The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction

Sir: We read with interest the article entitled “The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction.”1 We would like to congratulate the authors on this publication and commend them for adding their experience with bipedicle abdominal perforator flaps to the published literature. We were intrigued, however, that Beugels et al. stated that their article describes a “new operation” and asserts that their publication reports “a novel approach designed to obtain increased flap volume using bipedicle hemiabdominal free flaps for each breast in patients undergoing bilateral breast reconstruction.” In 2015, our group published “Bipedicle-Conjoined Perforator Flaps in Breast Reconstruction” in the Journal of Surgical Research,2 describing exactly what Beugels et al. have termed a stacked hemiabdominal extended perforator flap—namely, bilateral breast reconstruction performed using deep inferior epigastric artery perforator (DIEP) flaps conjoined with ipsilateral abdominal perforator flaps harvested on vascular pedicles (deep circumflex iliac artery, superficial inferior epigastric artery, and superficial circumflex iliac artery) located lateral to that of each DIEP pedicle. Reconstruction of each breast, for bilateral reconstructions described in our 2015 report, was thus accomplished using a dual-pedicle composite formed by a combination of either DIEP plus deep circumflex iliac artery, DIEP plus superficial inferior epigastric artery, or DIEP plus superficial circumflex iliac artery conjoined perforator flaps. We referred to these multipedicle flaps as “bipedicle-conjoined abdominal perforator flaps,” a term we feel accurately reflects the specific surgical anatomy. We agree with Drs. Haddock and Teotia who, in their invited expert discussion,3 note that the term “stacked” is probably best applied to designate situations in which two totally separate flaps are literally stacked one atop the other, as described by DellaCroce et al.4 This is not just semantics, as different flap configurations actually have distinct advantages and disadvantages. For example, a DIEP “stacked” atop a deep circumflex iliac artery flap may create more projection for a reconstructed breast than can a conjoined DIEP plus deep circumflex iliac artery bipedicle flap, whereas a conjoined bipedicle perforator flap offers a much larger contiguous skin island that can properly restore the breast skin envelope and achieve satisfactory aesthetics in challenging irradiated delayed reconstruction.2 Indeed, the microsurgical community should come to consensus regarding the naming of multipedicle perforator flaps. Notwithstanding the authors’ assertion of reporting a “novel approach,” we support the authors’ conclusions concerning the potential benefits of using conjoined abdominally based perforator flaps for bilateral breast reconstruction for women in whom single-pedicle abdominal perforator flaps would not provide sufficient tissue. In addition to the rationale provided by the authors for favoring extended abdominal flaps over combinations of abdominal flaps with thigh flaps, we find that the use of bilateral bipedicle abdominal flaps results in excellent abdominal contour and avoids potentially adverse donor-site contour issues that can occur with thigh flap harvest.5 Thus, when two single-pedicle perforator flaps harvested from the trunk are inadequate for bilateral breast reconstruction, we preferentially favor the use of bilateral conjoined bipedicle abdominal perforator flaps over four-flap procedures that combine abdominal flaps with flaps harvested from the thigh.6 Finally, we agree with Beugels et al. that bilateral breast reconstruction with bilateral conjoined abdominal perforator flaps is an excellent option for women who have insufficient tissue to undergo adequate reconstruction using two single-pedicle abdominal perforator flaps. DISCLOSURE There was no funding source for this communication. The authors have no financial interest to declare in relation to the content of this communication. David T. Greenspun, M.D.Division of Plastic and Reconstructive SurgeryDepartment of SurgeryGreenwich HospitalGreenwich, Conn. Pieter G. L. Koolen, M.D.Department of Plastic, Reconstructive, and Hand SurgeryAmsterdam University Medical CenterAmsterdam, The Netherlands Bernard T. Lee, M.D.Samuel J. Lin, M.D.Division of Plastic and Reconstructive SurgeryDepartment of SurgeryBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, Mass Heather A. Erhard, M.D.Division of Plastic and Reconstructive SurgeryDepartment of SurgeryAlbert Einstein College of MedicineBronx, N.Y.