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Page 14 of 17 Garoosi et al. Plast Aesthet Res 2024;11:42 https://dx.doi.org/10.20517/2347-9264.2024.57

From a functional standpoint, DIEP flap reconstruction is favored over alternatives like the pedicled
transverse rectus abdominis muscle (TRAM) flap, with studies noting lower morbidity rates and shorter
hospital stays [48,49] . Notably, patients experience fewer complications such as fat necrosis and abdominal wall
hernias, underscoring the strength of DIEP flaps in preserving abdominal integrity and reducing donor-site
morbidity [4,48] . DIEP Flap bulge and hernia rates have been reported from 3.6% to 6.6%, whereas hernia rates
in TRAM flaps have been reported as high as 18% [50-52] . Furthermore, the bipedicled DIEP flap offers a viable
option for large-volume autologous breast reconstruction with ample tissue, shorter recovery, and limited
[27]
donor site morbidity, emphasizing its utility in specific reconstructive scenarios .
Long-term outcomes and patient satisfaction in stacked flap breast reconstructions, particularly with the use
of double DIEP flaps, have demonstrated a high degree of satisfaction among patients [10,53] . Surveys,
including BREAST-Q assessments, illustrate that patients exhibit similar satisfaction levels across DIEP,
profunda artery perforator (PAP), and lumbar artery perforator (LAP) flap reconstructions, highlighting the
effectiveness of these approaches in meeting patient expectations for aesthetic outcomes and minimal
donor-site morbidity [20,47,49] . Moreover, the durability of the results and the low incidence of long-term
complications like fat necrosis or flap failure likely contribute to this satisfaction [8,20,27,46] .

Complications
Stacked and conjoined flap breast reconstructions, while more complex than traditional single-flap
procedures, have not been associated with an increased overall risk of complications [7-10,13,29,36] . This suggests
that despite their complexity, these advanced surgical techniques are capable of achieving desired outcomes
without necessarily adding to the patient’s risk profile. Studies comparing these methods to non-stacked
flaps procedures report reduced rates of fat necrosis and comparable rates of other complications, such as
infections and donor site morbidity, pointing to proficient risk management [8,10,12,21,46] . Furthermore, the
outcomes reflect the capability of these methods to meet clinical goals without significantly adding to the
complication burden [7,8,10,13,29,36] .

Delving deeper into specific complications, the rate of fat necrosis in stacked or conjoined flaps is markedly
lower than in non-stacked flaps (8.3% stacked flap vs. 25.4% non-stacked flap), with a significant reduction
in risk substantiated by further analysis [odds ratio (OR) 0.278, P = 0.045] . Moreover, these findings are
[21]
further solidified in a meta-analysis by Salibian et al., showing a general decrease in flap-related
complications, particularly emphasizing the lowered incidence of fat necrosis in stacked flap procedures
compared to their non-stacked/conjoined counterparts [8,21] . These findings underline the technical efficacy
of stacked flaps in preserving tissue viability and reducing complications.

In terms of operative intricacies, stacked/conjoined flaps present technical challenges and necessitate longer
surgeries, especially in bipedicled procedures [7,8,12,21] . However, these extended operative times have not
translated into an increase in either donor-site morbidity or systemic complications, demonstrating the
resilience of the surgical outcomes to the demands of procedure duration [7,8,12,21] . Furthermore, long-term
follow-up on bipedicled DIEP flap reconstructions suggests that the increase in donor-site morbidity is
insignificant, even when compared to unilateral and bilateral unipedicled methods, ensuring their safety and
acceptability, particularly for patients with specific anatomical needs like midline infraumbilical incisional
scars [12,17,54] . The risk profile does shift slightly, however, with a marginal increase in deep vein thrombosis
rates contrasting with lower infection rates, highlighting the complexity of risk assessment in stacked flap
reconstructions .
[46]