Comparative Analysis of Bilateral Stacked Flap and Hybrid Breast Reconstruction: Clinical Results and Patient-reported Outcomes

Abstract

Background:

In autologous breast reconstruction, there may be a disparity between the volume necessary to achieve the ideal reconstruction and the volume of tissue available from a single flap donor site. In such cases, stacked flap reconstruction or hybrid breast reconstruction may provide patients with their desired breast size and shape.

Methods:

This retrospective cohort study included 119 patients (69 bilateral stacked flap reconstructions, 50 bilateral hybrid reconstructions) who underwent breast reconstruction between 2016 and 2024. Patient demographics, oncological treatment, and operative details were compared. Primary outcomes included postoperative complications and patient-reported outcomes (BREAST-Q).

Results:

There were no significant differences in patient comorbidities or oncological treatment plans. The hybrid reconstruction group had a shorter duration for the flap procedure (532.6 versus 637 min, P < 0.001), shorter length of stay (4.1 versus 5.1 d, P = 0.003), less frequent use of a cosurgeon (48% versus 95.6%, P < 0.001), and a higher number of total revision procedures (P = 0.004). There were no significant differences in breast, donor site, or medical complications aside from a higher risk of postoperative breast infection in the hybrid reconstruction group (P = 0.011). BREAST-Q demonstrated no significant differences in patient-reported outcomes.

Conclusions:

Stacked flap and hybrid breast reconstructions are both safe and reliable techniques in appropriately selected patients when a single flap donor site lacks sufficient volume to achieve the desired result. There are nuanced differences in the reconstructive processes and surgical outcomes that necessitate thorough patient education and patient selection.

Takeaways.

Question: For bilateral breast reconstruction with inadequate donor-site volume, are there differences in outcomes between stacked flap and hybrid breast reconstruction?

Findings: Retrospective review of bilateral stacked flap (2 flaps per breast) or hybrid reconstruction (addition of implant to autologous reconstruction) was done. No significant differences in patient-reported outcomes, flap complications, or donor-site complications were found. There was a higher breast infection rate and revision rate in the hybrid group.

Meaning: Both stacked flap and hybrid breast reconstruction are safe and reliable techniques with high patient satisfaction and comparable complication profiles.

INTRODUCTION

Breast cancer incidence continues to rise approximately 1% per year in the United States; however, despite this increased prevalence, mortality rates from breast cancer have steadily declined during the past 30 years.¹ As such, the proportion of patients seeking breast reconstruction continues to increase.^1–3 Autologous breast reconstruction provides a long-lasting, natural feeling and aesthetically pleasing result without the need for breast implants. However, consideration of the candidacy of a patient for autologous reconstruction includes evaluation for the presence of an appropriate donor site with adequate tissue volume to reconstruct the absent breast. For some patients, disparities exist between the volume of required tissue for breast reconstruction and available tissue present at a single donor site. In these cases, the plastic surgeon must consider other options to provide the patient with their desired breast size and shape following reconstruction.

There are multiple strategies to augment the volume of a single free tissue transfer to the breast, including autologous fat grafting, locoregional pedicled flaps, stacked flaps, or the addition of a breast implant.^4–8 Stacked flaps, or the use of 2 free flaps per breast, is a useful technique for patients with insufficient volume from a single donor site. These procedures typically involve stacked or bipedicled deep inferior epigastric artery perforator (DIEP) flaps, stacked profunda artery perforator (PAP) flaps, or stacked PAP/DIEP flaps.⁹ An additional consideration in the volume-deficient patient is the application of hybrid breast reconstruction which involves placing an implant under the autologous flap to provide the desired breast volume and contour.¹⁰ Although prior studies have independently evaluated the safety and efficacy of each of these strategies, there remains a paucity of literature comparing outcomes of stacked flaps versus hybrid breast reconstruction.

PATIENTS AND METHODS

Following institutional review board approval, a retrospective cohort review was performed for all consecutive patients who underwent bilateral stacked flap and hybrid breast reconstruction between August 2016 and September 2024. Data were collected and managed with the REDCap electronic data capture tool.^11,12 Patient demographics collected included age; body mass index; race; ethnic origin; comorbidities (hypertension, diabetes mellitus, major depressive disorder or generalized anxiety disorder, history of deep vein thrombosis [DVT] or pulmonary embolism [PE], hypothyroidism, or other autoimmune disease); and history of smoking. Additionally, breast and oncological data collected included laterality of breast with tumor, history of neoadjuvant or adjuvant chemotherapy or radiation therapy, and history of prior breast surgery.

Operative details included type of mastectomy, use of a tissue expander and/or acellular dermal matrix, type of breast reconstruction (stacked versus hybrid), use of a cosurgeon, and total length of the procedure during which the flap was performed. Outcomes collected included length of stay, postoperative complications, and number and type of revision procedures performed to complete breast reconstruction. Breast-related complications collected per breast included seroma, hematoma, delayed wound healing, nipple necrosis, mastectomy skin flap necrosis (partial or full-thickness), and flap loss (partial or complete). Breast and donor-site complications collected on a patient level included infection, seroma, hematoma, delayed wound healing, donor-site revision, and abdominal wall bulge or hernia on examination. Complications analyzed included only those occurring after the autologous procedure for both groups. Additional patient-level complications included DVT or PE, and the number of revision procedures needed to complete reconstruction. Notably, for the hybrid reconstruction group, a breast revision was defined as a procedure following implant placement; initial implant placement was not included.

Patient satisfaction was assessed using the BREAST-Q questionnaire, administered after completion of reconstruction.¹³ Domains evaluated included “satisfaction with breasts,” “psychosocial well-being,” “sexual well-being,” and “chest physical well-being.” For patients who underwent abdominal flap harvest, additional modules assessed “satisfaction with the abdomen” and “abdominal physical well-being.” BREAST-Q scores were compared with established normative values from women without a history of cancer or reconstruction.¹⁴

Statistical analysis was performed using IBM SPSS, version 30 (IBM Corp., Armonk, NY) software. Independent samples t tests and Mann-Whitney U tests were used to perform statistical analyses for comparison of patient demographics and operative details, whereas χ² analysis was used to compare postoperative complications between patients who underwent stacked versus hybrid reconstruction. Significance was set at P values of less than 0.05. Mean BREAST-Q scores within each domain were compared between groups using an independent t test. Additionally, backward Wald stepwise multivariable logistic regression analysis was used to stratify significant risk factors for postoperative complications, the goodness-of-fit tests for the model was assessed using Nagelkerke R².

RESULTS

A total of 119 patients underwent bilateral breast reconstruction, which included 376 flaps. Of these, 69 (58%) patients underwent bilateral stacked flap reconstruction, and 50 (42%) patients underwent bilateral hybrid reconstruction. Of the 69 patients in the stacked flap cohort, the majority had bilateral stacked PAP/DIEP flaps (50, 72.5%) followed by unilateral bipedicled DIEP flaps with contralateral stacked PAP flaps (12, 17.4%), and bilateral stacked lateral thigh perforator/PAP flaps (5, 7.2%). One patient each underwent stacked PAP flaps augmented with split omentum and stacked DIEP flaps augmented with split omentum (Fig. 1). No patients in the stacked flap cohort underwent staged secondary flap augmentation; all stacked flaps were performed simultaneously.

Fig. 1.

Distribution of stacked flaps.

Of the 50 patients within the hybrid patient cohort, most underwent bilateral abdominally based free flaps with implant placement (43 patients, 86%), which was followed by bilateral thigh-based flaps (7 patients, 14%) (Fig. 2). Additionally, 80% (n = 40) of the hybrid group underwent staged implant placement following the initial autologous reconstruction, whereas 20% (n = 10) had immediate implant placement simultaneously with the microvascular reconstruction. Additional details of the hybrid reconstructions are given in Table 1.

Fig. 2.

Distribution of hybrid flaps.

Table 1.

Characteristics of Hybrid Breast Reconstructions

Characteristic
Hybrid reconstructions (n = 50)
Implant plane	91% prepectoral	9% subpectoral
Implant volume	50–480 mL (average, 254.9 mL)
Timing of implant placement	Immediate implant placement	Staged implant placement
Patients, n (%)	10 (20)	40 (80)
Use of acellular dermal matrix, n (%)	5 (50)	20 (50)
Implant type
Silicone implant, n (%)	5 (50)	39 (97.5)
Adjustable volume saline implant, n (%)	5 (50)	1 (2.5)
Planned secondary augmentation of flap with implant, n (%)	N/A	3 (7.5)

Comparison of Patient Characteristics and Oncological Treatment Plans

Patients who underwent hybrid breast reconstruction were significantly younger (44.4 versus 47.6 y, P = 0.048), had a higher body mass index (28.5 versus 25.8 kg/m², P = 0.001), and had lower incidence of smoking history (12% versus 24.6%, P = 0.010) than patients who underwent stacked reconstruction. There were no other significant differences in patient comorbidities between the groups. There were no differences in rates of neoadjuvant or adjuvant chemotherapy or in prereconstruction or postreconstruction radiation therapy between the groups (Table 2).

Table 2.

Patient Demographics of Study Population

Patient Characteristic	Stacked Flap Patients (n = 69)	Hybrid Flap Patients (n = 50)	P
Age, y	47.6 (SD, ±8.8)	44.4 (SD, ±8.1)	0.048
Body mass index, kg/m2	25.8 (SD, ±3.5)	28.5 (SD, ±4.8)	0.001
Smoking history, %	24.6	12	0.010
Comorbidities
Hypertension, n (%)	10 (14.5)	14 (28%)	0.070
Diabetes mellitus, n (%)	2 (2.9)	0 (0%)	0.509
Depression or anxiety, n (%)	13 (18.8)	9 (18)	0.907
History of DVT/PE, n (%)	1 (1.4)	3 (6)	0.308
Hypothyroidism, n (%)	15 (21.7)	10 (20)	0.818
Autoimmune disease, n (%)	2 (2.9)	0 (0)	0.509
Neoadjuvant chemotherapy, n (%)	23 (33.3)	20 (40)	0.455
Adjuvant chemotherapy, n (%)	22 (31.9)	14 (28)	0.649
Prereconstruction radiation therapy, n (%)	27 (39.1)	24 (48)	0.335
Postreconstruction radiation therapy, n (%)	1 (1.4)	1 (2)	1.000

Bold indicates statistically significant outcomes.

Comparison of Clinical and Operative Details

The flap procedure operative time was significantly shorter in patients who underwent hybrid reconstruction (532.6 versus 637 min, P < 0.001). The length of stay following the microvascular procedure was also shorter in hybrid reconstruction as compared with the stacked flap group (4.1 versus 5.1 d, P = 0.003). A cosurgeon technique was used in 66 of the 69 stacked flap cases compared with 24 of the 50 hybrid cases (95.6% versus 48%, P < 0.001). There was a significantly higher total number of revisions required to complete reconstruction in the hybrid group with an average of 1.19 revisions in the stacked group versus 1.92 revisions in the hybrid group (P = 0.004). The initial implant placement for hybrid reconstruction was not included in calculation of revisions when performed in the delayed setting; however, any returns for alterations in implant size were included (Table 3). Within the hybrid group, analysis of immediate versus delayed implant placement showed an increased revision rate in patients with delayed placement with a mean of 2.1 revisions per patient compared with 1.2 revisions per patient in the immediate group (P = 0.028).

Table 3.

Clinical and Operative Details of Stacked Flap Versus Hybrid Reconstruction

	Stacked Flaps (n = 69)	Hybrid Flaps (n = 50)	P
Flap procedure time, min	637 (SD, ±143.2)	532.6 (SD, ±116.1)	<0.001
Use of co-surgeon technique, n (%)	66 (95.6)	24 (48)	<0.001
Immediate autologous reconstruction at time of mastectomy, %	31.2	33	0.764
Length of stay after flap procedure, d	5.1 (SD, ±2.7)	4.1 (SD, ±1.2)	0.003
Total number of revisions required to complete reconstruction, n (%)			0.004
3+ revision procedures	5 (7.2)	12 (24)
2 revision procedures	15 (21.7)	15 (30)
1 revision procedure	35 (50.7)	22 (44)
0 revision procedures	14 (20.3)	1 (2)

Bold indicates statistically significant outcomes.

Comparison of Postoperative Complications

Evaluation of postoperative complications was performed based on the breast, donor-site, and medical complications. Breast complication rates were evaluated per breast (stacked = 138 breasts, hybrid = 100 breasts) except for breast infection, which was collected per patient to identify those with unilateral versus bilateral infection. Donor-site complications were evaluated per patient (stacked = 69 patients, hybrid = 50 patients). There were no significant differences in breast-related complications except for a higher rate of infection in the hybrid cohort (16% unilateral and 0% bilateral infection in the hybrid group versus 2.9% unilateral and 2.9% bilateral infection in the stacked group, P = 0.011). There was 1 instance of Baker grade III capsular contracture, which occurred unilaterally in a patient within the hybrid group (1%). Of particular note for microsurgical procedures, there were no significant differences between the groups with regard to pedicle thrombosis (0% versus 1%, P = 0.420), flap congestion (0% versus 1%, P = 0.420), emergent return to the operating room for flap exploration (2.2% versus 4%, P = 0.256), partial flap loss (4.3% versus 1%, P = 0.236), or total flap loss (0% versus 0%, P = 1.0). There were no significant differences in donor-site complications, including seroma, hematoma, infection, delayed wound healing, hernia, bulge, and return to the operating room for donor-site revision. The incidence of postoperative DVT or PE was compared, with no significant differences identified (Table 4).

Table 4.

Comparison of Complication Rates in Stacked Flap Versus Hybrid Reconstruction

Complications per Breast	Stacked Flaps (n = 138)	Hybrid Flaps (n = 100)	P
Breast seroma, n (%)	3 (2.2)	1 (1)	1.000
Breast hematoma, n (%)	5 (3.6)	5 (5)	0.741
Breast wound dehiscence, n (%)	4 (2.9)	2 (2)	0.076
Mastectomy skin flap necrosis, n (%)	6 (4.3)	7 (7)	0.850
Nipple necrosis, n (%)	3 (2.2)	1 (1)	1.000
Partial flap necrosis, n (%)	6 (4.3)	1 (1)	0.236
Pedicle thrombosis, n (%)	0 (0)	1 (1)	0.420
Flap congestion, n (%)	0 (0)	1 (1)	0.420
Emergent return to operating room for flap exploration (within 5 d), n (%)	3 (2.2)	4 (4)	0.256
Total flap loss, n (%)	0 (0)	0 (0)	1.000
Complications Per Patient	Stacked Flaps (n = 69)	Hybrid Flaps (n = 50)	P
DVT/PE, n (%)	4 (5.8)	1 (2)	0.397
Donor-site infection, n (%)	4 (5.8)	3 (6)	1.000
Breast infection			0.011
Unilateral, n (%)	2 (2.9)	8 (16)
Bilateral, n (%)	2 (2.9)	0 (0)
Donor-site seroma, n (%)	2 (2.9)	4 (8)	0.237
Donor-site hematoma, n (%)	1 (1.4)	1 (2)	1.000
Donor-site delayed wound healing, n (%)	9 (13)	4 (8)	0.384
Hernia, n (%)	2 (2.9)	0 (0)	0.509
Abdominal bulge, n (%)	3 (4.3)	2 (4)	1.000
Return to operating room for donor-site revision not due to complication, n (%)	42 (60.9)	38 (76)	0.083

Bold indicate statistically significant outcomes.

Multivariate logistic regression analysis evaluating stacked versus hybrid reconstruction as exposure of interest identified diabetes mellitus as a significant predictor for breast infection in both cohorts. Age, adjuvant chemotherapy, and diabetes mellitus were significant risk factors for fat necrosis. Finally, donor-site seroma was significantly associated with hypertension and a history of thromboembolic event (Table 5).

Table 5.

Multivariable Logistic Regression Analysis of Breast and Donor-site Complications

Complication	P	OR	95% Confidence Interval for Odds Ratio
			Lower	Upper
Breast infection
Diabetes mellitus	0.046	21.333	1.058	430.167
Stacked versus hybrid	0.047	4.063	1.019	16.197
Flap necrosis
Age	0.010	1.294	1.064	1.573
Adjuvant chemotherapy	0.012	32.783	2.121	506.615
Diabetes mellitus	0.004	2325.083	12.387	436,429.291
Donor-site seroma
Hypertension	0.047	7.633	1.029	56.627
DVT/PE history	0.004	53.385	3.535	806.146

Comparison of Patient-reported Outcomes

BREAST-Q responses were available for 49 (41.2%) patients, including 40.6% of the stacked flap group and 42% of the hybrid group. The median time from completion of reconstruction to survey completion was 26 months (range, 11–85 mo) for the hybrid group and 29 months (range, 5–74 mo) for the stacked flap group, with no significant difference between groups (P = 0.608). No significant differences in patient-reported outcomes were observed between the cohorts across any domain (Fig. 3).

Fig. 3.

Comparison of patient-reported outcomes following stacked flap vs hybrid reconstruction using the BREAST-Q.

Compared with a normative population without a history of breast cancer or surgery, patients in both reconstruction groups reported higher satisfaction with breasts and psychosocial well-being.¹³ Physical well-being of the chest and abdomen in both groups was lower, whereas sexual well-being was split, being higher than the normative population in the hybrid group and lower in the stacked group, although these observed differences did not reach statistical significance (Table 6).

Table 6.

Comparison of Patient-reported Outcomes Using the BREAST-Q in Stacked Flap Versus Hybrid Reconstruction as Compared With Normative Data

Category	Stacked Breast Reconstruction (Mean ± SD)	Hybrid Breast Reconstruction(Mean ± SD)	P	Normative14 (Mean ± SD)
Satisfaction with breasts	67 ± 31	70 ± 20	0.810	58 ± 18
Physical well-being: chest	80 ± 17	81 ± 23	0.606	93 ± 11
Physical well-being: abdomen	73 ± 15	73 ± 19	0.871	78 ± 20
Psychosocial well-being	73 ± 24	80 ± 23	0.451	71 ± 18
Sexual well-being	47 ± 21	65 ± 24	0.065	56 ± 18

DISCUSSION

Autologous breast reconstruction is a valuable surgical option in postmastectomy breast reconstruction due to its long-term patient satisfaction and improved quality of life.^15,16 However, the availability of an adequate volume of donor tissue to reconstruct the absent breast remains an obstacle in thin patients, those with significant radiation injury requiring large volume skin resurfacing, or patients with a surgical history that precludes the use of a particular flap donor site. Various strategies have been proposed to overcome this limitation including the use of multiple free flaps to reconstruct a single breast as in stacked flap breast reconstruction, or the addition of an implant to the autologous reconstruction to augment the volume of the flap as seen in hybrid breast reconstruction.^10,17,18 There are benefits and drawbacks of these procedures, with critics of stacked flap reconstruction citing increased operative time, the added recovery burden assumed by multiple flap donor sites, and a higher complication rate. Similarly, concerns regarding hybrid reconstruction involve its complication profile and the drawbacks associated with alloplastic breast reconstruction itself; namely the need for implant surveillance, possible implant replacement, and the risks of capsular contracture or implant-associated neoplasms. Despite these concerns, multiple studies have demonstrated the safety and efficacy of both stacked and hybrid approaches, with similar complication profiles and postoperative outcomes despite the perceived increase in operative complexity.^9,10

Individual patient factors, including patient preferences, assessment of donor-site availability, surgical history, and evaluation of the mastectomy defect to determine amount of volume restoration and skin resurfacing required, remain the most important considerations in whether to proceed with single-flap reconstruction or stacked flap versus hybrid reconstruction. When the volume requirement of the reconstructed breast is greater than the donor tissue availability of a single site, clinical decision-making then pivots to consideration of how best to augment a single flap in autologous reconstruction. The present study provides level 3 evidence demonstrating that both options can achieve excellent overall results with high patient satisfaction, making the decision for which option to pursue multifactorial. This involves a nuanced discussion with the patient; stacked flap reconstruction requires more foresight in surgical planning as well as increased patient buy in to accept the longer operative time and multiple donor sites required in 4-flap breast reconstruction, whereas hybrid reconstruction can be performed in a stepwise fashion if a patient is unsatisfied with the reconstructed breast volume following single-flap autologous reconstruction. This remains a shared decision-making process between surgeon and patient to determine what best fits their needs and desired outcome.

In our patient cohort, most patients who underwent hybrid reconstruction with delayed implant placement did not originally plan for hybrid reconstruction. The most common reasons for delayed implant placement were the desire for increased volume or projection of the reconstruction, or postoperative weight loss resulting in flap volume loss which was then corrected with implant placement. Alternatively, others have demonstrated high success rates with an immediate hybrid approach which can limit the number of operations but may introduce other risks and costs as acellular dermal matrix is often used in these circumstances. Regardless, these patients also had significantly higher revision rates compared with patients undergoing an entirely autologous reconstruction, and they must also understand the potential need for further surgery in the future to exchange their implants. Thus, although patients undergoing a stacked reconstruction required longer operative times and hospital stays during the initial surgery, those undergoing a hybrid reconstruction require more total operations with the associated recovery time and time off work for the implant placement and subsequent revisions.

Our experience has shown a similar complication profile between stacked flap and hybrid reconstruction, except for an increased rate of postoperative infection in the hybrid group, which occurred following implant placement, likely due to the addition of the alloplastic device. However, most infections were able to be managed conservatively and did not warrant a reoperation for exchange or removal of the implant. Thus, both options can provide patients with highly reliable, safe results with comparable satisfaction rates. There were no significant differences in donor-site complications, rate of DVT or PE, or flap take-back rates, and there were no flap losses in either group.

Stacked flap reconstruction does require more initial time and resources, as demonstrated by the significantly longer operative duration, use of a cosurgeon, and longer hospital length of stay. However, this initial investment of time and resources may be offset by the significantly lower number of revision procedures required to complete breast reconstruction in the stacked group compared with the hybrid cohort.

Patient-reported outcome measures remain a critical method for evaluating results following breast reconstruction by allowing the surgeon to better understand the effectiveness and impact on patient quality of life following surgery.¹³ Our study demonstrated no significant differences in the 5 domains evaluated. Surprisingly, despite the additional donor-site morbidity of stacked flap reconstruction, there were no significant differences seen in the physical well-being domains between the stacked and hybrid groups. Although sexual well-being trended higher for the hybrid group; possibly related to the lower incidence of medial thigh scars in this population, this did not reach statistical significance.

When compared with the normative cohort of women without a history of breast cancer or surgery, patients in both the hybrid and stacked flap reconstruction groups demonstrated higher satisfaction with their breasts and greater psychosocial well-being.¹⁴ This suggests that autologous reconstruction plays a meaningful role in restoring body image and emotional health following mastectomy. Patients with reconstructive surgery expectedly reported lower physical well-being of the chest and abdomen, reflecting the physical morbidity associated with flap harvest and reconstructive surgery. Notably, sexual well-being outcomes were divergent: patients in the hybrid group reported higher sexual well-being than the normative cohort, whereas those in the stacked flap group reported lower scores. This variation may reflect differences in surgical burden, recovery, or patient selection between the 2 groups and warrants further investigation.

Overall, the present study demonstrates that both stacked flap and hybrid reconstructions can be safely performed in the appropriately selected patient, with similar success rates and postoperative complication profiles and equivalent patient satisfaction. The decision on the best method of breast reconstruction requires a thorough evaluation of all preoperative patient factors to optimize aesthetics and outcomes.

This study is not without limitations, including those that exist with any retrospective study, and that it reflects the practice of several reconstructive surgeons, introducing heterogeneity in counseling and management of patients. These cohorts may represent somewhat discrepant populations, as the decision to augment flaps with delayed implant placement is often made after a less satisfactory autologous-only result. This may influence the number of subsequent revision procedures. This study does not answer whether the revisions would have been obviated by an initial plan for stacked flap or immediate hybrid reconstruction. Further, all surgeons included were fellowship-trained microsurgeons, allowing for convenient use of cosurgeons for a stacked flap or bilateral microvascular free flap reconstruction, which may not be applicable to other institutions, introducing potential bias. The follow-up is also variable, and patient-reported outcomes may change over time, as may the need for additional operations, underscoring the need for continued evaluation and long-term follow-up to provide surgeons evidence to best counsel their patients. Finally, due to the retrospective nature of the study, the evaluation of patient-reported outcomes was performed at the time of data collection. For some patients, this was years following their surgery, which may explain the relatively low response rate.

Our findings demonstrate that both stacked flap and hybrid reconstructions provide a safe, reliable option for breast reconstruction with comparable complication rates and equivalent patient satisfaction. These procedures are best suited for patients in whom autologous breast reconstruction is desired, but an appropriate volume of tissue cannot be harvested from a single donor site.

CONCLUSIONS

Although many options exist for breast reconstruction, autologous tissue affords patients the most natural and durable result. However, some patients lack sufficient tissue at a single donor site for adequate volume restoration or skin resurfacing following bilateral mastectomy, requiring the use of adjunct procedures to optimize the reconstruction. Under these circumstances, both stacked flap and hybrid breast reconstructions are safe and reliable techniques that can achieve high patient satisfaction with comparable complication profiles.

DISCLOSURES

MD Anderson Cancer Center receives research funding for Food & Drug Administration postmarket approval trials sponsored by Allergan, Mentor Worldwide LLC, and Establishment Labs. Dr. A.F. Mericli is a Scientific Advisory Board Member and consultant for Mentor Worldwide LLC and a Breast Reconstruction Advisory Board Member for AbbVie Inc. Dr. J.B. Olenczak has received honorarium from Evergen. The other authors have no financial interest to declare in relation to the content of this article.