Listeners of the DiepCJourney podcast are familiar with the DIEP flap breast reconstruction. This is a procedure where the abdominal skin, tissue, and underlying blood vessels are used to replace the breast tissue lost due to mastectomy after being affected by breast cancer. This is a summary of the podcast entitled, “Stacked Flap in Breast Reconstruction for Radiated Skin and to Achieve Volume.”
Introduction to Dr. Matatov
Dr. Tim Matatov is a returning guest and for good reasons. He is a highly skilled, board-certified surgeon who is specifically trained in microsurgery. It is the specialty of microsurgery that is required to perform a stacked flap procedure. Dr. Matatov and his team perform these and why I reached out to him for this interview. It is important to remind readers that at Southwest Breast and Aesthetics they practice the co-surgeon model in autologous breast reconstruction.
They have added new team members to the organization that have trained at various medical institutions. This brings a collective talent of microsurgical expertise to their practice. We have interviewed Dr. Arvind Gowda and Dr. Kelsey McClure who work with Dr. Matatov along with Dr. Joseph Zachary and Matthew Mino.
What is the Definition of a Stacked Flap in Breast Reconstruction?
Dr. Matatov shares the original definition of a stacked flap. It is when you put one flap on top of the other and place those two flaps into a surgical site, in this instance, the breast area to recreate a breast after mastectomy.
It has evolved to a flap from the abdomen, a bipedicle flap with two blood vessels that are connected to the entire abdomen and taken as one piece. He points out that at his practice it is used for skin resurfacing in the radiated patient where a lot of the damaged tissue would have to be removed. This type of flap provides enough skin to repair the area damaged and needing repair from radiation.
Another purpose for a stacked flap is in the setting of a single mastectomy. When a patient chooses to remove only one breast and keep the other and there is not enough tissue from a single flap from the back, thigh, or abdomen. In this instance, the stacked flap then provides the volume needed to achieve symmetry with the existing breast. Dr. Matatov also utilizes a four-flap breast reconstruction, using two flaps in each breast to increase size.
Stacked Flap in the Radiated Breast
Dr. Matatov points out in radiated tissue there is an atrophy that occurs. It is ionized radiation; therefore, every atom that has been radiated in that area has lost an electron. It becomes permanently changed tissue that cannot be undone. There are some improvements to bring new blood flow to the area but there is permanent change.
This happens at the breast skin level, the pectoralis major muscle, and sometimes the intercostal muscles where the ribs can be affected. In this radiated field, you need way more skin, way more volume than you would on the contralateral breast where they had a mastectomy or not just to achieve shape and wound closure.
Blood Vessels of a Stacked Flap
A stacked flap means two different blood vessels will be connected. This might mean they are connected in a series or connected to the chest vessels at the internal mammary vessels. This means there are two different anastomosis of the artery and the vein. It is a more complex procedure and requires a bit more skill to be predictable with the success rate.
There is a smaller field, a lot more traffic with blood vessels going in all kinds of directions, so it takes a little bit longer. Dr. Matatov and his team have completed this more complex procedure at about the same time as a bilateral DIEP flap. Designing the flap and shaping it in the radiated field to achieve the desired aesthetic outcomes takes a little bit longer.
Donor Sites for a Stacked Flap in Breast Reconstruction
The most common site would be the tummy or abdominal area. The second more common site would be from a PAP flap (profunda artery perforator flap) from the inner thigh. He relates his experience during training when Dr. Robert Alan would perform the LTP flap (lateral thigh flap) from the upper, outer thigh.
He points out that the PAP flap has a crescent shape whereas the DIEP flap is shaped more like a triangle. Being a plastic surgeon requires artistic prowess for sure. Dr. Matatov tells us in a stacked flap procedure they may use the PAP flap to shape the bottom portion of the breast. He then uses the DIEP flap portion to achieve the volume at the upper pole. You can listen to further details in our podcast interview on Blood Vessels in Breast Reconstruction.
The anastomosis can be done either at the breast site or “at the back table.” It depends on what is more ergonomic and in consideration of where they can shave more time off. He describes connecting the various “branches of the tree trunk,” the blood vessels at the back table while a colleague is preparing the donor site to receive the stacked flap. He refers to these as a “daisy chain” anastomosis or an “in series” anastomosis.
Recovery for Stacked Flap and Monitoring the Flap
Dr. Matatov tells us that the recovery for a stacked flap is not much different than for a bilateral DIEP flap. Although the surgery takes a bit longer he states that most patients don’t notice much difference compared to those recovering from a standard DIEP flap. He says that patients notice pain during recovery from the donor site where the pain signal is the most intense. This can vary from patient to patient, depending on how the brain processes pain.
I ask Dr. Matatov about monitoring a stacked flap and what is done to make sure the flap survives. Because of the ergonomics of the stacked flap, he will put two sensors on one breast to make sure to monitor the site. This is only done if the reconstruction was done with an antegrade and retrograde anastomosis. This is because they have independent blood flow. If they are doing “in series,” he only monitors the flap connected to the other flap.
He points out using the T-Stat system is beneficial because it remotely transmits data to his phone. He can look at the results at any time and know what is going on. Dr. Matatov shares a case study when a patient was bleeding, and the T-Stat monitoring system picked it up earlier than the blood pressure monitor. The oxygen suddenly dropped. The nurse was alerted, went in to check the patient, and the information was relayed to Dr. Matatov via the remote monitoring system on his phone from T-Stat.
What Should Patients Be Asking at Consult about the Stacked Flap for Breast Reconstruction?
Dr. Matatov answers this question. He says the most important question to ask your surgeon is “How often is this being done?.” At his practice they are doing on average around two a month, pointing out that is common, but not really that common. When a plastic surgeon does not do a lot of microsurgery or stacked flaps, the procedure can be challenging. Thinking through the process and doing it frequently, in other words, being able to think outside the box, is a requirement to perform a stacked flap.
Patients who have had radiation should ask and consult with their surgeon if they have enough tissue to create a new breast and achieve symmetry with the contralateral breast. As with any microsurgical breast reconstruction, the volume of procedures done is important to hone the skill. Dr. Matatov shares with us the importance of the co-surgeon model in the setting of stacked flaps. A team is important!
You will gain valuable information from the interview with Dr. Matatov and can listen to the entire interview here. I am grateful for his time and expertise.