14 Stacked DIEP/PAP Flap Breast Reconstruction

James L. Mayo and Robert J. Allen, Sr.

Stacking free flaps when a single flap would fall short in providing adequate volume has proven to be a safe and effective option for breast reconstruction.1–7 Several flap combinations can offer the desired volume. However, as perforator-based free flap breast reconstruction evolves, so too does the quest for the most aesthetically pleasing reconstruction. To create the natural breast shape, the surgeon must construct a breast with both lower pole projection and width that gradually tapers into the superior pole, maintaining appropriate superior pole fullness. When stacking flaps from the same donor site, molding the natural breast shape can be challenging.

The combination of the deep inferior epigastric perforator (DIEP) and profunda artery perforator (PAP) flaps can be inset in such a way that the thicker PAP flap is inset in the inframammary fold, providing ideal projection and base width, while the DIEP flap reconstructs the superior pole, providing fullness and a likeness to the natural axillary tail at its apex ( Fig. 14.1 ). This combination is most commonly utilized in four-flap breast reconstruction when the abdominal tissue provides too little reconstructive volume but can also be considered when the hemiabdomen is contraindicated due to previous surgery.8

Technique

Preoperative magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is utilized to locate and follow the course of favorable perforators. Patients are seen and marked in the office setting the day prior to surgery ( Fig. 14.2 ). The next day, in the operating room, the patient is placed in the supine position with bilateral arms and legs prepped into the surgical field. The legs are placed in a frog-legged position. A two-team approach is used to simultaneously raise the DIEP and PAP flaps. The surgeon who completes flap harvest first will then harvest the internal mammary vessels.

Typically, the PAP flap is anastomosed to the antegrade internal mammary vessels and the DIEP flap to the retrograde internal mammary vessels. In our experience, the retrograde vessels are consistently favorable recipient vessels, which spare the thoracodorsal system. The PAP flap is then coned and inset inferiorly. The DIEP flap is inset superiorly, providing upper pole fullness that tapers into a pseudo-axillary tail. The pedicles rest without tension in a crisscrossed fashion within the breast pocket ( Fig. 14.3 ). The flaps are then de-epithelialized and secured as appropriate to the chest wall. Skin paddles are utilized for monitoring of flaps.

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