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Page 2 of 9 Black et al. Plast Aesthet Res 2023;10:31 https://dx.doi.org/10.20517/2347-9264.2023.04

incidence of breast cancer and the number of patients seeking prophylactic mastectomies for risk
[2,3]
reduction . As such, over 137,000 breast reconstructive procedures following mastectomy were performed
[4]
in the United States in 2020 . Roughly 75% of these surgeries involved implant-based, or alloplastic,
reconstruction, while the other 25% utilized autologous reconstruction.

The types and incidences of complications following both mastectomy and reconstruction are well-
documented. Among the most prevalent of these adverse effects is mastectomy skin flap necrosis, caused by
disruption of the vascular supply to the breast. Damage to the subdermal plexus and its deep perforators
with subsequent skin necrosis has a documented incidence ranging from 1.4% to 43.4% . This wide range
[5-9]
is attributed in part to a lack of uniform definition of necrosis; different studies classify necrosis by various
criteria, including the intervention needed, the timing of occurrence, the depth of necrosis, or the surface
[6]
area of tissue involved .
Though the framework for determining necrosis may be up for debate, the negative impact is clear: while
mild necrosis can be managed with local wound care, moderate to severe skin flap necrosis often requires
debridement and reoperation in both alloplastic and autologous reconstructions [8,10,11] . Necrosis can lead to
[6]
infection and/or implant exposure, ultimately resulting in reconstructive failure . Prior studies have shown
that mastectomy skin necrosis greater than 6 cm after autologous reconstruction benefits from operative
2
2
management due to prolonged healing with conservative care, and that necrosis exceeding 10 cm can lead
to severe breast distortion [11,12] . Revision for breast reconstruction is also costly and resource intensive [13,14] .

The risk of developing mastectomy skin flap necrosis is influenced by a myriad of factors, including patient
demographics and comorbidities, mastectomy technique, and reconstructive pathway. This review paper
will detail each of these known risk factors, as well as the intraoperative techniques used to anticipate skin
necrosis. We will also review postoperative strategies to prevent skin necrosis. Lastly, we will discuss the
future directions of necrosis detection and treatment.

PREOPERATIVE PLANNING
Patient-specific risk factors
A number of both retrospective and prospective studies have identified potential risk factors for developing
breast skin necrosis after mastectomy. Independent of both mastectomy technique and reconstruction type,
these established determinants include increased body mass index (BMI), older age, diabetes mellitus, and
tobacco use [10,12,15-18] . A history of breast irradiation and surgery, including augmentation and reduction, has
also been shown to increase the risk of skin necrosis [5,9,17] . Based on our ten-year institutional cohort of 530
patients and 902 breast reconstructions, obesity (BMI > 30 kg/m ) and hypertension were risk factors across
2
[19]
all patients .
Increased breast size has also been implicated in skin necrosis, as measured through proxies such as
mastectomy specimen weight and volume on mammograms [7,9,20] . However, we have shown that direct
anatomic measurement in the preoperative period provides similar predictive power. During the initial
consultation, we routinely collect five anatomic breast measurements: nipple-sternal notch distance, nipple-
inframammary fold distance, chest width, breast height, and breast circumference [Figure 1]. In our
experience, the risk of necrosis increases significantly with a nipple-sternal notch distance > 27 cm, nipple-
inframammary fold distance > 8.5 cm, chest width > 15 cm, breast circumference > 29 cm, and breast height
> 10.5 cm .
[21]