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Page 8 of 10 García Nores et al. Plast Aesthet Res 2023;10:33 https://dx.doi.org/10.20517/2347-9264.2022.146

the introduction of the APEX flap or a secondary venous outflow have shown promise in improving flap
physiology to improve outcomes, but require slightly more technical effort with additional anastomoses and
an unclear benefit. Minimizing ischemia time is an easy goal for all surgeons and often can be achieved by
creating dedicated microsurgical care teams.

The current evidence is often inconclusive and poor in quality (level 3 or lower evidence). This calls for the
need to standardize the diagnosis of fat necrosis, evaluate the timing of intervention and techniques, and
establish a classification grading system to allow for prospective large-volume studies to better understand
the true incidence of fat necrosis and the most appropriate management strategies. Consideration during
flap inset to bury any areas of questionable perfusion can avoid partial flap necrosis and convert this into fat
necrosis which is easier to manage. HBO and fat aeration have been suggested to improve fat necrosis in the
postoperative period with limited evidence. Mild to moderate partial flap necrosis or fat necrosis can often
be conservatively managed successfully to minimize deformity. Ultimately, most patients with symptomatic
fat necrosis due to pain or deformity require secondary correction with a combination of techniques,
including fat transfer, liposuction, flap advancement, addition of local or secondary free flaps for soft tissue,
and addition of an expander or implant for volume.

CONCLUSIONS
As Benjamin Franklin wisely stated, “An ounce of prevention is worth a pound of cure”, and that certainly
still holds true in dealing with partial flap failure and fat necrosis following autologous breast
reconstruction. As such, the majority of the suggested strategies are focused on pre-surgical planning and
intraoperative decision-making to successfully harvest a maximally perfused flap. Navigating this
complication remains a complex challenge for even the most skilled of microsurgeons, and often requires
multiple additional procedures to remove the necrotic tissue and restore the deficiency using fat transfer,
additional flaps, and/or placement of an expander or implant.

DECLARATIONS
Authors’ contributions
Contributed to the article: Garcia Nores GD, Cheng A

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2023.