Stacked DIEP Flap and Other Stacked Flap Reconstruction Procedures

In stacked flap reconstruction, surgeons use multiple flaps to reconstruct a breast, rather than just a single flap. You might consider a stacked procedure if you don’t have enough fatty tissue for flap reconstruction with a single flap. Stacked flaps can be used to create more volume.

During stacked flap reconstruction, surgeons take two flaps of tissue and stack them together to reconstruct a breast. Surgeons can take two flaps from one site, such as the abdomen, to reconstruct a breast. Highly specialized plastic surgeons can combine flaps from different parts of the body. Although there are many possible flap combinations, some of the more common approaches include:

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  stacked DIEP flap

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  stacked PAP or GAP flap

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  stacked DIEP plus PAP or GAP flap

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  hybrid flap implant (HyFI)

Combining flaps from different donor sites is more complicated than taking two flaps from a single donor site because all the additional blood vessels need to be reattached to make sure each flap has enough blood supply.

DIEP, or deep inferior epigastric perforator, flap: uses only the blood vessels running through the abdominal muscle for blood supply and leaves the muscle itself in place.

PAP, or profunda artery perforator, flap: named for a blood vessel that runs through the thigh; comes from the back of the upper thigh.

GAP, or inferior gluteal artery perforator, flap: named for a blood vessel that runs through the lower buttocks.

A stacked DIEP flap procedure is a newer approach that may be right for you if you want to reconstruct one breast but aren’t eligible for a standard DIEP flap because you don’t have a lot of extra belly tissue. 

Stacked DIEP flap surgery may not be right for you if:

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  you’ve had a colostomy (surgery that attaches the large intestine to an opening in the abdominal wall) or a tummy tuck (abdominoplasty)

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  your abdominal blood vessels are small or not in the best location to do a stacked DIEP flap procedure.

You might still be eligible for stacked DIEP flap reconstruction if you’ve had a C-section, a hysterectomy, gallbladder surgery, an appendectomy, or tubal ligation. But surgeons may recommend another type of flap procedure for people who want to have both breasts reconstructed. There isn’t enough tissue in the donor site to get the flaps you’d need for a stacked flap procedure for both breasts. 

During a stacked DIEP flap procedure, surgeons make an incision along the bikini line and take a single flap of tissue from the lower abdomen in one continuous piece or one flap from each side to reconstruct the breast. No muscle needs to be moved or cut, so no mesh material is required to support the abdominal wall. Surgeons then bring the navel back out through a separate incision and reshape it.

Surgeons can either fold the single flap in half or stack the two flaps to reconstruct the breast, and then attach the tiny blood vessels in the flap to the blood vessels in the chest using microsurgery.

After stacked DIEP flap reconstruction, your belly is flatter and tighter — as if you’d had a tummy tuck — because of the skin, fat, and blood vessels the surgeon moves from the belly to the chest.

The resulting scar is long and horizontal, running from one hipbone to the other and about one-third of the way between the top of your pubic hair and your navel. In most cases, the scar is below your bikini line.

Stacked DIEP flap reconstruction surgery takes from four to six hours.

For a stacked DIEP flap procedure, you usually stay in the hospital for about three to four days. Recovery can take about six weeks.

Your surgeon may recommend you wear a compression girdle for up to eight weeks after surgery.

Follow your surgical team’s instructions on when to start stretching exercises and regular daily activities.

A stacked PAP or GAP flap procedure is a newer approach that may make sense for you if you want to reconstruct one breast but aren’t eligible for a standard PAP or GAP flap.

During a stacked PAP or GAP flap procedure, surgeons take a flap of skin from the back of the thigh (PAP) or the top of the buttocks (GAP) and stack the flaps one on top of the other to reconstruct the breast.

The stacked PAP or GAP flap procedure may make sense for you if:

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  you don’t have enough belly tissue

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  you’ve already had multiple abdominal surgeries

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  you’ve already had an abdominal flap procedure

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  you have enough tissue in your thighs (PAP) or buttocks (GAP) 

The stacked PAP or GAP flap procedure may not be right for you if:

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  you’ve previously had liposuction on your thighs or buttocks or don’t have enough tissue

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  you have larger breasts and don’t have enough tissue in the thighs or buttocks

During a stacked GAP flap procedure, surgeons make an incision along the top of the buttocks and take a flap of skin from each side. Surgeons then stack the flaps one on top of the other to reconstruct the breast, and then attach the tiny blood vessels in the flaps to the blood vessels in the chest using microsurgery.

After stacked GAP flap reconstruction, your buttocks may feel tighter, as if you’d had a butt lift. The resulting scar near the top of the buttocks can be easily covered by underwear.

Stacked GAP flap reconstruction surgery takes from five to six hours.

During a stacked PAP flap procedure, surgeons make an incision in the back of the upper thigh just below the buttocks and take a flap of tissue to reconstruct the breast, and then attach the tiny blood vessels in the flap to the blood vessels in the chest using microsurgery.

After stacked PAP flap reconstruction, your thigh can feel tighter — as if you’d had a thigh lift.

The resulting scar is just below the crease where the thigh and buttocks meet, so it’s relatively hidden — but there is also a risk of healing issues, so it’s important to keep the area clean, dry, and protected. 

Stacked PAP flap reconstruction surgery takes from three to five hours.

For a stacked GAP or PAP flap procedure, you usually stay in the hospital for three to four days. Recovery can take from six to eight weeks.

Your surgeon may recommend you wear a compression girdle for up to eight weeks after surgery.

Follow your surgical team’s instructions on when to start walking, doing stretching exercises, and resuming regular daily activities.

The stacked DIEP and PAP or GAP flap procedure combines a DIEP flap with a PAP flap or GAP flap and requires two plastic surgeons with experience in microsurgery. 

After stacking the DIEP flap (from the belly) on top of the PAP flap (from the thighs) or GAP flap (from the buttock), surgeons attach the tiny blood vessels in each flap to the blood vessels in the chest using microsurgery.

Surgeons who use stacked DIEP and GAP or PAP flaps sometimes refer to the procedure as a body lift perforator flap because the scar goes all the way around the body similar to a body lift scar.

Although not widely available, the stacked DIEP and PAP or GAP flap procedure may make sense for you if:

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  you have medium to large breasts and don’t have enough tissue in just the belly or just the thighs or buttocks to ensure the reconstructed breast matches the unaffected breast

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  you have medium to large breasts and want to reconstruct both breasts without breast implants

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  you want to replace breast implants with tissue flaps

This stacked flap procedure is more extensive than other flap procedures, so it may take you longer to recover.

Follow your surgical team’s instructions on when to start walking, doing stretching exercises, and resuming regular daily activities.

Stacked DIEP and PAP or GAP flap reconstruction surgery takes about seven hours.

Hybrid flap implant (HyFI) combines a DIEP flap with an implant. If you don’t have enough tissue in your belly, and stacked flaps don’t make sense for you, HyFI may be an option. 

In the HyFI procedure, the surgeon places a small implant beneath the DIEP flap to achieve the size you would like. It’s important to know that the implant may need to be replaced at some point in the future. 

The HyFI procedure avoids the additional scars and longer recovery time associated with stacked flaps. Recovery time depends on the type of flap your surgeon combined with an implant, but you can expect to be in the hospital for two to three days.

Your surgical team provides guidelines on when you can start walking, doing stretching exercises, and resuming regular daily activities.

Hybrid flap implant surgery can take about three hours.

Not all breast reconstruction surgeons offer stacked flap procedures, so they’re not widely available. It may help to ask your cancer care team to refer you to plastic surgeons who specialize in stacked flap reconstructions.

As with any surgical procedure, stacked flap reconstruction surgery has some risk of necrosis and fat necrosis. There is also a small risk of hernia or muscle weakness at the donor site with stacked DIEP flap reconstruction.

It can take as long as a year or more for your tissue to completely heal and for your scars to fade.