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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Fat Necrosis After Autologous Breast Reconstruction: A Classification System and Treatment Algorithm
Stephanie A. Caterson, MD, Adam M. Tobias, MD, Sumner A. Slavin, MD, Bernard T. Lee, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

Purpose:
Fat necrosis following autologous breast reconstruction is a frequent complication. It can be described as an area of firmness within adipose tissue that results after fat becomes devitalized. Although several theories exist, the exact pathophysiology resulting in fat necrosis has not yet been illustrated. Regardless of the cause, these firm areas can alter the aesthetic result as well as be painful to the patient. Unfortunately a consistent gradation scale is not universally employed amongst authors which make comparisons between studies difficult, if not impossible, and the determination of the true incidence of this complication unknown. Current literature reports wide ranges of incidence that vary between methods of pedicled transverse rectus abdominis myocutaneous (TRAM) (12-35%), free TRAM (5.9-12.9%), and deep inferior epigastric artery perforator (DIEP) (6-62.5%) flap breast reconstructions. We suggest a standardized classification system that more accurately determines incidence and treatment strategies.
Methods:
All diagnoses of fat necrosis were made at three months post reconstruction. At this point the majority of post operative flap edema had resolved and second stage operations were planned. A thorough history was obtained and reports of pain associated with the firm areas were recorded. On physical exam areas of fat necrosis were measured along the largest diameter. The fat necrosis was then categorized dependant on symptoms and size (Table 1). A treatment plan was developed with options of aggressive massage, suction-assisted lipectomy (SAL), ultrasound-assisted lipectomy (UAL), and/or direct excision.
Results:
Our series of 194 breast reconstructions with perforator flaps from 2004 to 2006 at Beth Israel Deaconess Medical Center Division of Plastic Surgery revealed 33 flaps (17%) that developed fat necrosis. Nine flaps had areas that measured less than 2 cm and were initially managed conservatively with massage therapy. Of the nine, three (1.5%) of the patients could not tolerate massage therapy due to pain and went on to UAL or SAL. Twenty four (12%) of the flaps had areas of fat necrosis greater than 2 cm and required surgical intervention. UAL or SAL was used in 13 flaps (7%) and direct excision performed in 11 flaps (6%).
Conclusions:
We believe that a descriptive classification system will assist plastic surgeons in accurately comparing their personal results to the literature, will allow different institutions to compare results without bias, and will improve discrepancies that now exist in the literature regarding the incidence of fat necrosis. Most importantly, currently there is a paucity of treatment options described for fat necrosis beyond direct excision. In our institution we have had success in the management of fat necrosis using the above described treatment options.
TABLE 1

ClassificationDescriptionSizeTreatmentResults
Grade 1: AMinimal fat necrosis, no pain< 2cmMassage6 (3%)
Grade 1: BMinimal fat necrosis, with painMassage +/- UAL of SAL3 (1.5%)
Grade 2Moderate fat necrosis2 - 5 cmUAL or SAL13 (7%)
Grade 3Severe fat necrosis>5 cmDirect excision +/- UAL or SAL11 (6%)

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