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García Nores et al. Plast Aesthet Res 2023;10:33 https://dx.doi.org/10.20517/2347-9264.2022.146 Page 7 of 10

be applied to minimize the risk of infection until the tissue fully demarcates. Patients should be advised to
expect wound dehiscence and development of an eschar and home health care may be useful to arrange.
Once the tissue is fully demarcated, debridement of the eschar and underlying dead fat is easy to perform in
the clinic as this area is usually insensate. Wet-to-dry dressings and/or negative pressure therapy can also be
applied to facilitate wound closure via secondary intention. It is often not necessary to fully debride all the
fat necrosis as the healthy portion of the flap will granulate and cover deeper fat necrosis. Deep areas of fat
necrosis are often not palpable or noticeable to the patient and do not require any further intervention.
Secondary correction of the smaller resulting deformity can be performed with scar revision, flap
repositioning or advancement, and/or fat grafting once the wound is fully healed.

Small vs. moderate vs. large size deformity
The size of the defect must be considered when discussing treatment options to correct the deformity. Small
areas adjacent to the scars can be directly excised. Deeper areas or more remote areas from the scar (i.e., the
upper medial breast) can be removed with liposuction rather than reopening the entire incision for
exposure and risk creating a large dead space. Autologous fat transfer is the most minimally invasive
treatment which can readily correct minor deformities. A more aggressive cutting tip cannula may be
necessary for very dense areas of fibrosis. Ultrasound-assisted liposuction (UAL) can facilitate the removal
of moderately large areas. A larger area may require multiple sessions to slowly scrape out the fat necrosis
and replace it with autologous fat transfer. Hassa et al. successfully treated 54 breast reconstructions with fat
necrosis with UAL. The average size was 2.72 cm and half the patients only required one session. Thirty-
seven percent (20 patients) required two sessions, and the remaining 13% (7 patients) required three
sessions. Complete resolution was confirmed in 44 patients (81.5%) and only one thermal burn
[32]
complication was noted . We personally believe it is not necessary to fully remove the fat necrosis with
direct liposuction, as simply breaking up a larger fibrotic mass facilitates the body’s natural lytic process.
During liposuction for moderately large zones of fat necrosis, our group’s primary goal is to soften the area
of concern and minimize visible deformity prior to transfer of autologous fat. Patients must be warned to
expect multiple sessions to fully address moderately large zones of fat necrosis.

Larger volume loss can also be corrected with the addition of an implant if the soft tissue envelope is
adequate and the patient is amenable. Care must be taken to avoid damaging the pedicle during pocket
dissection for the implant. We would strongly encourage waiting at least 3 months to maximize the
revascularization from the surrounding soft tissue before risking injury to the primary pedicle. In larger
defects where both skin and volume are deficient, a secondary flap and/or expander-implant may be
necessary. The thoracodorsal artery perforator flap (Tdap), latissimus flap and epigastric perforator flaps are
great local flap options that can be advanced, rotated, or transferred as propeller flaps into the defect. In the
most severe scenarios, it may be beneficial to consider another free flap. Common alternative secondary free
flaps include the transverse upper gracilis, profunda artery perforator, lumbar artery perforator, lateral thigh
perforator, and gluteal free flaps. Careful evaluation of the remaining donor sites and discussion with the
patient is needed to address the defect with the most appropriate flap.

DISCUSSION
Despite significant advances in preoperative and intraoperative surgical technology and a better
understanding of flap perfusion, partial flap necrosis and fat necrosis remain persistent nemesis for
surgeons performing autologous breast reconstruction. The majority of studies are retrospective and limited
in size. Current evidence supports the use of both preoperative imaging and intraoperative ICG
Angiography to maximize flap perfusion and debride poorly perfused tissue. The choice of which
perforators to harvest remains a challenge to maximize perfusion and minimize donor site morbidity. Both