BACKGROUND: As breast reconstructive microsurgeons increase their available flap techniques with experience, the need for stacked and multiple flaps may generate an improved aesthetic outcome. The authors present their institutional experience of using single versus stacked free flap breast reconstruction. METHODS: ONE THOUSAND SEVENTY: flaps were performed on 509 patients from 2010 to 2018 by two senior surgeons at a single university hospital. Three hundred eighty-eight flaps were either stacked profunda artery perforator (PAP) flaps, four-flap flaps [bilateral PAP plus bilateral deep inferior epigastric perforator (DIEP) flap], or double-pedicle DIEP/superficial inferior epigastric perforator flaps. Six hundred eighty-two flaps were either unilateral or bilateral DIEP or PAP flap (one flap per breast). Demographics, patient comorbidities, and flap complications were compared between the two groups. RESULTS: Of the 509 patients, 359 underwent single DIEP or PAP flap (one flap per breast) and 150 patients underwent stacked free flaps. The stacked flap group had statistically lower body mass index, higher rates of radiation therapy, longer procedure time, smaller flaps, higher deep venous thrombosis rates, and higher take-back rates compared with the single flap group. There were no statistical differences in the rates of flap loss (2.2 percent in stacked flaps versus 1.1 percent in single flaps), wound complication, hematoma, or pulmonary embolism. CONCLUSIONS: Autologous breast reconstruction is the gold standard for natural and durable breast reconstruction, often giving superior aesthetic outcomes and higher patient satisfaction. However, the true success of autologous breast reconstruction is limited to the amount of tissue available to provide total breast reconstruction. This study shows that stacked flap breast reconstruction is safe and has similar complication rates as single-flap breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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