Optimizing perfusion and volume in autologous breast reconstruction: dual-plane, conjoined and stacked flaps
Abstract
Microsurgical breast reconstruction has continued to evolve to improve outcomes and minimize complications. Dual-plane, conjoined and stacked flaps represent one aspect of this evolution in an effort to improve tissue perfusion and flap volume. Dual-plane flaps combine the superficial and deep circulation in abdominally-based free flaps to augment perfusion. Conjoined flaps use additional pedicles to supply multiple perforasomes combined in a single flap. Stacked flaps utilize separate flaps on individual pedicles to increase volume at a single recipient site. Multiple donor sites, pedicle configurations and recipient vessel choices have been described, primarily focusing on using the cranial and caudal internal mammary system as well as intra-flap anastomoses. Though more technically demanding, dual-plane, stacked and conjoined flaps allow for improvement in flap perfusion and volume, and are important tools for optimizing results in autologous breast reconstruction.
Keywords
INTRODUCTION
Since the description of the free transverse rectus abdominis myocutaneous (TRAM) flap in 1979, microvascular breast reconstruction has continuously evolved to refine outcomes and minimize morbidity[1]. Autologous breast reconstruction has demonstrated consistently high rates of patient satisfaction and superior aesthetic outcomes[2-4]. With the advent of perforator-based techniques, an armament of flap donor site options have expanded reconstructive options for patients, including the abdominally-based deep inferior epigastric artery perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps; thigh-based profunda artery perforator (PAP) and lateral thigh perforator (LTP) flaps; and lower back/buttock-based superior gluteal artery perforator (SGAP), inferior gluteal artery perforator (IGAP), and lumbar artery perforator (LAP) flaps.
In an effort to improve tissue perfusion and optimize flap volume, particularly in situations of a discrepancy between desired breast size and donor tissue availability, multi-pedicled and multiple flap techniques have been developed. Pennington et al. first described a conjoined transverse rectus abdominis myocutaneous (TRAM) flap with intra-flap anastomosis to augment zone IV perfusion in 1993[5]. Today, multiple variations of this technique are used to maximize donor tissue perfusion and volume. Dual-plane flaps most commonly refer to the abdominal donor site where both the deep and superficial systems are harvested. Conjoined flaps utilize multiple pedicles supplying different perforasomes within a single flap. Stacked flaps involve multiple separate flaps that are transferred to the same recipient site for additional volume. Nomenclature does vary significantly in the literature and “stacked” flaps have also been referred to as what some would consider traditional bipedicled flaps.
These techniques can be challenging due to the need for additional flap dissection, numerous anastomoses, multiple pedicles that can affect lie as well as more tedious flap inset and shaping. However, in cases of compromised donor sites, a discrepancy between volume of tissue and area of perfusion and a need for increased overall reconstruction size compared to the availability of donor tissue, these procedures can be invaluable tools to deliver an ideal breast reconstruction. The purpose of this paper is to present a narrative review and discussion of autologous breast reconstruction techniques for optimizing flap perfusion and breast volume.
Dual-Plane abdominal flaps
The variability in the perfusion of the abdomen between the deep and superficial systems is not a new concept. The concern for a superficial dominant flap, however, has primarily been focused on venous drainage and the importance of the superficial inferior epigastric vein (SIEV). Blondeel et al. first described the importance of augmenting venous outflow in congested flaps with a large SIEV in 2000[6]. Since then, the use of additional superficial venous outflow in DIEP flaps has become common practice for addressing intrinsic congestion. While SIEV caliber has been suggested to not correlate with a dominant superficial venous system, approaches have focused on algorithmically preserving the SIEV if flap congestion is noted despite an undamaged and patent deep venous system[7,8].
The modern “dual plane DIEP”(DP-DIEP) describes an abdominally based perforator flap where the superficial inferior epigastric artery (SIEA) and/or SIEV [Figure 1] is utilized in addition to the deep system to perfuse a flap[9,10]. A retrospective cohort study by Sbitany et al. compared 25 DP-DIEP flaps utilizing the SIEA/V with 35 traditional DIEP flaps, and demonstrated a lower rate of fat necrosis in flaps augmented with superficial perfusion[9]. Other authors have argued that hypoperfusion remains solely a venous outflow problem, as originally described, that is improved with SIEV augmentation, without an arterial component[11]. While the need for venous outflow augmentation is indeed most prevalent, the utility of augmenting superficial inflow is likely to be multifactorial and continues to be elucidated.
Figure 1. Harvest of the SIEA (yellow bulldog) and SIEV (green bulldog) to their origin in a DIEP flap provides adequate length to allow for multiple different recipient vessel options (intra-flap branch or runoff, caudal IM vessels, etc.). DIEP: deep inferior epigastric artery perforator; SIEA: superficial inferior epigastric artery.
Deciding to utilize the superficial system to augment both arterial and venous outflow is multifactorial and depends not only on the size of the SIEA, but the amount of tissue harvested in relation to the number, size, row and centricity of deep perforators utilized. Sbitany et al. described assessment of flap perfusion on the deep system in situ, and hypoperfusion of the suprascarpal fat or persistent skin hyperemia as an indicator to augment with the superficial system[9]. While the superficial system should be used in cases that demonstrate clinical hypoperfusion, it can also be utilized to minimize morbidity by limiting the number of deep perforators harvested. Larger flaps that might otherwise require multiple perforators or perforator rows can be harvested on a single dominant perforator while using the SIEA and SIEV for additional perfusion [Figure 2]. Such techniques can help to limit the fascial incisions and to optimize the perfusion of a large amount of tissue harvested on a single perforator based on individual anatomy.
Figure 2. Dual-plane DIEP flap based on single high medial perforator with the SIEA and SIEV anastomosed to the lateral branch of the deep system. DIEP: deep inferior epigastric artery perforator; SIEA: superficial inferior epigastric artery.
The use of both the deep and superficial system in DIEP flaps with a superficial dominant system or diminutive deep system has also been supported. Hembd et al. demonstrated a significantly lower rate of fat necrosis and flap failure with SIEA/SIEV DP-DIEP flaps compared with SIEA flaps[10]. From these findings, the authors advocate for the use of a dual-plane system over superficial-only perfusion if preoperative imaging demonstrates deep system perforators <1.0 mm in size or with intraoperative findings of venous congestion or ICG hypoperfusion[10].
CONJOINED FLAPS
The conjoined flap combines different flap territories that are in close proximity, thus enabling optimization of the balance of perfusion and the amount of tissue harvested[12,13]. Often referred to as bipedicled flaps, a single piece of tissue is harvested, including more than one perforasome based on separate pedicles. Conjoined flaps are most commonly harvested from the abdomen as bipedicled DIEP flaps but can also be from different donor sites. The use of an additional vascular pedicle allows the surgeon to increase the amount of skin and soft tissue harvested while minimizing the risk of fat necrosis in watershed areas.
Abdominal donor site
The conjoined DIEP flap utilizes the entire abdomen in a bipedicled design with both the right and left deep inferior epigastric systems to increase the amount of tissue harvested for a unilateral reconstruction while optimizing perfusion [Figure 3]. This technique was initially born out of a need to circumvent midline abdominal scars and subsequently evolved from the extended hemi-abdominal flap to improve perfusion across the midline and address a discrepancy between available donor-site tissue and desired breast volume[14]. The conjoined DIEP is particularly useful in delayed reconstructions or in cases with damaged chest wall skin secondary to radiation, as it provides ample skin for resurfacing.
Figure 3. Conjoined or bipedicle DIEP flap for unilateral breast reconstruction. DIEP: deep inferior epigastric artery perforator.
Multiple studies have demonstrated the safety of unilateral breast reconstruction with the conjoined or bipedicled DIEP flap[15-20]. Compared to extended hemi-abdominal flaps, bipedicled abdominal flaps have been shown to have a lower rate of fat necrosis across the midline[21]. Importantly, donor-site morbidity has also been comparable between single pedicle and bipedicled conjoined flap designs in retrospective studies[22].
Several anastomotic configurations can be implemented, most commonly including the cranial and caudal IM vessels or the use of intra-flap anastomoses for the secondary pedicle. Managing pedicle lie is critical to avoid kinking or twisting[23]. In the case of IM vessel recipients, criss-crossing pedicles to the cranial and caudal IM artery and vein can help avoid sharp angles in the proximal pedicle[21]. Inset and shaping of conjoined abdominal flaps can be challenging, but still focus on the three critical principles of the footprint, conus and skin envelope[24]. Most commonly, conjoined flaps are either folded in the vertical dimension with the caudal flap buried or coned horizontally around the midline. Variations in these patterns can be tailored to achieve the necessary breast height, width, ptosis, projection, and skin replacement[25].
Extended donor sites
The use of additional vessels based on adjacent known perforasomes has also expanded the volume limitations of traditional flaps. The stacked hemiabdominal extended perforator (SHAEP) flap combines the DIEP pedicle with more lateral pedicles to enable additional tissue harvest outside the zone of DIEP perfusion[26]. Multiple perforator combinations have been described, most commonly utilizing the DIEP and deep inferior circumflex artery (DCIA) pedicles[26]. Utilization of the lateral flank perfusion based on the superficial circumflex system can also help recruit more skin and volume when needed [Figure 4].
Figure 4. A: 35-year old female with a history of left total mastectomy and radiation planned for right prophylactic mastectomy. B: Left ShAEP flap using medial DIEP perforators and SCIA/SCIV planned to resurface and restore volume to radiated left chest (A small right DIEP flap for concomitant immediate right prophylactic mastectomy reconstruction was performed). C: 6-month postoperative photo prior to nipple reconstruction and tattooing.
The lower extremity has also been utilized for conjoined flaps. A 2023 study by Chu et al. described harvesting PAP and LTP flaps as a conjoined “L-PAP flap” to optimize coning and projection[12]. The flap utilizes the medial, posterior, and lateral thigh tissues to improve reconstruction volume influenced by body contouring thigh-lift procedures[12]. Additional bipedicled designs in the lower extremity include combinations of the gracilis and PAP flaps, though PAP perforators typically provide robust perfusion of the medial thigh in isolation[27].
STACKED FLAPS
Stacked flaps typically consist of two physically separate flaps with isolated pedicles which are then anastomosed independently[14,28-30]. The individual flaps are shaped and inset to obtain the desired breast conus, volume, and footprint. The use of multiple flaps can help provide additional projection, overall volume, and skin resurfacing, depending on the need.
Single donor site
When the abdomen is utilized as a single donor site, the vast majority of reports have utilized a conjoined or bipedicled design.29 However, splitting the abdomen and stacking hemiabdominal flaps is also a reported technique.14 In such cases, the flaps are often placed on top of each other with an unmonitored buried flap, though alternative means of monitoring, including flow coupler and Doppler blood flow monitors, are possible.
Some techniques preferentially call for splitting a conjoined flap into two independent stacked flaps[31]. DellaCroce et al. suggest that the folding of the bipedicled flap may actually compromise the shared blood supply and that separation of the flaps allows for independent inset and enhanced ability to shape the reconstruction[32]. While conjoined flap do offer less maneuverability and flexibility for inset, multiple techniques have been described to optimize shaping for both conjoined and stacked abdominally-based flaps[25].
Multiple donor sites
Independent stacked flaps are most commonly used from multiple donor sites. In autologous breast reconstruction, the lower extremity, particularly the medial thigh, is frequently utilized[33]. Flaps harvested from the medial thigh typically include the transverse upper gracilis (TUG), diagonal upper gracilis (DUG), and PAP flap[33]. The PAP flap was first described for breast reconstruction in 2012 and since then has become the second or third choice for autologous breast reconstruction after DIEP[34]. In cases where the abdominal donor site is unavailable or insufficient, the stacked PAP flap provides ample skin and soft tissue for unilateral reconstructions [Figure 5]. A retrospective series of 20 stacked PAP flaps by Haddock et al. reported an average combined flap weight of 685.5 g[28]. The long pedicle in the PAP flaps affords multiple options for recipient vessels. Flaps are typically anastomosed to the cranial and caudal IM vessels, though the thoracodorsal system or intra-flap anastomoses can also be utilized if necessary[28,35]. Stacked LTP flaps have similarly been described to provide adequate skin and volume in unilateral reconstructions[36].
Figure 5. Stacked PAP flaps in a patient with prior bilateral mastectomy as well as a history of circumferential body lift with severe left chest wall radiation. A: A large proximal branch of one flap (blue background) is utilized as recipients for the second flap. B: Left stacked PAP reconstruction and right tissue expander placement in first stage of delayed reconstruction.
The use of multiple flaps per breast lends itself to many opportunities for improving volume in autologous breast reconstruction. Several different configurations and donor sites for bilateral breast reconstruction have been described with stacking flaps at each recipient site, performing “four-flap reconstructions”. Dellacroce et al. described bilateral stacked DIEP and SGAP flaps with intra-flap anastomoses effectively resulting in a body lift four-flap reconstruction[37]. More recently, a similar configuration of stacked DIEP and LAP flaps has also been described for a circumferential four-flap body lift reconstruction[38].
Four-flap reconstructions have classically utilized bilateral stacked DIEP and PAP flaps. In these cases, the PAP flap typically restores the lower pole contour while the hemi-abdominal DIEP is rotated 90 degrees for the upper pole, mimicking the shape of a mastectomy specimen[39]. Recently, studies have advocated for asymmetric four-flap reconstructions in cases of bilateral reconstruction, utilizing a conjoined bipedicled DIEP on the side requiring additional skin resurfacing and stacked PAP flaps on the contralateral side[39,40].
RECIPIENT VESSELS
Recipient vessels are a critical consideration when planning stacked and conjoined flaps, given the need for additional anastomoses. The most commonly used vessels in a systematic review of 2,006 flaps were the cranial and caudal internal mammary (IM) vessels [Figure 6][29]. A 2011 study by Stalder et al. showed that the anterograde and retrograde IMAs are adequate to perfuse a flap with a reported 97.5% success rate[35]. Their study also showed that the retrograde IM mean arterial pressure (MAP) is 74%-78% that of the anterograde[28,35]. If sizeable IM perforators are identified, these can also be utilized for secondary anastomoses [Figure 7][41]. A recent study by Teotia et al. examining anastomotic configurations in stacked flaps revealed a higher rate of postoperative venous compromise in caudal IM anastomoses, though this was attributed to vessel lie[42]. The caudal IM vein, however, has been demonstrated as a reliable means of outflow in multiple studies, and regression analysis of recipient vessels in a systematic review of stacked and conjoined flaps demonstrated that choice of recipient vessel was not associated with an increased risk of anastomotic complications[29,35,43-45].The use of intra-flap anastomoses is also common. Multiple options exist based on the needed vessel caliber, including the use of large branches in DIEP or PAP pedicles or the cranial runoff in DIEP flaps. This technique has been described for multiple different flap types, including sole SIEV venous outflow augmentation, conjoined abdominal flaps, stacked DIEP/GAP flaps, stacked PAP reconstruction, and bilateral stacked DIEP/PAP flap reconstruction with high success rates[11,37,46,47]. With intra-flap secondary anastomoses, it is important to remember that vascular issues in the primary pedicle would result in potential compromise of both flaps.
Figure 6. Anastomosis of a conjoined, bipedicled DIEP to the cranial and caudal internal mammary vessels. A: Wide rib-to-rib exposure of internal mammary vessels; B: Completed anastomosis with hemiabdomen 1 anastomosed to anterograde IMA, VC’s anastomosed to anterograde medial IMV and retrograde medial IMV and hemiabdomen 2 anastomosed to retrograde IMA and anterograde lateral IMV. DIEP: deep inferior epigastric artery perforator.
Figure 7. Anastomosis of dual-plane DIEP flaps with DIEA/V and SIEA/V pedicles. The DIEA/V are anastomosed to the cranial IM vessels and the SIEA/V are anastomosed to an IM perforator artery and vein. DIEP: deep inferior epigastric artery perforator; IM-P: IM-perforator.
If the IM vessels are not suitable for use, additional options include the ipsilateral subscapular (SC) system comprising thoracodorsal or serratus vessels[28,35]. Utilization of the lateral thoracic vessels has also been described[48]. Finally, the contralateral IM vessels can also be used through a subcutaneous tunnel across the sternum[49].
CONCLUSION
Modern autologous reconstruction has evolved toward the goal of improving aesthetic outcomes and minimizing donor site morbidity with microsurgical techniques. Dual-plane, conjoined and stacked flaps represent the continued innovation in this field, as well as the understanding and manipulation of perforator anatomy to achieve these goals. While the combinations of different types of flaps, pedicle designs, and anastomotic configurations are endless, the principles of perforator flap autologous reconstruction are continuous throughout these procedures. These modern techniques serve as tools to further assist the microsurgeon in tailoring individual reconstructive plans to each patient’s unique needs and desires.
DECLARATIONS
Authors’ contributions
Made substantial contributions to the conception and design of the study and contributed significantly to the writing of the study: Salibian AA
Performed data acquisition, literature review, and contributed significantly to the writing of the study, as well as providing administrative, technical, and material support: Farajzadeh MM
Availability of data and materials
Not applicable.
Financial support and sponsorship
None.
Conflicts of interest
Salibian AA is a research consultant for Abbvie, Inc. There were no internal or external funding sources for this study. All other listed authors declared that there are no conflicts of interest.
Ethical approval and consent to participate
The UC Davis IRB Administration has reviewed the manuscript, and IRB review is not required. Consent has been obtained for the use of images contained in the publication.
Consent for publication
Consent for publication has been obtained.
Copyright
© The Author(s) 2024.
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Cite This Article
How to Cite
Farajzadeh, M. M.; Salibian A. A. Optimizing perfusion and volume in autologous breast reconstruction: dual-plane, conjoined and stacked flaps. Plast. Aesthet. Res. 2024, 11, 32. http://dx.doi.org/10.20517/2347-9264.2024.24
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