
● Stacked (Separate) Flap Approach: Each flap should have its own independent blood supply, capable of
adequately perfusing the flap and reaching the recipient site vessels without tension. The flaps can be
divided in a symmetric or asymmetric manner to meet the tissue needs at the recipient site. Dividing the
flaps will also be dependent on the locations of the perforators [7,12,34] .

4. Recipient Site Preparation
● Prepare the recipient vessels, often the internal mammary artery and vein(s), in the chest wall. Rib