Extended or stacked flap breast reconstruction uses multiple perforator flaps stacked on top of another to create a larger breast. For a bilateral breast reconstruction, four flaps can be used, such as bilateral DIEP and PAP flaps or bilateral DIEP and DCIA flaps (extended DIEP) or various other combinations of multiple flaps. Usually, multiple flaps are used to reconstruct the breast when a patient is very thin and she wants larger breasts using natural tissue that cannot be achieved using one flap for one breast.
The extended DIEP flap is a four-flap breast reconstruction that extends the tissue that is removed from a DIEP flap so another set of blood vessels are harvested to allow more tissue to be removed than in a traditional DIEP flap for bilateral breast reconstruction. For example, the extended DIEP flap may harvest the bilateral deep inferior epigastric perforator (DIEP) and the deep circumflex iliac artery (DCIA) vessels so that tissue across the abdomen and around to the flanks may be successfully used to create more volume for the breasts. There will be four microsurgical anastomoses performed, so it is longer and more complex operation, and the lower abdominal scar will also be longer. There are usually only two drains at the abdominal donor site, however. The benefit is that more tissue is harvested to create larger breasts than would be possible from a traditional bilateral DIEP flap that only uses two perforators.
The stacked flap is a breast reconstruction that literally stacks two flaps on top of each other. It can be a unilateral stacked DIEP flap, also known as a bipedicled double abdominal perforator flap, in which both halves of the abdominal donor site are used to reconstruct a single breast. In a bipedicled stacked DIEP flap, the entire abdomen is usually kept together as one unit to minimize scarring. Two microsurgical anastomoses are performed to keep all of the tissue alive and healthy. The resulting breast will have twice as much volume as a traditional DIEP flap that only uses tissue from one side of the abdomen with one microsurgical anastomosis to reconstruct one breast.
A stacked PAP flap can also be performed, in which two PAP flaps are stacked on top of each other to double the volume of a single breast reconstruction. Since each PAP flap will be harvested from one leg, there will be a seam where the two skin paddles from each leg are brought together to create the new breast. Like a stacked DIEP flap, two microsurgical anastomoses are performed to keep al of the tissue alive and healthy. The resulting breast will have twice as much volume as a traditional PAP flap that only uses tissue from one leg with one microsurgical anastomosis to reconstruct one breast.
Stacked flaps can be performed in either one stage or multiple stages. When the operation is performed in one stage, it is a longer operation with more anesthesia time due to the increased complexity of the operation. In addition, if the patient ends up with breasts that are too large for her because she has too much volume, she may want to be reduced at a second stage. Thus, sometimes it makes more sense to stage the reconstruction to evaluate whether or not a second stacked flap is necessary. On the other hand, if a patient is extremely thin and wants a much larger breast, it can also be beneficial to stack the flaps in one procedure.
four-FLAP stacked DIEP/PAP FLAP breast reconstruction
A four-flap stacked breast reconstruction uses four flaps from different donor sites to create larger breasts in a bilateral breast reconstruction. For example, a stacked DIEP/PAP flap breast reconstruction would stack a DIEP flap or PAP flap on top of a DIEP flap or PAP flap. Thus, the resulting breasts would be larger than the breasts that would result from just a bilateral DIEP or PAP flap. Since there are multiple surgical sites - the chest, the abdomen, the legs - there will be multiple drains involved as well.
Like other stacked flaps, the four-flap stacked DIEP/PAP flap breast reconstruction can be performed in one stage or multiple stages. When a four-flap stacked DIEP/PAP flap breast reconstruction is performed in one stage, it is a very long and complex operation that involves multiple surgical sites. There are six surgical drains - one in each breast, two in the abdomen, and one in each leg. The patient should be certain that she needs the additional volume, because if she ends up with too much volume then she may want to be reduced at a second stage. Given this, it may make more sense to stage the reconstruction to evaluate whether or not the second set of stacked flaps is actually necessary. On the other hand, if a patient is extremely thin and wants a much larger breast, it can also be beneficial to stack the flaps in one procedure.
What is special about the STACKED/EXTENDED flaps?
Stacked and extended flaps allow even very thin patients to combine donor site tissue from multiple sites to create larger breasts. We believe it is very important to have a tight, cohesive team that works together safely and efficiently. In our practice, breast restoration with stacked and extended flaps are performed by at least two experienced board-certified microsurgeons with specialized expertise. We often obtain preoperative imaging of the blood vessels to map out the surgical plan before the operation. In our hands, the average stacked/extended flap breast reconstruction takes about 4-6 hours for a unilateral reconstruction and 8-12 hours for a bilateral reconstruction.
Postoperatively, the flaps are monitored overnight while the patient is in the hospital. Patients are allowed to get out of bed, walk, and eat anything they want postoperatively. Most patients stay in the hospital one night. Drains are placed in the reconstructed breast(s) and the donor site. At home, daily drain output needs to be measured, and most drains are removed in 1-2 weeks. Patients should take at least 2 weeks off of work, and avoid heavy lifting and strenuous activities for 4-6 weeks. Most patients are fully recovered without any physical limitations in 6-8 weeks.