Autologous breast reconstruction is considered superior to alloplastic options. In cases of large-volume breast reconstruction, stacked flaps from a single area or multiple donor areas are required. In bilateral stacked four-flap reconstructions, when a large amount of skin is required, an asymmetric reconstruction involving the use of a conjoined deep inferior epigastric perforator (DIEP) flap with a uniform skin paddle to reconstruct the side where most skin is required and the use of two independently perfused stacked flaps to reconstruct the side that requires less skin can provide superior aesthetic results compared with the usual hemi-DIEP and profunda artery perforator (PAP) four-flap configuration. This study was a retrospective review of all asymmetric DIEP/PAP four-flap breast reconstructions between March of 2015 and October of 2020. Seven patients underwent asymmetric DIEP/PAP breast reconstructions. One of the PAP flaps was lost on postoperative day 1 because of thrombosis of the retrograde inferior mesenteric artery or inferior mesenteric vein. No other immediate, early, or late complications were encountered. Asymmetric four-flap breast reconstruction, using a unilateral bipedicled flap combined with two PAP flaps, can provide superior aesthetic results, avoiding common problems associated with the classic configuration of DIEP/PAP four-flap breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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