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. 2024 Dec 27;36(6):e598–e605. doi: 10.1097/SCS.0000000000011060

Reduce Flap Necrosis After Autologous Breast Reconstruction: A Systematic Review

Yiwen Gao 1, Lu Yin 1, Tinghong Xiang 1, Tianyi Ni 1, Jingping Shi 1,✉
PMCID: PMC12376823  PMID: 39729252

Abstract

Background:

Autologous breast reconstruction provides substantial benefits in terms of aesthetics and longevity. However, the risk of flap necrosis poses potential challenges to patients’ appearance and psychological well-being, while also escalating health care costs. Consequently, examining the risk factors, assessment techniques, and therapeutic approaches for flap necrosis is critically important.

Method:

The authors conducted a comprehensive search for relevant studies from January 2010 to August 2024 using PubMed, Web of Science, and the Cochrane Library. The search terms included “autologous breast reconstruction”, “flap necrosis”, “risk factor”, “assessment”, and “treatment”. The authors initially screened titles and abstracts, followed by a detailed review by 3 investigators to determine the studies that met the inclusion criteria.

Result:

A total of 68 studies were ultimately selected for analysis. Identified risk factors for flap necrosis include smoking, advanced age, obesity, diabetes, large breast volume, previous radiotherapy, and abdominal surgery. Various assessment methods (e.g., preoperative imaging, intraoperative blood flow monitoring, and postoperative evaluations) can enhance flap survival. The review also covered surgical treatment strategies and non-surgical interventions, including local wound care, hyperbaric oxygen therapy, and pharmacological treatments.

Conclusion:

This review highlights the critical role of thorough planning and management in minimizing the risk of flap necrosis after autologous breast reconstruction. Effective preoperative assessments, perioperative monitoring, and specific postoperative interventions can significantly lower the incidence of flap necrosis.

Key Words: Autologous breast reconstruction, breast cancer, flap necrosis, mastectomy, postoperative complications

Breast cancer is one of the most prevalent malignant tumors among women globally and a leading cause of cancer-related mortality in females. Global statistics from 2022 indicate that breast cancer represents the highest proportion of all cancer diagnoses in women, with ~2.3 million new cases identified worldwide.1 As the prevalence of breast cancer rises, mastectomy has become a widely adopted treatment option. Over the last decade, there has been a noticeable shift towards choosing mastectomy even for patients who are candidates for breast-conserving surgery. The use of prophylactic mastectomy is also increasing.2 Mastectomy significantly impacts the physical appearance of patients and can adversely affect their psychological health. The loss of a breast frequently triggers a crisis in self-image identity among women, subsequently impacting their self-esteem and overall quality of life. Consequently, breast reconstruction surgery is widely acknowledged as an essential component of comprehensive rehabilitation after mastectomy.3

Compared with implant-based reconstruction, autologous breast reconstruction utilizes the patient’s own tissue, yielding a more natural appearance and feel in the reconstructed breast. Autologous tissue closely mimics the shape of a natural breast and adapts to the body’s natural changes, such as fluctuations in weight or aging. This method is ideal for patients seeking long-term, natural-looking outcomes.4

However, autologous breast reconstruction surgery places an extremely high demand on the blood supply to the flap. The success of the surgery largely depends on the precision of vascular anastomosis and the adequacy of postoperative blood flow to the flap.4 Insufficient blood supply can lead to flap necrosis, resulting in wound dehiscence, infection, and potential failure of the reconstruction. Necrosis may vary from mild epidermolysis, which requires local care, to full-thickness necrosis that necessitates surgical debridement and salvage, potentially causing scarring, deformity, and increased rates of reoperation. The extent and severity of tissue necrosis determine the required treatments, which can range from simple dressing changes to more extensive surgical debridement. More severe cases may lead to failure of the reconstruction or necessitate a revision of the surgical plan, impacting the patient’s physical and mental health as well as health care costs.5 Preventing flap necrosis involves understanding risk factors, conducting thorough assessments, and implementing appropriate interventions.

METHODS

This review is based on a systematic search and analysis of literature concerning flap necrosis after autologous breast reconstruction. We conducted searches across PubMed, Web of Science, and the Cochrane Library, covering publications from January 2010 to August 2024. The search keywords included “autologous breast reconstruction”, “flap necrosis”, “risk factor”, “assessment”, and “treatment”. We used Boolean logic operators and MeSH terms to enhance the precision of our search results.

Inclusion and Exclusion Criteria

Inclusion criteria encompassed original research, clinical studies, and prospective or retrospective cohort studies that discussed flap necrosis after autologous breast reconstruction. Exclusion criteria ruled out case reports, animal experiments, and non-English literature. We also omitted studies not pertinent to breast prosthesis reconstruction. A manual cross-review of the literature was conducted for studies meeting these criteria. The initial screening was based on titles and abstracts, followed by a full-text review of the selected studies. Any differences of opinion regarding the inclusion of studies were resolved through discussions among researchers to ensure consistency.

Screening

According to the PRISMA guidelines, 2 researchers independently screened the titles and abstracts of the initial search results. For any literature deemed controversial, a third researcher conducted a review to reach a final consensus. The process for selecting articles is illustrated in the flow diagram shown in Figure 1.

FIGURE 1.

FIGURE 1

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PRISMA flow diagram. PRISMA indicates Preferred Reporting Items for Systematic Reviews.

Quality Evaluation

For the included literature, we assessed the quality of observational studies using the Newcastle-Ottawa Scale (NOS). Studies scoring below 6 were deemed low quality and excluded to ensure the reliability of the literature reviewed.

RESULTS

A total of 274 articles were identified through the search. Of these, 215 were excluded for not being relevant to the purpose of this review. In addition, the authors referenced 9 further papers that were cited in related articles or deemed potentially important. Consequently, the total number of papers actually utilized in this review amounted to 68 (Fig. 1).

DISCUSSION

Risk Factors for Flap Necrosis After Autologous Breast Reconstruction

The risk factors for flap necrosis after autologous breast reconstruction are primarily categorized into patient factors and other factors (Fig. 2).

FIGURE 2.

FIGURE 2

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Risk factors for flap necrosis after autologous breast reconstruction.

Patient Factors

Patient factors primarily encompass smoking,6 age,7 diabetes,8 obesity,9 large breast volume,10 radiotherapy in the operative area, history of abdominal surgery, severe comorbidities, drug use (including immunosuppressants and corticosteroids), and connective tissue diseases such as Ehlers-Danlos.11,12

Smoking

Smoking is a significant risk factor for various complications, including fat necrosis (P=0.006), wound infection (P=0.002), mastectomy flap necrosis (P=0.039), and abdominal flap necrosis (P=0.042).13 The underlying mechanisms may involve nicotine, a known vasoconstrictor, reduced hemoglobin oxygenation due to binding by carbon monoxide, and increased platelet aggregation.14

Age

Age is a contributing factor to flap necrosis, likely because older patients often have more age-related comorbidities and health conditions.15 Research evaluating surgical complications in elderly populations has indicated that a patient’s overall health status is a more significant predictor of outcomes than age alone.16 For patients aged 65 and older, although there is an elevated risk of flap necrosis, this risk is generally considered acceptable in light of the substantial benefits provided by the procedure.17

Diabetes

Patients with diabetes may develop several vascular abnormalities, such as increased blood viscosity, impaired intimal repair, and dysfunction of endothelial cells, red blood cells, and platelets. These factors collectively can compromise the blood supply to the flap, thereby heightening the risk of flap necrosis.

Obesity/Body Mass Index (BMI)

Patients with obesity (BMI ≥30 kg/m2) face an increased risk of complications. Numerous studies have demonstrated that obese patients are more likely to experience mastectomy flap necrosis, along with a higher incidence of hematomas, partial flap detachment, fat necrosis, and wound infections. These issues are often linked to diminished blood supply due to obesity. A systematic review and meta-analysis by Rawan and colleagues indicated that among patients with a BMI >30 kg/m2, autologous reconstruction resulted in a lower incidence of flap necrosis and other complications, as well as higher satisfaction after reconstruction compared with prosthesis reconstruction.18 Given that obese patients typically have poorer vascular conditions, which can compromise the blood supply to the flap and increase the risk of surgical complications, a thorough preoperative evaluation is crucial to determine the most suitable method of reconstruction.

Large Breast Volume

Large breast volume may contribute to an increased rate of flap necrosis, which can be explained through several factors. Firstly, a larger breast typically requires a flap to cover a more extensive surface area, necessitating a broader blood supply. This increases the risk of inadequate perfusion, particularly to the areas at the periphery of the flap. In addition, reconstructing a larger breast volume often results in increased skin tension over the flap. This heightened tension can compress the blood vessels, thereby restricting blood flow to the flap. Such ischemic conditions elevate the likelihood of flap necrosis.

Radiotherapy

Radiotherapy can cause flap necrosis, primarily by damaging local blood vessels and tissues, which diminishes blood flow and jeopardizes flap survival. In addition, the impaired tissue healing post-radiotherapy heightens the risk of complications, such as infections and wound dehiscence, further endangering the flap’s health. Radiotherapy-induced fibrosis can also cause flap shrinkage or deformation, negatively affecting the aesthetic results of breast reconstruction. In their retrospective analysis of 185 patients who underwent immediate deep inferior epigastric perforator (DIEP) flap breast reconstructions between 2006 and 2020, Zhang et al19 observed an increased incidence of fat necrosis due to radiotherapy. For those concerned about these complications, delayed breast reconstruction may be an option.20

History of Abdominal Surgery

A retrospective study by Mehrara et al21 revealed that patients who had undergone abdominal surgery for transverse rectus abdominis myocutaneous (TRAM) flap reconstruction were at an increased risk of both flap necrosis and fat necrosis. Previous surgeries can compromise the epigastric artery perforators, alter perfusion and lymphatic drainage of the abdominal wall skin, disturb the normal anatomical structure, and generate scar tissue that complicates the layers of the abdominal wall. The detection of abdominal scars during a physical examination may necessitate alterations to the surgical approach for breast reconstruction.

Other Factors

Other factors influencing flap viability primarily include the thickness of the preserved flap, the choice of flap type, the prophylactic use of antibiotics,22 operation duration exceeding 6 hours,23 and perioperative management of the operative area.

Thickness of the Preserved Flap

Studies indicate that up to 56% of women possess a subcutaneous tissue layer, with a median thickness of 10 mm (ranging from 0 to 29 mm) between the dermis and breast parenchyma, which contains few mammary gland epithelia.24 Interestingly, this thickness does not correlate with BMI, age, breast weight, or even the thickness of subcutaneous layers in different breasts of the same patient. Although thicker flaps may minimize necrosis, they also increase the risk of retaining residual tumor tissue, thus requiring a careful balance between complete tissue removal and maintaining reliable flap integrity during mastectomy. Wiberg et al25 reported a 6-fold increase in flap necrosis when flap thickness was ≤5 mm. Conversely, Magnus observed an increased likelihood of residual breast tissue in flaps thicker than 5 mm, with a notable increase when thickness exceeded 7 mm.26 Determining whether maintaining a flap thickness of 5 mm represents an optimal balance still requires further clinical verification.

Selection of Flaps

In a retrospective study by Gart et al, the 30-day complication and reoperation rates were highest with free skin flaps, whereas complications were notably rare with latissimus dorsi myocutaneous flap (LDP).27 Massenburg’s univariate and multivariate logistic regression analyses indicated that, after adjusting for confounding variables, TRAM flaps were twice as likely to fail [odds ratio (OR) 2.279, P=0.001], and free flaps were 3 times more likely to fail (OR 3.172, P<0.001) compared with LDP.28 Levine’s review of 133 breast cancer patients undergoing delayed breast reconstruction post-radiotherapy showed that abdomen-based autologous reconstructions experienced fewer complications and failures than those using LDP.29 Overall, abdominal and dorsal flaps are more commonly used in breast reconstruction, demonstrating a lower incidence of flap necrosis and other complications.

EVALUATION OF FLAP NECROSIS AFTER AUTOLOGOUS BREAST RECONSTRUCTION

Flap necrosis arises when the blood supply to the flap is inadequate to meet its metabolic demands. To prevent flap necrosis after reconstruction, it is crucial to assess the incidence of flap necrosis at all stages of the process: preoperatively, intraoperatively, and postoperatively.

Pre-operation

Preoperative imaging is crucial for accurately locating the perforating vessels in autologous breast reconstruction. Techniques such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), color Doppler ultrasonography (CDU), and dynamic infrared thermography (DIRT), not only help shorten the operative time but also reduce the incidence of complications, thereby enhancing flap survival and the overall effectiveness of the reconstruction.

Currently, CTA is considered the “gold standard” for assessing preoperative vascular anatomy.30 A systematic literature review by Teunis et al demonstrated that preoperative CTA significantly reduced the incidence of partial flap necrosis (P<0.0001) compared with CDU in patients undergoing DIEP flap breast reconstruction.31 Preoperative CTA enables precise assessment of vascular anatomy in the thoracic and abdominal walls, accurate localization of perforating vessels in the abdominal donor area, and identification of dominant perforators (Fig. 3). It facilitates the choice of intercostal space, inspection of the internal thoracic artery and its perforating vessels in the thoracic recipient area, and allows for the reconstruction of the volume of abdominal flaps to match the size of the contralateral breast. In addition, it aids in precontouring of the abdominal flap, which is crucial for developing the surgical plan and enhancing flap reliability. Preoperative CTA holds significant potential and promise for locating perforating vessels in the donor area, selecting recipient vessels, and evaluating breast volume for autologous DIEP flap breast reconstructions.32

FIGURE 3.

FIGURE 3

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This is a preoperative CTA image of a 50-year-old female patient who underwent a right mastectomy 9 years ago and is scheduled for a second-stage autologous breast reconstruction. CTA is used preoperatively to locate the perforating vessels in the abdominal donor area. CTA indicates computed tomography angiography.

Although CTA is highly effective, it does have drawbacks, including radiation exposure from repeated imaging and the risk of reactions to contrast agents, which can strain renal function. DIRT33 is an emerging technique that offers a noninvasive, portable, and rapid alternative for localizing perforating vessels. It provides real-time vascular information and enables the precise location of perforators, thereby optimizing surgical planning. DIRT allows for the use of projection-based augmented reality, projecting thermal information directly onto the patient’s skin. This facilitates the marking of vessel locations before DIEP flap breast reconstruction and enables the assessment of anastomotic stoma patency and reperfusion of the skin flap during surgery, and postoperative flap viability monitoring. DIRT also shows promise for other free flap surgeries where CTA is less suitable, such as in anterolateral thigh flaps or when the scanning direction for deep femoral artery perforator flaps is challenging. Further research is underway to explore DIRT’s potential and feasibility for intraoperative projection in autologous breast reconstruction and other free flap procedures.

An accurate preoperative prediction of flap thickness is also crucial; typically, a sufficiently thick flap indicates a robust vascular distribution and an adequate blood supply. Preoperative clinical measurements, along with breast ultrasonography, breast magnetic resonance imaging, and mammography, can enhance the prediction of flap thickness, thereby effectively reducing the incidence of complications.34

During Operation

Assessing the quality and survival potential of the flap is essential during surgery. It is crucial to closely monitor the blood flow to the flap to ensure the effectiveness of the vascular anastomosis, which in turn improves flap survival.

A clinical examination provides a straightforward and practical method for assessing the blood perfusion of the flap. The incisal margin of the flap should be meticulously inspected for signs of bleeding. In addition, a preserved layer of fat on the medial side of the flap is important because the presence of subcutaneous tissue indicates that the subcutaneous vascular network is well-maintained, suggesting that the flap is likely to be viable and well-supplied with blood.

Studies indicate that blood glucose measurements offer a straightforward method to monitor the blood supply status of microsurgical flaps, thereby helping to reduce the incidence of flap necrosis after tissue transplantation. Measurements should be taken at 3 critical junctures: upon the patient’s entry into the operating room, after the mastectomy, and upon the completion of breast reconstruction before skin closure. It is advisable to select the measuring site either in the areolar region near the incision, at the distal or free margin of the areolar pedicle, along with a control measurement from the systemic blood. If the blood glucose level of the skin flap is lower than the patient’s normal blood glucose level, it signals a heightened risk of flap necrosis.35 Early detection of nipple-areola complex (NAC) necrosis allows surgeons to implement timely excision measures during the surgery to prevent subsequent complications.

Over the past few decades, optical imaging has garnered increasing interest in reconstructive surgery. These noninvasive or minimally invasive real-time imaging techniques are poised to revolutionize postoperative monitoring of patients with DIEP flaps. Although clinical evaluation and traditional monitoring methods such as handheld doppler ultrasound (HHD) remain essential, optical imaging offers significant benefits. Techniques such as near-infrared spectroscopy (NIRS), laser speckle contrast imaging (LSCI), indocyanine green angiography (ICGA), and hyperspectral imaging not only provide comprehensive information about tissue oxygenation, perfusion, and viability but also enhance the accuracy and reliability of postoperative monitoring. These advancements allow surgeons to more thoroughly assess the health status of the flap, identify potential issues promptly, and thereby ensure flap survival and optimal surgical outcomes for patients.36

In recent years, ICGA has emerged as a valuable tool for the intraoperative assessment of tissue perfusion, significantly reducing the incidence of flap necrosis after breast reconstruction.37 A meta-analysis conducted by Pruimboom et al indicated that ICGA substantially decreases the need for skin flap repairs after breast reconstruction.38 ICGA is invaluable in assessing the viability of DIEP flaps, thus reducing postoperative complications.39 Furthermore, studies report that the success rate of ICGA in reducing the overall incidence of complications in free flaps is 92.0%.40 However, it is associated with a risk of anaphylactic shock, even in patients with no history of drug allergies.41 In addition, there is still a lack of high-quality evidence supporting the routine use of ICGA for evaluating flap necrosis post-mastectomy.

NIRS42 is a valuable noncontact, wide-angle, rapid, and portable device that offers objective numerical values for evaluating intraoperative flap perfusion areas. In addition, it can be used multiple times as needed, such as during flap collection, after vascular anastomosis, and after wound closure. NIRS is capable of detecting normal temporal and spatial differences in tissue oxygenation during autologous breast reconstruction. However, to determine its sensitivity and specificity in detecting flap necrosis, multicenter, prospective clinical trials are still required.43

Postoperation

Marks et al44 proposed a paintable phosphorescent bandage to assess tissue oxygenation after DIEP flap reconstruction. This dressing continuously monitors the blood oxygen levels of the flap through a phosphorescent response triggered by changes in oxygenation. It aims to enable surgeons to take early intervention measures when the flap risks hypoxia, thereby reducing the likelihood of postoperative flap necrosis. This technique, being noninvasive and simpler to apply, offers an improvement over traditional monitoring methods. Moreover, by enhancing the monitoring accuracy of tissue perfusion, it elevates the overall success rate of breast reconstructions and increases patient satisfaction. This method holds broad potential in monitoring tissue blood supply and could become a standard technique for assessing flap necrosis after breast reconstructions in the future.

The Skin Ischemia and Necrosis (SKIN) score was initially recognized as a predictor of postoperative outcomes and the need for reoperation in breast flap necrosis cases. It allows for the prediction of breast flap necrosis through a straightforward calculation.45 However, recent studies suggest that although the SKIN score can predict certain outcomes, it does not correlate well with long-term flap necrosis after mastectomy and is ineffective at predicting the likelihood of reoperation. Consequently, this scoring system still necessitates further refinement.

TREATMENT OF FLAP NECROSIS AFTER BREAST RECONSTRUCTION

Unlike prosthetic breast reconstruction, autologous reconstruction often retains living, healthy tissue beneath the necrotic flap, providing a range of treatment options for managing necrotic flaps. Typically, local wound care and minor debridement are sufficient to promote gradual healing of the wound without necessitating more aggressive interventions.

However, prolonged wound healing can result in scar deformity of the breast and delay adjuvant therapies such as chemotherapy or radiotherapy. Studies indicate that a secondary healing process exceeding 3 weeks elevates the risk of scar deformity, adversely affecting the aesthetic results of breast reconstruction.46 Consequently, for wounds requiring more than 3 weeks to heal, surgical intervention may be the preferable option, particularly when considering the size of the necrotic flap. For patients needing adjuvant chemotherapy or radiotherapy, expediting wound closure can reduce the delay before initiating these therapies.

Gloria R. Sue developed an algorithm to manage flap necrosis after breast reconstruction through retrospective analysis.47 This analysis highlighted that a necrotic flap area >10 cm² is a critical threshold for deciding on surgical intervention. This metric aids in assessing the urgency of surgery and serves as an essential reference in choosing treatment options. However, the evaluation of flap necrosis is not based solely on one indicator, the depth of the necrotic skin flaps, the color of the flap margins, and the presence or absence of infection are all crucial factors to consider. In clinical practice, it is typically recommended to regularly change dressings and closely monitor the color, area, and margins of the necrotic flap to inform the subsequent treatment strategy.

Operative Treatment

The decision between outpatient operative treatment and inpatient surgery is determined by the area and depth of flap necrosis. For small necrotic areas with ample skin redundancy, outpatient debridement and suturing can be performed under local anesthesia. Conversely, if the necrotic area is too large for direct suturing post-excision, consideration is given to skin flap transplantation.

Reichl et al48 discovered that skin banking becomes a practical approach to postpone flap implantation during mastectomy when the risk of flap necrosis is exceedingly high. This method involves prophylactically placing the flap beneath the skin rather than de-epithelializing the autologous tissue during the initial reconstruction. The extra tissue is beneficial not only in cases of flap necrosis but also allows for secondary excision if needed, thus enhancing the aesthetic outcome for patients who undergo radiotherapy and experience local recurrence of breast cancer. Surgeons should carefully evaluate the risk of flap necrosis as a basis for deciding whether to use this technique to avoid unnecessary secondary surgeries.

The “Surgical Delay”49,50 technique enhances the survival of the skin flap and NAC. This method involves separating the skin and subcutaneous tissue from the underlying breast parenchyma around 5 cm from the nipple, 21 days before surgery. By delaying vascularization before surgery, this technique boosts blood perfusion to the NAC, thereby reducing the risk of postoperative necrosis. Study results indicate that this approach is highly effective in nipple-sparing mastectomies, yielding improved surgical outcomes and offering better options for patients.

Nonoperative Treatment

Postoperative flap necrosis after mastectomy is typically managed with nonoperative treatments, which primarily include pharmacotherapy and various adjunctive therapies.

Pharmacotherapy

Common medications used include nitroglycerin (NTG) ointment, prostaglandin E1 (PGE1), cilostazol, and dimethyl sulfoxide (DMSO) ointment.

NTG acts as a local vasodilator that relaxes vascular smooth muscles and dilates veins and arteries. In addition, topical NTG prompts endothelial cells to synthesize prostacyclin and inhibits the activation of blood platelets, thereby enhancing flap survival by reducing thrombosis in smaller vessels.51 Numerous studies, including randomized controlled trials, have consistently demonstrated NTG’s therapeutic effect on flap necrosis after breast reconstruction. However, the precise dosage, duration of application, and potential factors influencing drug efficacy still require further investigation.52,53

PGE1 is also a vasodilator that enhances tissue perfusion.54 Animal studies indicate that PGE1 may reduce leukocyte-endothelial cell adhesion by decreasing the expression of intercellular cell adhesion molecule-1 (ICAM-1), thereby improving flap survival.55 A prospective study by Hwang et al56 found that the use of PGE1 significantly lowered overall flap complications in cases of immediate implant-based breast reconstruction (P=0.018). However, no studies have conclusively shown that PGE1 is effective in alleviating flap complications after autologous breast reconstruction. Further research is needed to assess the potential role of PGE1 in enhancing flap survival and preventing complications.

Cilostazol, a potent Phosphodiesterase 3 (PDE3) selective inhibitor, enhances cyclic adenosine monophosphate (cAMP), which in turn lowers intracellular calcium in smooth muscle cells. This causes relaxation and vasodilation, and it also promotes inhibition of platelet activation and aggregation, thereby reducing thrombogenesis. These effects improve blood perfusion in ischemic skin flaps, increasing their survival.57 Consequently, several studies have demonstrated that cilostazol can be effectively used in both the prevention and treatment of flap necrosis.58,59

DMSO is an organic solvent known to stimulate histamine release, causing vasodilation that enhances tissue perfusion and reduces ischemia in tissue flaps.60 Several studies have shown that DMSO effectively mitigates breast flap necrosis.61 Furthermore, a study by Silverstein and colleagues suggests that DMSO may be an effective local treatment for NAC necrosis after breast surgery. It is cost-effective, easy to apply, and associated with no significant side effects, making it a candidate for further research in comparison to treatments like nitroglycerin ointment.62

Other Adjunctive Therapies

Treatment of flap necrosis after autologous breast reconstruction encompasses a variety of adjunctive therapies. These include negative-pressure therapy, local thermal pretreatment, and hyperbaric oxygen therapy (HBOT), among others. Each of these therapies contributes to improving tissue viability and promoting healing by enhancing blood flow and oxygenation to the affected areas.

The postoperative use of negative-pressure therapy has been demonstrated to decrease the complication rate in breast reconstruction, proving to be a well-tolerated and adaptable method.63 A retrospective study by Kim et al64 showed that negative-pressure therapy resulted in a significantly lower overall complication rate (11.1% versus 27.9%; P=0.019) and a reduced rate of mastectomy flap necrosis (8.9% versus 23.5%; P=0.030) compared with standard surgical dressing.

Local thermal treatment has been shown to have a supportive effect on managing flap necrosis. Early prospective experiments indicate that local thermal pretreatment can enhance the blood supply to the flap in certain scenarios, suggesting its potential as a prophylactic measure to improve outcomes in breast reconstruction.65

HBOT is increasingly used to manage various ischemic flaps. By hyperoxygenating the tissues, HBOT helps prevent ischemia-reperfusion injury, reduces edema, and promotes rapid neovascularization, which can halt the progression of ischemia to necrosis and thus limit the extent of necrosis.66 Recent studies have highlighted the notable effectiveness of HBOT in retaining flaps in breast reconstruction patients.67 A brief course of HBOT may be enough to successfully salvage flaps at risk of necrosis. In addition, HBOT has been observed to offer benefits beyond wound healing, including mood enhancement, alleviation of posttraumatic stress disorder (PTSD) symptoms and anxiety, and the potential to increase the effectiveness of chemotherapy.68

CONCLUSION

This review systematically analyzes the potential risk factors, assessment methods, and treatment options for flap necrosis after autologous breast reconstruction (Fig. 4). Autologous reconstruction offers significant benefits in terms of postoperative appearance and durability; however, it demands a high blood supply, and flap necrosis continues to be a major complication. Effective preoperative planning and interventions are crucial, including the management of risk factors, precise imaging for localization, and body temperature regulation. In addition, intraoperative hemodynamic monitoring and postoperative multimodal interventions such as negative-pressure therapy, hyperbaric oxygen therapy, and topical medications have proven beneficial in enhancing flap survival and minimizing complications. Future research should aim to develop personalized risk prediction models and advanced imaging techniques to prevent flap necrosis in autologous breast reconstruction, ultimately enhancing patient quality of life and postoperative satisfaction.

FIGURE 4.

FIGURE 4

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How to avoid flap necrosis after autologous breast reconstruction. CDU indicates color Doppler ultrasonography; CTA, computed tomography angiography; DIRT, dynamic infrared thermography; HBOT, hyperbaric oxygen therapy; ICGA, indocyanine green angiography; MRA, magnetic resonance angiography; NIRS, near-infrared spectroscopy.

Footnotes

Y.G. and L.Y. share co-first authorship.

The authors report no conflicts of interest.

Contributor Information

Yiwen Gao, Email: gao_yiwen1@163.com.

Lu Yin, Email: marco7@163.com.

Tinghong Xiang, Email: 617597172@qq.com.

Tianyi Ni, Email: nitianyi1999@163.com.

Jingping Shi, Email: drshi_njmu@163.com.

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