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Page 10 of 17 Garoosi et al. Plast Aesthet Res 2024;11:42 https://dx.doi.org/10.20517/2347-9264.2024.57

Example 4. Separated stacked DIEP flaps for a patient with a large unilateral volume requirement. Independent pedicle anastomoses to
the internal mammary vessels in an antegrade and retrograde fashion. DIE: Deep inferior epigastric; IMA: internal mammary artery;
IMV: internal mammary vein; DIEP: deep inferior epigastric perforator.

cartilage resection is typically necessary to allow optimal length and access to these vessels because
antegrade and retrograde anastomoses might be necessary [1,10,16,30,33,35,36] .

5. Microvascular Anastomoses
● For separate stacked flaps, each flap’s vessels are typically anastomosed separately to the internal
mammary vessels in an antegrade and retrograde fashion [Example 4] [12,27,29,32,33,35-37] .

● For bipedicled flaps, there are two main options:
●● The first option is to anastomose each flap’s vessels separately to the internal mammary vessels in an
antegrade and retrograde fashion [Example 5] [7,27,33,38] .
●● The second option is to complete an intraflap anastomosis with typically three variations depicted in
Figure 2 [27,38] . The first variation involves one pedicle attached to the cephalad extension of the other pedicle
with end-to-end anastomoses. The second variation involves one pedicle attached to a branch of the other
[34]
pedicle with end-to-end anastomoses . The third variation involves one pedicle attached directly to the
other pedicle with end-to-side anastomoses . The main DIEA pedicle is next anastomosed to the internal
[34]
[34]
mammary vessels in an antegrade fashion .
6. Shaping and In-setting the Flap
● Carefully shape the flap to mimic the natural contour of a breast. This involves de-epithelializing certain
parts of the flap and precise fat trimming [Example 6]. The various insetting options are shown in
[34]
Figure 1 .
● Consider performing a symmetry procedure on the contralateral breast, either in the same operation or as
a separate procedure [Example 7] .
[34]