BREAST

Body Lift Perforator Flap Breast Reconstruction:A Review of 100 Flaps in 25 Cases

Frank J. DellaCroce, M.D.Scott K. Sullivan, M.D.

Chris Trahan, M.D.Carly E. Jenkins

New Orleans, La.

Background: Advances in autologous breast reconstruction continue to mountand have been fueled most substantially with refinement of perforator flaptechniques.Methods: For patients with a desire for autogenous breast reconstruction andinsufficient abdominal fat for conventional abdominal flaps, secondary options suchas gluteal perforator flaps or latissimus flaps are usually considered. Patients whoalso have insufficient soft tissue in the gluteal donor site and preference to avoidan implant, present a vexing problem. The authors describe an option that allowsfor incorporation of four independent perforator flaps for bilateral breast recon-struction when individual donor sites are too thin to provide necessary volume. Theauthors present their experience with this technique in 25 patients with 100 indi-vidual flaps over 5 years.Results: The body lift perforator flap technique, using a layered deep inferiorepigastric perforator/gluteal perforator flap combination for each breast, was per-formed in this patient set with high success rates and quality aesthetic outcomes overseveral years. Patient satisfaction was high among the studied population.Conclusions: The body lift perforator flap breast reconstruction technique can bea reliable, safe, but technically demanding solution for patients seeking autogenousbreast reconstruction with otherwise inadequate individual fatty donor sites. Thissophisticated procedure overcomes a limitation of autogenous breast reconstruc-tion for these patients that otherwise results in a breast with poor projection andoverall volume insufficiency. The harvest of truncal fat with a circumferential bodylift design gives the potential added benefit of improved body contour as a com-plement to this powerful breast reconstructive technique. (Plast. Reconstr. Surg.129: 551, 2012.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The benefits of autogenous tissue breast re-construction have been well described.1,2

Women who want their breasts restored withthe most natural and longest lasting material pos-sible seek soft-tissue reconstruction and have ben-efited from the continuing evolution that has al-lowed for progressively better outcomes. Thisprogress has been fueled most substantially in re-cent years by the refinement and increased un-derstanding of perforator flap concepts. The sur-gical power, provided by techniques that allowautogenous transplantation of any soft-tissue com-posite supplied by an underlying perforating ves-sel, gives the well-experienced microsurgeon a setof tools with which to accomplish breast recon-

struction with a finesse beyond that of more basicprocedures. The essence of these techniques is totransfer skin and fat to provide natural tissue re-construction with an attendant goal of minimizingdamage at the donor site; however, the flexibility

From the Center for Restorative Breast Surgery.Received for publication March 21, 2011; accepted Septem-ber 7, 2011.Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31824127fc

Disclosure: The authors have no financial inter-ests to report.

Supplemental digital content is available forthis article. A direct URL citation appears inthe printed text; simply type the URL addressinto any Web browser to access this content. Aclickable link to the material is provided in theHTML text of this article on the Journal’s Website (www.PRSJournal.com).

www.PRSJournal.com 551

of these techniques affords outcome potentials farbeyond that premise.

Female body shapes vary considerably, fromgynecoid to android3 and everywhere in between.Women with moderate to full breast size oftenwish to maintain their breast volume and, in somecases, increase it. Add to that the tendency foroverall weight and resultant fatty thickness in areasof the trunk to vary considerably, and it is notuncommon to encounter patients who are incred-ibly difficult reconstructive challenges as a resultof this single issue alone. The increased numberof women who now undergo bilateral mastectomy,both prophylactic and therapeutic, compound thefrequency with which these reconstructive dilem-mas may be expected to present themselves. Thequandary encountered when consulting with thepatient who presents with a request for naturaltissue reconstruction and an inadequate amountof donor fat with which to rebuild the breast is asituation with which every experienced plastic sur-geon has dealt. In some cases, reconstructing thebreast to a smaller size is an option. For others, theamount of donor tissue in the trunk is so inade-quate that the ultimate result with a standard ab-dominal, gluteal, or latissimus tissue transfer willbe disappointing and aesthetically poor. A thinflap provides minimal projection, and the basediameter of the breast needs to be considered, justas it does with cosmetic breast augmentation.Women who have had tissue expansion and failedimplant reconstruction often have the addedproblem of a flattened bony rib cage, resulting ina need for even more volume to restore the breastthan would otherwise be required.4

For those who wish to maintain their breastsize and/or in whom the amount of abdominal fatis insufficient to give projection and shape tomatch the opposite breast, a number of second-tier options are usually considered. Gluteal arteryperforator (GAP) flap reconstruction can oftenprovide ample tissue in even the most athletic ofpatients5; however, if the gluteal donor sites arealso thin, overreaching for fatty harvest in this areacan produce resultant deformities that are chal-lenging to correct. Tissue transfers from the thighsuch as the transverse gracilis myocutaneous (TUG)flap have limited volume potential and may createscarring of an unfavorable nature. The sacrifice ofthe gracilis muscle must also be considered and dis-cussed with the patient beforehand.

Augmenting the breast reconstructed with thedeep inferior epigastric perforator (DIEP), trans-verse rectus abdominis myocutaneous (TRAM), orGAP flap with an implant may also be considered

with an otherwise insufficient flap. In the case ofthe latissimus flap, this option almost universallyrequires an implant for adequate volume restora-tion. The muscle sacrifice and scar across the backare considerations that the patient and surgeonshould take into account with this option as well.These options are less desirable for the patient whowishes to avoid the use of implants and the attendantpotential risks that they incur.6–9 Practitionersshould also consider and disclose the deforming anddynamic contractile distortion that a submuscularimplant may produce in a reconstructed breast, assome patients will find this troubling.10,11 (See Video,Supplemental Digital Content 1, which demon-strates dynamic distortion as seen with implant re-construction and activation of the pectoralis mus-cles, http://links.lww.com/PRS/A455. Results fromsubmuscular implant placement with a thin skin en-velope tethered to underlying muscle surface areshown.) For patients who have insufficient soft tissuein the abdomen, gluteal, and latissimus donor sitesand prefer to avoid an implant, a vexing problem ispresented.

Fat injections are becoming more accepted forcontour improvement in breast reconstruction;however, reconstructing a breast with an inade-quate flap, with plans to make up the shortage byinjecting it, has not been shown to be a reliableor lasting way to make up a substantial volumedeficit. The tendency for fat injections to resorbin an unpredictable way, and the attendant suc-tioning of potential flap harvest sites, may leavepatients with few options if the injections fail,and they should be counseled accordingly.Those attempting complete reconstruction with

Video. Supplemental Digital Content 1 demonstrates dynamicdistortion as seen with implant reconstruction and activation ofthe pectoralis muscles, http://links.lww.com/PRS/A455. Resultsfrom submuscular implant placement with a thin skin envelopetethered to underlying muscle surface are shown.

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fat injection alone should also understand theimplications of suctioning potential flap donorsites away should the injections result in a less-than-hoped-for outcome.

Volume shortages in a unilateral breast recon-struction may be overcome with use of the wholeabdominal pannus in a layered configuration witha bipedicled TRAM flap or our more recently de-scribed stacked DIEP flap.12,13 Applying a multi-component concept to the bilateral mastectomypatient allows the reconstructive surgeon to usemultiple flaps in each breast reconstruction siteand thereby overcome the volume limitations ofconventional flap procedures. The body lift per-forator flap technique as described in this articleallows the fat of the abdominal donor site and thegluteal donor site to be used in each breast toreconstitute the volumetric requirement. ADIEP flap and a GAP flap are inset in a layeredfashion to bring added volume and projection tothe reconstructive field. This stacked DIEP/GAP free flap combination allows for a recon-struction that takes advantage of the soft-tissuevolume of the entire midriff without sacrifice ofthe underlying muscles.

Harvesting the truncal fat with a belt lipectomyallows for substantial volume acquisition withoutoverharvesting the abdominal skin or gluteal fatand affords the aesthetic benefit of a body liftdesign.14,15 Using a set of techniques that also pre-serves the rectus abdominis in the abdomen andthe gluteus maximus posteriorly minimizes theattendant morbidity and speeds recovery to themaximum extent possible.16,17

We now present this new procedure for bilat-eral autogenous breast reconstruction and an ex-perience with 25 consecutive patients over a 5-yearperiod. It is used in the patient with otherwiseinadequate truncal fatty tissue volume by incor-porating four independent perforator flaps whenthe abdomen and gluteal donor sites are individ-ually too thin to provide for adequate reconstruc-tive volume.

DESCRIPTIONThe body lift perforator flap procedure is con-

sidered for patients presenting with a need forbilateral breast reconstruction and who have in-adequate abdominal or gluteal fatty volume for aroutine DIEP/TRAM or GAP flap procedure. Ourexperience includes those undergoing delayedand immediate reconstruction in a patient popu-lation treated for cancer and/or prophylactic con-cerns, and those with previous unsatisfactory orfailed implant reconstruction.

Clinical examination allows for estimation offatty volume in the truncal donor site both ante-riorly and posteriorly. When the estimate of vol-ume in a single site in the various donor fields fallsroughly between one-third and one-half ofthe desired final breast volume, considerationof the body lift perforator flap procedure begins.The desired final breast volume predicates furtherconsideration, quantified as less than, equal to, orgreater than before mastectomy. For women seek-ing replacement of unsatisfactory implant recon-structions, the volume estimate is related to thesize of the existing implants, with an added volumeof at least 20 percent to account for the flattenedthoracic platform that is often found and the an-ticipated recoil of the explanted skin. This num-ber is arbitrary and based on clinical experience ofthe treating team. Perforators of the deep inferiorepigastric system, the lumbar system, and septo-cutaneous and muscular gluteal perforators areidentified, mapped, and marked before surgerywith an 8-MHz handheld Doppler probe. Com-puted tomography–guided angiography is thenreferenced against these markings to allow formaximum precision in the presurgical plan withrespect to exact donor-site marking location, plan-ning of microsurgical linkages, and anticipatedflap flow source (Fig. 1).

Surgery begins with dissection of the DIEP flapopposite the breast being reconstructed. Inspec-tion of the superficial system is undertaken firstand, if adequate, dissected just short of its entryinto the common femoral, where it is ligated. Per-forators of the deep inferior epigastric system arethen identified and carefully dissected free of sur-rounding fascia and muscle. As the deep inferiorepigastric vessels are identified, the branch pointsare carefully inspected. All large branches, includ-ing the distal extent of the deep inferior epigastric,are dissected for at least 2 cm and doubly ligatedto serve as anastomosis points for the correspond-ing (GAP) flap (Fig. 2). Careful inspection of ar-terial and venous caliber of all components withinthe pedicle is undertaken during the dissection. Amental image of the desired vascular arrangementon flap linkage and associated inset is developedas the surgical dissection progresses and adjustedas surgical findings dictate. This process is aided bypresurgical imaging as discussed. This allows thesurgeon to develop the most appropriate plan forvascular construct as the elevation of the flap pro-gresses. Once the pedicle dissection is complete,attention is directed to the opposite hemiabdo-men, and the mirror image dissection is com-pleted. Once the pedicle is dissected free, the flap

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is stapled back into position and continues to per-fuse as preparation of the recipient internal mam-mary artery and vein in the breast pocket is un-dertaken. The patient is then placed into proneposition for harvest of the gluteal perforator flaps.

The gluteal perforator flaps are then dissectedalong a continuous design extending from the an-terior abdominal incisions. Typically, the amount offat harvested will be less than an isolated GAP flapprocedure would mandate, but is adjusted to volumerequirements relative to the abdominal fatty volumepresent and the breast volume that the surgeon istrying to achieve. This minimizes the impact on thegluteal aesthetic, as does placement of the design

high on the hip. The perimeter of each flap is de-fined with electrocautery, and incision through thesuperficial fascia of the gluteus maximus follows.The subfascial plane is then entered and serves as theplane for perforator identification. Once the dom-inant perforator is identified, it is followed downthrough the substance of the muscle by spreadingand preserving the surrounding fibers (Fig. 3). Thedissection is then carried through the deep glutealfascia to reach the larger caliber vessels in the sub-gluteal fat pad as they emerge from the sacral fo-ramina. Extreme care must be taken in this portionof the dissection, when required, as entry into thelarge venous confluence or a poorly controlled ar-

Fig. 1. Presurgical markings applied after computed tomographic angiography and Dopplerexamination for a patient with implant reconstruction complicated by chronic pain and ani-mated breast.

Fig. 2. DIEP flap dissection completed with selected branchpoints dissected to length.

Fig. 3. GAP flap dissection.

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terial branch point in the tight confines of this por-tion of the harvest can make for unnecessary bloodloss and potential injury to the flap pedicle.

Once adequate vascular caliber is attained, theflaps are harvested and passed off the field. Thedonor sites are closed and the patient is returnedto the supine position. The DIEP flaps are har-vested expeditiously and the flap weights are de-termined (Fig. 4). The GAP flaps are then broughtinto the field, where they are deepithelialized andplaced dermal side down into the breast pocket.The DIEP flaps are laid atop the GAP flaps, andtheir anastomoses to the internal mammary sys-tem are completed. The feeding branch of thepedicle is anastomosed to the pedicle of the un-derlying GAP flap (Fig. 5). Implantable Dopplerdevices are applied to the primary anastomosissites as preference dictates. Once complete, theoverlying flap is positioned carefully, takingparticular care to inspect the vascular arrange-ment and design of inset (Fig. 6). ImplantableDoppler devices were not routinely applied tothe branch point anastomoses in this seriesbecause of concern regarding displacement ofthe vascular construct with Doppler wire remov-al; however, use for all anastomoses may beconsidered.

EXPERIENCE REVIEWCircumferential body lift perforator flap

breast reconstruction was performed on 25 pa-tients over a 5-year period from 2005 to 2010.Twenty-eight of the 50 breasts were recon-structed immediately at the time of mastectomy,of which 17 were prophylactic and 11 were ther-apeutic. Twenty-two breasts were reconstructed

in a delayed fashion after previous mastectomy.Twelve breasts were treated for unsatisfactoryimplant reconstruction because of capsular con-tracture, impending extrusion, unsatisfactoryaesthetics, dynamic distortion, discomfort, orsome combination of these issues (Table 1).

Average patient age was 50.52 years (range, 33to 65 years). Two patients were active smokers with

Fig. 5. Anastomosis between flaps with coupled venous con-nection completed.

Fig. 6. Breast with stacked DIEP/GAP flaps and restored projec-tion and shape.

Table 1. Patient Characteristics

No. of Breasts Reconstructed

Immediate reconstruction 28Prophylactic 17Therapeutic 11

Delayed reconstruction 10Implant failure 12

Extrusion 2Capsular contracture 9Nonspecific discomfort 1Other 0

Failure of previous flap 0Total 50

Fig. 4. Four independent flaps dissected free.

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associated instruction to quit 3 weeks before sur-gery. Average patient weight was 139.32 lb (range,115 to 190 lb). One patient suffered from hyper-tension and three were hyperthyroid, but no othersignificant medical problems were present in thispatient population. Notably, six patients had un-dergone previous cesarean section, one had pre-vious inguinal hernia repair, and three had ap-pendectomies. Despite these previous abdominal

Fig. 7. Preoperative (left) and postoperative (right) views of a patient who underwentbilateral mastectomy with immediate body lift perforator flap breast reconstruction. Mas-tectomy weights were 385 and 435 g, and the combined weight of two DIEP/GAP flaps ineach associated breast was 475 and 495 g.

Table 2. Patient Satisfaction with Body LiftPerforator Flap Breast Reconstruction*

BreastSize(%)

Donor-SiteOutcome

(%)

OverallOutcome

(%)

Excellent/very good 8 (88.9) 8 (88.9) 8 (88.9)Good 1 (11.1) 0 1 (11.1)Average/acceptable 0 0 0Poor 0 1 (11.1) 0Very poor 0 0 0*n � 9 respondents (36%).

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procedures, no problems were encountered withthe microvascular dissections.

In those undergoing immediate reconstruc-tion, the average mastectomy weight was 555.86 g.The average combined weight of the stacked DIEPand GAP flaps in these patients was 542.63 g. Theoverall average combined flap weights for the en-tire patient population was 551.5 g.

Operative time averaged 10 hours 15 minutesinclusive of mastectomy in those undergoing im-mediate reconstruction. Hospital stay averaged4.32 days. Two patients required return to theoperating room on postoperative day 1 for hema-toma evacuation. These hematomas occurred inpatients undergoing immediate reconstructionand were found to originate from small bleedingpoints in the breast pockets with no compromiseof flap vascularity. Four patients required bloodtransfusion of 2 units postoperatively. All of thesewere noted to have also undergone bilateral mas-tectomy at the time of their body lift perforatorflap reconstruction. One patient suffered total fail-ure of the gluteal flap component on one side anda portion of the gluteal flap on the opposing side.The flap with partial loss resulted from overinclu-sion of soft tissue in a flap with a peripherallylocated perforator. The flap with total loss was a

consequence of inset design, which resulted in atensioned pedicle. Both losses occurred in thesame individual, who was one of the first patientsin the series and, coincidentally, continued tosmoke postoperatively despite counseling regard-ing the associated risks. The overlying abdominalflaps in this patient were unaffected and the ne-crotic portions of the underlying gluteal flaps weredebrided away in the postsurgical period withoutany problem other than volume loss. The side withthe total loss of the underlying gluteal flap wasrestored with rotation of a latissimus flap into thesoft-tissue defect. In the cases subsequent to this,the inset design was modified from a side-by-sidearrangement of the flaps to a layered configura-tion with careful attention to avoid tension, kink,or compression of the pedicles during inset. Noflap losses occurred in this series subsequent tothese modifications.

The donor sites among the studied popula-tion healed without incidence other than onepatient who developed cellulitis in the abdom-inal soft tissue that responded to oral antibiotics,and another who suffered from a seroma in theabdominal harvest site that responded to serialaspiration. Average return to work time for thepatient group was 5 weeks. Patient satisfaction

Fig. 8. Posterior donor site of patient in Figure 7. Before (left), postoperative (center) demonstrating preservedgluteal aesthetic, and easily hidden scarline placement (right).

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with the procedure and associated outcomewere analyzed by means of questionnaire. Al-though the number of respondents (36 percent)was limited, Likert scale analysis revealed anoverall high level of satisfaction among patientssurveyed (Table 2), comparing favorably withlevels of satisfaction reported for other perforatorflap– based breast reconstruction techniques.18

All patients indicated that they would haveelected to undergo the procedure again based

on their experience and associated outcome(Figs. 7 through 10).

DISCUSSIONThe combining of various flaps with indepen-

dent pedicles or single vascular sources into com-posite flaps with associated microvascular linkageshas been referred to as “chimeric” assembly of areconstructive composite. This is considered whena need arises that, for whatever reason, is inade-

Fig. 9. Preoperative (left) and postoperative (right) views of a patient who underwent bilateralmastectomy with immediate body lift perforator flap breast reconstruction. Mastectomyweights were 620 and 800 g, and the combined weight of two DIEP/GAP flaps in each asso-ciated breast was 865 and 765 g. Radiated skin envelope on left with resultant mild peripheralcontour constriction.

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quately addressed by a single flap technique.19 Inthe purest sense, one might conjecture that dif-ferent tissue types are necessarily incorporated tofulfill the spirit of the term; however, the idea thata single flap may not always be adequate to do thejob at hand is an age-old reconstructive truth. Thisprinciple may be applied to overcome volume lim-itations of a single tissue type in the field of breastreconstruction. The DIEP and GAP flaps havebeen described ad infinitum as techniques to pro-vide for natural tissue breast reconstruction.20,21

The combination of these techniques for individ-ual patients has not been previously described. Weadd to that a substantial series with repeated suc-cess and a demonstration of a technique that ad-dresses a reconstructive challenge that otherwiseis very difficult if not impossible to overcome. Spe-cifically, we describe reconstructing two breastswith autogenous tissue when both the abdominaland gluteal donor sites are inadequate to restorebreast volume or, at a minimum, provide a breastof lesser size with adequate projection and shape.The added circumferential body lift with this ap-proach (Fig. 11) may also be considered a favor-able benefit or, at the very least, a means of han-dling the donor site with minimal impact.

Multiple authors have described various ap-proaches for including more volume in a unilat-

eral breast reconstruction than is possible with asingle flap.22–25 This report simply does the samefor those with a need for bilateral reconstruction.The concern regarding use of all four flaps in asingle operation, in an effort to provide propervolume, as opposed to using only one or the otherand preserving the remaining donor site as abackup, is offset by technical expertise and prac-tical success as described in this experience. A planthat produces a grossly insufficient breast, justifiedby preserving other insufficient flaps as a backupplan, is counterintuitive if there is a technique thatproduces a full breast with the tradeoff of addedtechnical demand and more effort on the part of theoperator. These matters are discussed thoroughlywith each patient before surgery and, in our expe-rience, the likelihood of a successful outcome equalsthat of other available techniques. This affords aninformed consent and allows for those in need of thistype of reconstruction reassurance in their decision.

The body lift perforator flap breast reconstruc-tion technique gives the woman with need formore tissue than can be transferred from the ab-dominal thigh, or gluteal donor site with an isolatedTRAM, DIEP/SIEA, TUG, or GAP flap another op-tion for autogenous tissue reconstruction. The ver-satility of perforator flaps in terms of pediclelength, pedicle exposure, and location of pedicle

Fig. 10. Posterior donor site of patient in Figure 9. Before (left), postoperative (center) demonstrating preservedgluteal aesthetic, and easily hidden scarline placement (right).

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in the base of the flap is well demonstrated withthis approach. This versatility is the singular rea-son that a procedure of this type is possible. Ourexperience reviews the repeated use of the bodylift perforator flap technique in a large number ofpatients with high success rates and quality aes-thetic outcomes over a relatively short period. It isour opinion that high patient satisfaction ratesoffset the added time and technical difficulty of theoperation. The technical demands on even a well-experienced microsurgeon must be considered;however, if the success rate is equivalent to or betterthan the average for microsurgical breast reconstruc-tion, as demonstrated in this series, the demandshave a very real and tangible return on effort spent.

CONCLUSIONSThe body lift perforator flap breast reconstruc-

tive technique has been shown in this series and inthis center’s experience to be a reproducible, safe,and soundly conceived, yet technically demandingsolution for patients seeking bilateral autogenousbreast reconstruction with otherwise inadequateabdominal or gluteal fatty volume. Avoidance ofsacrifice of the muscular core in the donor site isa major consideration, as is the aesthetic impact ofa circumferential (“belt”) body lift. These qualitiesprovide a unique autogenous solution for thewoman in need of greater breast volume in thesetting of bilateral reconstruction than can beachieved with any other reconstructive technique.This type of procedure entails a degree of micro-

surgical complexity and an associated need forefficiency that must be considered by practitionersconsidering its use.

Frank J. DellaCroce, M.D.Center for Restorative Breast Surgery

1717 St. Charles AvenueNew Orleans, La. 70130

drd@breastcenter.com

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5. DellaCroce FJ, Sullivan SK. Application and refinement ofthe superior gluteal artery perforator free flap for bilateralsimultaneous breast reconstruction. Plast Reconstr Surg. 2005;116:97–103.

6. Weintraub JL, Kahn DM. The timing of implant exchange inthe development of capsular contracture after breast recon-struction. Eplasty 2008;8:e31.

7. Nguyen MD, Chen C, Colakoglu S, Morris DJ, Tobias AM,Lee BT. Infectious complications leading to explantation inimplant-based breast reconstruction with AlloDerm. Eplasty2010;10:e48.

8. Berry T, Brooks S, Sydow N, et al. Complication rates ofradiation on tissue expander and autologous tissue breastreconstruction. Ann Surg Oncol. 2010;17:202–210.

9. Snell L, McCarthy C, Klassen A, et al. Clarifying the expectationsof patients undergoing implant breast reconstruction: A qual-itative study. Plast Reconstr Surg. 2010;126:1825–1830.

Fig. 11. Preoperative (left) and postoperative (right) views show the donor-site impact on apatient who underwent body lift perforator flap breast reconstruction.

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10. Pelle-Ceravolo M, Del Vescovo A, Bertozzi E, Molinari P. Atechnique to decrease breast shape deformity during musclecontraction in submuscular augmentation mammaplasty.Aesthetic Plast Surg. 2004;28:288–294.

11. Figus A, Mazzocchi M, Dessy LA, Curinga G, Scuderi N.Treatment of muscular contraction deformities with botuli-num toxin type A after latissimus dorsi flap and sub-pectoralimplant breast reconstruction. J Plast Reconstr Aesthet Surg.2009;62:869–875.

12. DellaCroce FJ, Sullivan SK. Chimeric stacked deep inferiorepigastric perforator flap breast reconstruction: A new solu-tion to an old problem. J Reconstr Microsurg. 2007;23:418.

13. DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferiorepigastric perforator flap breast reconstruction: A review of110 flaps in 55 cases over 3 years. Plast Reconstr Surg. 2011;127:1093–1099.

14. Jones BM, Toft NJ. Bodylifting: Indications, technique andcomplications. J Plast Reconstr Aesthet Surg. 2008;61:730–735.

15. Lockwood TE. Maximizing aesthetics in lateral-tension ab-dominoplasty and body lifts. Clin Plast Surg. 2004;31:523–537.

16. Kroll SS, Sharma S, Koutz C, et al. Postoperative morphinerequirements of free TRAM and DIEP flaps. Plast ReconstrSurg. 2001;107:338–341.

17. Petit JY, Rietjens M, Ferreira MA, Montrucoli D, Lifrange E,Martinelli P. Abdominal sequelae after pedicled TRAM flapbreast reconstruction. Plast Reconstr Surg. 1997;99:723–729.

18. Damen TH, Timman R, Kunst EH, et al. High satisfactionrates in women after DIEP flap breast reconstruction. J PlastReconstr Aesthet Surg. 2008;63:93–100.

19. Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y,Nagayama H. Free combined composite flaps using the lat-eral circumflex femoral system for repair of massive defectsof the head and neck regions: An introduction to the chi-meric flap principle. Plast Reconstr Surg. 1993;92:411–420.

20. DellaCroce FJ, Allen R, Sullivan SK. Deep inferior epigastricperforator flap reconstruction. Semin Plast Surg. 2002;16:7–17.

21. Craigie JE, Allen RJ, DellaCroce FJ, Sullivan SK. Autogenousbreast reconstruction with the deep inferior epigastric per-forator flap. Clin Plast Surg. 2003;30:359–369.

22. Arnez ZM, Scamp T. The bipedicled free TRAM flap. Br JPlast Surg. 1992;45:214–218.

23. Agarwal JP, Gottlieb LJ. Double pedicle deep inferior epi-gastric perforator/muscle sparing TRAM flaps for unilateralbreast reconstruction. Ann Plast Surg. 2007;58:359–363.

24. Figus A, Fioramonti P, Ramakrishan V. Stacked free SIEA/DIEP flap for unilateral breast reconstruction in a thin pa-tient with an abdominal vertical midline scar. J Reconstr Mi-crosurg. 2007;23:523–526.

25. Ng RL, Youssef A, Kronowitz SL, Lipa JE, Potochny J, Reece GP.Technical variations of the bipedicled TRAM flap in unilateralbreast reconstruction: Effects of conventional versus microsur-gical techniques of pedicle transfer on complication rates. PlastReconstr Surg. 2004;114:374–384; discussion 385–388.

Plastic Surgery Level of Evidence RatingScale—Therapeutic Studies

Find out more from the “Evidence-Based Medicine: How-to Articles”Collection at www.PRSJournal.com

Level of Evidence Qualifying Studies

I Highest-quality, multicentered or single-centered, randomizedcontrolled trial with adequate power; or systematic review of thesestudies

II High-quality, randomized controlled trial; prospective cohort orcomparative study; or systematic review of these studies

III Retrospective cohort or comparative study; case-control study; orsystematic review of these studies

IV Case series with pre/post test; or only post testV Expert opinion developed via consensus process; case report or

clinical example; or evidence based on physiology, bench research, or“first principles”

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