Bilateral Outpatient Breast Reconstruction with Stacked DIEP and Vertical PAP Flaps

Background: Stacking free flaps for breast reconstruction is far from novel, even in the case of a deep inferior epigastric perforator (DIEP) plus profunda artery perforator (PAP) configuration, where the latter is always described in the traditional transverse configuration. We present a series of consecutive patients undergoing bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. Methods: Patients with inadequate abdominal donor tissue were offered the possibility of a stacking breast reconstruction. The DIEP flap was harvested via microfascial incisions, whereas the vertical PAP flap was harvested in the lithotomy position, following the course of the gracilis muscle. Results: In total, 28 consecutive patients with a mean BMI of 24.9 underwent bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. The internal mammary artery and vein were used as recipient vessels in all 56 stacked flaps. Fifty-three PAP flaps were anastomosed to the distal portion of the (primary) DIEP flaps utilizing a sequential flap anastomosis technique, and one DIEP flap was anastomosed to the distal portion of the (primary) PAP flap. Hospitalization for the initial eight patients averaged 35 hours, whereas the following 20 patients were discharged within 23 hours. There were no postoperative takebacks or vascular complications. Conclusions: Stacked DIEP/PAP flaps offer an excellent option for patients who require more volume than available from DIEP flaps alone. When compared with transverse PAP flaps, the vertical PAP offers excellent variability of volume and ease of shaping to allow for excellent results, while minimizing donor site tension in the seated position and preserving the gluteal fold.