The stacked transverse rectus abdominis musculocutaneous flap revisited in breast reconstruction

Since its original description, the transverse rectus abdominis musculocutaneous (TRAM) flap has been used primarily as a single pedicle, bipedicle, or free flap procedure for breast reconstruction. A fourth option, rarely used in the past, involves using two single pedicle flaps to reconstruct only one breast by using the flaps in a "stacked" or overlapping configuration. Until now, this stacked technique has been used primarily for radical mastectomy defects. Stacked TRAM flaps are useful for four additional situations beyond the radical defect. In patients with meager abdominal donor tissues, stacked TRAM flaps may be the best way to provide the required central tissue volume in the small surface area of the reconstructed breast. In patients with a long thorax and good breast projection, overlapping or partially stacking the two flaps can best solve the problems of surface area and projection simultaneously. For patients with large projecting breasts without significant ptosis, the stacking option may best duplicate the original breast shape. Finally, for women who want their reconstruction larger than the original, the second flap can serve as an autologous augmentation. Ten patients with stacked TRAM flaps are presented, covering all of these indications. All patients achieved excellent functional and aesthetic outcomes. The stacked TRAM flap option is an effective, safe, and reliable method of achieving excellent results in difficult situations.