Breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap is now widely used because it has a high quality of skin texture, rich adipose tissue, and less donor site morbidity 1) . However, a disadvantage of the DIEP flap is that it can only be used once for the same patient. A patient in our institution developed metachronous breast cancer after contralateral breast reconstruction with a DIEP flap. The DIEP flap cannot be used or considered for breast reconstruction;

more »

... therefore, the latissimus dorsi musculocutaneous flap (LD flap), profunda artery perforator flap (PAP flap), superior gluteal artery perforator flap (SGAP flap), inferior gluteal artery perforator flap (IGAP flap), fasciocutaneous infragluteal flap (FCI flap) and tensor fasciae latae perforator flap (TFL flap) were the alternative choices [2] [3] [4] [5] [6] [7] [8] . B cause the patient had a large breast size, the LD flap, TFL flap, and PAP flap could not be considered owing to the lack of tissue volume. The patient was expected to have more adipose tissue volume in the lumbar area than in the gluteal region, and the patient preferred to have a donor site scar in the lumbar area. The stacked PAP flap was also considered because it allows simultaneous flap harvesting during mastectomy, while maintaining the same patient position. In addition, it has the advantage of a shorter surgical time. However, this patient had