Maximizing volume in autologous breast reconstruction: stacked/conjoined free flaps

Since the first report of abdominally based tissue breast reconstruction with a free flap of rectus abdominis muscle to reconstruct mastectomy defects, autologous breast reconstruction has continually increased in popularity due to improved cosmesis, patient satisfaction, and quality of life. While abdominal tissue is frequently used as the principal donor site, other flap options are available, including from the buttocks, thighs, and back. Microsurgical advancements in recent years have continued to improve patient outcomes and decrease operative times. One innovative technique is the use of stacked or conjoined free flaps which can be used when more breast volume is needed than can be provided by one free flap alone. These stacked or conjoined free flaps can be used unilaterally or bilaterally and can include combinations of nearly every free flap depending on the volume of tissue desired for the reconstruction. Though these flaps are increasing in popularity, there is limited comparative data on the safety and efficacy of stacked or conjoined free flaps as compared to single free flaps. In this review, we aim to highlight the use of stacked/conjoined free flaps for autologous breast reconstruction, as well as highlight recent data on this technique and provide recommendations for its safe use.