Fat necrosis remains an important complication following deep inferior epigastric perforator (DIEP) flap breast reconstruction. It can affect the appearance and durability of the reconstruction and may lead to additional investigations or treatment.
This systematic review examined the factors associated with fat necrosis and the potential role of intraoperative perfusion assessment in reducing its occurrence.
Evidence from More Than 3,600 DIEP Flaps
The review included 13 studies involving 3,609 flaps in 3,013 patients. Reported rates of fat necrosis varied considerably, ranging from 7.5% to 59.5%.
Several factors were associated with the risk of fat necrosis: higher flap weight; body mass index above 30 kg/m²; perforator selection; and intraoperative perfusion assessment.
Lateral-row perforators were associated with a significantly lower rate of fat necrosis than medial-row perforators—8.2% versus 24.5%. Total flap loss was uncommon, occurring in fewer than 1% of cases. However, localised fat necrosis remained a considerably more frequent complication.
ICGA Was Associated with Reduced Fat Necrosis
Across the included evidence, intraoperative indocyanine green angiography (ICGA) was associated with a 51% relative reduction in the risk of fat necrosis:
- Relative risk: 0.49
- 95% confidence interval: 0.25–0.97
- p=0.021
ICGA allows surgeons to assess perfusion across the flap during surgery and identify areas that may have an inadequate blood supply. This information can support decisions about flap design, tissue removal or the need for additional vascular intervention.
What Does This Mean for Clinical Practice?
The review indicates that the risk of fat necrosis is influenced by a combination of patient characteristics, flap size, perforator selection and intraoperative perfusion.
Its findings support the use of ICGA alongside clinical assessment to help surgeons:
- identify inadequately perfused tissue;
- refine flap design and tissue selection;
- consider whether the vascular strategy requires modification; and
- potentially reduce postoperative fat necrosis.
As the included studies differed in design, patient population and definitions of fat necrosis, the findings do not prove that ICGA alone prevents the complication. Nevertheless, this systematic review provides broader evidence that incorporating real-time perfusion assessment into DIEP-flap decision-making may contribute to improved reconstructive outcomes.
Reference
Risk Factors and Predictive Models for Fat Necrosis in DIEP Flap Breast Reconstruction: A Systematic Review. https://pubmed.ncbi.nlm.nih.gov/42621158/
