What are stacked free flaps? Stacked free flaps use two independent microvascular flaps to reconstruct one breast. So, for example, a left and a right DIEP flap may be used to reconstruct the right breast. The free flaps can be mixed and matched depending on specific nuances of patient anatomy, what flap tissue the patient has available, and what volume of tissue is required to reconstruct the breast. Other examples could include a PAP (profunda artery perforator) flap with a DIEP flap, a right SIEA flap with a left free TRAM flap, or several other combinations.
Stacked flaps are generally used when the patient’s breast is larger than the volume that can be provided by a single flap. Alternative to using stacked flaps include combining an implant with a flap reconstruction, using fat grafting along with a flap, or performing a more substantial reduction procedure on an opposite breast to improve symmetry between the healthy and reconstructed breast.
Stacked flaps are among the most highly technical operations performed for breast reconstruction. It involves microsurgery, a high degree of preoperative planning and imaging, and longer operative times. Not all patients will be candidates for stacked flaps. Surgeons, operating room teams and hospitals that have extensive experience with microsurgery perform stacked flaps.
Not all patients are candidates for a stacked flap, but, as stated above, other options may still be available. An implant can be placed at the time of, or in a delayed fashion in conjunction with a flap such as a DIEP or free TRAM flap to add volume. In other cases, breast reduction can be performed on the other side to improve the balance between breasts.
Reconstructive timeline for stacked flaps:
- First operation: Breast reconstruction with stacked flaps ± mastectomy
- Office visits: Drain removals and wound checks
- 3 months*: “Touch up” cosmetic appearance of stacked flaps if required; possible balancing procedure on other side. Possible fat grafts to optimize breast contours.
- 6 months*: Nipple reconstruction. Possible fat grafts to optimize breast contours.
- 8 months*: Areola (pigmented circle that surrounds the nipple) reconstruction with tattoo
- 12 -24 months*: Laser or IPL scar therapy
* If you are having an immediate stacked flaps (mastectomy and stacked flaps at the same time) and chemotherapy is required, please add 4 months to the timeline. If radiation therapy is also required, please add 9 months to the timeline.
Anesthesia: Stacked flaps are performed with the patient under general anesthesia.
Length of procedure: 6 to 8 hours for one breast.
Estimated recovery time: Hospitalization is usually 3 to 5 days. You can return to work after 3 to 6 weeks, depending on your job, and you should avoid vigorous activities for 6 weeks. Visible bruising and swelling should begin to improve within 3 weeks. Recovery time, however, is highly variable and depends on your health before surgery and history of smoking and radiation therapy. Unless you have an allergy, you will be required to take aspirin for one year after surgery. To learn how to prepare for a stacked flap breast reconstruction and what to expect afterwards, click here to download our patient instructions for SIEA, DIEP flap and free microvascular TRAM flap breast reconstruction.
Side effects: Common side effects include bruising and swelling. Blood flow to your flap will be carefully monitored after surgery. If there are concerns about the flap, you may require reoperation to assess the blood flow. Delayed wound healing and infections may occur. Click here to download a detailed consent form from the American Society of Plastic Surgeons that lists the risks and benefits of a DIEP flap breast reconstruction, which are similar to those for a stacked flap.
Before-and-after photos of breast reconstructions with SIEA, DIEP and TRAM flaps: Click here