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Black et al. Plast Aesthet Res 2023;10:31 https://dx.doi.org/10.20517/2347-9264.2023.04 Page 7 of 9

Figure 2. Skin banking during stage 1 of NSM with DIEP flap reconstruction. During stage 2, banked skin can be removed, or used to
replace native breast skin in the event of necrosis or additional oncologic resection.

surgical management algorithm for maintaining core body temperature . Heat-induced vasodilation not
[44]
only improves skin perfusion following both alloplastic and autologous reconstruction, but also helps
mitigate microvascular compromise in flap-based reconstructions [19,44] . However, care should be taken, as
denervated skin lacks some of the protective vasodilatory effects of normally innervated skin and is
therefore at higher risk of suffering thermal burns. Patients should not treat themselves with warming
devices after discharge.

CONCLUSION
Skin flap necrosis is a common complication after mastectomy. It is influenced by patient factors such as
age, BMI, diabetes, tobacco use, prior surgery, and irradiation. Larger breast size, both in terms of volume
and surface area, also increase risk. In the operating room, nipple-sparing mastectomies, thin skin flaps,
periareolar incisions, and autologous reconstructions may also promote skin necrosis. However,
indocyanine green angiography can assist surgeons with early detection and management of necrosis, and
banking skin flaps during autologous reconstruction can provide a cost-effective and aesthetically pleasing
option for revision. In the postoperative period, topical nitroglycerin and external warming can improve
skin flap perfusion and mitigate the severity of necrosis. In the future, other topical agents such as
tacrolimus may be used in similar clinical settings without the systemic effects on blood pressure that limit
the use of nitroglycerin. Clearly, while much is known about the risk factors, prevention, and treatment of
skin necrosis after mastectomy, more studies must be done to further this field of knowledge and thus
improve patient well-being.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the design of the study: Black GG, Otterburn DM