Background: Recently, the profunda artery perforator flap has become one of the popular flap choices for patients who desire autologous breast reconstruction but are not optimal candidates for deep inferior epigastric perforator (DIEP) flap surgery. These patients are not ideal patients for DIEP flap surgery because of having poor perforators, previous abdominal operations, low body mass index, or previously used/failed DIEP flap. In their institution, the authors have performed stacked profunda artery perforator flaps for these patients to provide full volumetric and aesthetic reconstruction. Methods: A retrospective review of 20 patients (40 flaps) who underwent stacked profunda artery perforator flap surgery from 2014 to 2018 was performed. Patient characteristics, demographics, and flap data were collected. Results: Forty flaps were used to reconstruct 20 breasts in 20 patients. The mean age of patients was 51.5 years (range, 38 to 74 years), the average body mass index was 27.3 kg/m 2 (range, 21.0 to 34.4 kg/m 2 ), and the mean flap weight was 398.5 g (range, 170 to 600 g). The majority of anastomoses were performed in internal mammary vessels (60 percent), followed by thoracodorsal (10 percent), serratus (10 percent), and side branch of profunda artery perforator vessels (20 percent). There were no flap losses, and two patients experienced donor-site wound dehiscence. Conclusions: Stacking profunda artery perforator flaps is an innovative yet technically challenging choice of flap for autologous breast reconstruction. It can provide an aesthetically pleasing result in the appropriately selected patient, and we recommend this technique in patients who are not optimal candidates for DIEP flap surgery because of previous flap failure or unavailable donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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