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Page 6 of 10 García Nores et al. Plast Aesthet Res 2023;10:33 https://dx.doi.org/10.20517/2347-9264.2022.146

[30]
has resolved and flap softening has occurred .

Many astute clinicians and patients often notice mild discoloration or firm areas of a flap postoperatively,
especially along the periphery. These areas are likely mild ischemia and/or congestion, which may evolve
into partial flap loss or fat necrosis. Routine imaging is not recommended, as these smaller areas of fat
necrosis are likely to resolve spontaneously and do not require any intervention. For any patients where
there is a palpable mass with significant concern, ultrasound is a cost-effective and simple tool to confirm
the benign post-surgical change and calm their fears. Our general recommendation is expectant
observation, massage, and providing reassurance that any persistent areas of concern can be addressed in
the future. Tenderness is expected, and some patients with mild or moderate discomfort can be offered non-
steroidal analgesics and careful observation. Narcotics may be necessary for patients suffering from severe
flap necrosis and severe pain until surgical intervention can be scheduled.

Hyperbaric oxygen (HBO) has been studied in animal models extensively, but there is more limited data on
human clinical use due to a lack of standardization and availability. Baynosa and Francis summarized the
recent studies which demonstrated utility in salvage of compromised grafts/flaps and improved flap
survival. The mechanism of action is likely related to improved tissue oxygenation, fibroblast function,
neovascularization and minimizing ischemic-reperfusion injury, which theoretically would also minimize
[31]
fat necrosis or partial flap loss . HBO may be relatively contraindicated in select patients due to the risk of
pneumothorax if there was any concern for iatrogenic injury during recipient vessel exposure. Further
research is needed to better understand the role of HBO for our autologous breast reconstruction patients.

Anecdotal reports have described a successful technique of aeration of fat necrosis under local anesthesia
after breast reduction. The authors recommend early intervention using an 18-gauge hypodermic needle to
puncture the area of fat necrosis multiple times. This technique is similar to lawn aeration done to minimize
soil compaction and maximize penetration of air, water, and nutrients to grass roots. Theoretically, this
technique introduces new channels into the threatened area of ischemia tissue to either deliver blood,
oxygen and/or nutrients, as well as creating channels for macrophages to access and break down the
necrotic fibrosis. The exact mechanism requires further study but is an interesting option to consider for the
management of areas of early fat necrosis. Obviously, this should be judiciously used near the pedicle to
avoid inadvertent damage to the entire flap perfusion.

In our experience, even moderately large areas of firmness and fat necrosis often fully or partially resolve
enough to become acceptable to patients after 3-6 months. For these smaller zones of fat necrosis that are
truly bothersome to the patient (visible, painful, and/or palpable), elective removal can easily be performed
during second stage revision, usually after 3 months.

For the management of more significant partial flap loss, the clinical evaluation must distinguish between
fat necrosis occurring within a fully buried portion of a flap or “partial flap necrosis” where a visible
superficial skin flap is necrotic. For an exposed area, earlier intervention with surgical debridement may be
necessary if there is a large volume of flap loss (> 25%) and concern for infection. However, these situations
can often be successfully managed conservatively with wound care and reassurance to minimize deformity.
In our experience, these rarely require a return to the operating room unless a majority of the flap is
necrotic and poses a significant risk of gangrenous necrosis. Aggressive debridement should be avoided as
this may actually expose tenuous tissue that would otherwise recover, and instead convert these tenuous
areas into additional volume loss, thereby creating a secondary deformity that is extremely difficult to
correct without further surgery or additional flap(s). Topical antimicrobials such as silver sulfadiazine can