Plastic Surgery Research Council

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Comparative Analysis of Single versus Stacked Free Flap Breast Reconstruction: A Single Center Experience
Min-Jeong Cho, M.D., Austin Hembd, M.D., Christopher Venutolo, B.S., Sumeet S. Teotia, M.D., Nicholas T. Haddock, M.D..
University of Texas Southwestern Medical Center, Dallas, TX, USA.

Background
As breast reconstructive microsurgeons increase their armamentarium of flaps with experience, need for stacked and multiple flaps may generate an improved aesthetic outcome. We present our institutional experience of using single vs. multiple free flap breast reconstruction.
Methods
769 flaps were performed on 427 patients from 2010-2016 by two senior surgeons at a university hospital. 197 of those flaps were either: Stacked PAP flaps, 4-flap (Bilateral PAP+Bilateral DIEP flap), or Double-pedicle DIEP/SIEA flaps. 595 flaps were either: unilateral or bilateral DIEP or PAP flap. Demographic, patient co-morbidities, and flap complications were compared between the 2 groups.
Results
Out of 427 patients, 322 patients (595 breast reconstructions) underwent single DIEP or PAP flap while 105 patients (197 flaps in 113 breasts) underwent multiple free flaps. The multiple flap patient group had statistically lower BMI, longer procedure time, had smaller flaps, and higher DVT compared to single flap group. There were no statistical differences in the rates of flap loss (1.3% in multiple flaps versus 1.7% in single flap), wound complication, hematoma, and PE.
Conclusion
Based on our large experience, stacked/multiple flaps are safe and preferred in properly selected patients with low volume from a unilateral donor site, exhibiting similar complications and success rates compared to single-flap patients. The ability to use multiple donor sites may represent a unique phase of innovation in breast microvascular surgery, with high patient tolerance and aesthetically pleasing results geared towards reconstructing breasts in all subunits. We present our indications and approach for successful multiple flap reconstruction.


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