"The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction".

Perforator Flap for Autologous Breast Reconstruction Sir: In a recent article about the stacked hemiabdominal extended perforator flap for breast reconstruction,1 we described our experience with a new approach to autologous breast reconstruction in bilateral cases. We learned about maximizing the abdominal donor site with the addition of a second, more lateral vascular pedicle in 2012 from Dr. Edward Buchel. We are indeed grateful to Dr. Buchel for generously sharing his knowledge and experience with us, and we thank him in our report, both explicitly as a standalone acknowledgement and in the reference list of our article. In their recent letter, Greenspun et al. call our attention to their publication in a general surgery journal,2 in which a small number of similar cases was mentioned as part of a broad overview of stacked abdominal flaps. We would also like to point out that in 2015 we presented our experience with 12 stacked hemiabdominal extended perforator flaps at local, national, and international meetings, and our report was subsequently published in Plastic and Reconstructive Surgery.3–6 At that time, we were also invited to show a video of the procedure at the World Society for Reconstructive Microsurgery meeting in March of 2015.7 Our goal then, as now, is to build on ideas, and make a meaningful contribution to the literature. Regarding the question in their letter about describing such contributions as "new" or "novel," we would refer Greenspun et al. back to their own article, in which they describe the stacked (“bipedicle-conjoined”) deep inferior epigastric artery perforator (DIEP) as “a novel technique.” The stacked DIEP procedure has been around at least since 1994,8 and even earlier versions with bipedicle free transverse rectus abdominis musculocutaneous flaps were published in 19929 and1993.10 Moreover, bipedicle DIEP/DIEP and DIEP/superficial inferior epigastric artery flaps, as two contiguous flaps and as two completely divided flaps, have been reported and discussed numerous times before their 2015 article.8,11–20 “There is no new thing under the sun” (Ecclesiastes 1:9), and we all build on the creative work that preceded ours. Our report on 90 stacked hemiabdominal extended perforator flap cases includes DIEP flaps combined with an ipsilateral deep circumflex iliac artery, superficial inferior epigastric artery, or superficial circumflex iliac artery, and we also added the use of the lumbar artery and intercostal artery as the second, lateral pedicle in selected cases. As far as we know, these variations, along with the tripedicle extended abdominal flap,21 and the four-flap-for-one breast reconstruction procedures,22 which we also describe in our article, have