DOI: 10.1097/01.PRS.0000153858.55820.5F
,
Issn Print: 0032-1052
Publication Date: 2005/03/01
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Excerpt
Fat necrosis is defined as the ischemic necrosis of an area of subcutaneous fat, usually at the periphery of the flap, giving rise to an area of firm or hard tissue.1 The blood supply to the flap is expected to be the least robust at the region farthest away from the pedicle. This is usually at the periphery of a musculocutaneous flap such as the transverse rectus abdominis musculocutaneous (TRAM) flap or the deep inferior epigastric artery perforator (DIEP) flap. This has been described as zone 4 in this particular flap.2 Although fat necrosis is considered a minor complication, it sometimes requires further excision, giving rise to inconvenience, discomfort, and additional costs for the patient. If left alone, it usually resolves spontaneously, but it may become infected, requiring débridement. The subsequent induration may give an impression suspicious of tumor recurrence,3 requiring further investigation and excision. The nodular area is cosmetically undesirable if it leads to distortion of the reconstructed flap. We report our method of débridement of fat necrosis in a pedicled TRAM flap using the liposuction technique. This was successfully carried out in our patient under local anesthesia.
Our patient was a 41-year-old woman who had undergone immediate breast reconstruction using the pedicled TRAM flap after mastectomy for breast carcinoma. As all four zones of the TRAM flap were used to fill the volume required to match the contralateral side, we anastomosed the deep inferior epigastric vein based on one perforator from the contralateral side for improved venous drainage. In the immediate postoperative period, zone 4 was noted to be congested. Within a week, the lateral aspect of the flap, where zone 4 was inset, was noted to be swollen and indurated, distorting the superior aspect of the reconstructed breast. We decided to débride the area concerned at 3 weeks, when the area became indurated and defined.
We infiltrated the skin at the lateral aspect of the previous flap incision with 2% Xylocaine mixed with 1:80,000 adrenaline (Astra). A small incision was made to allow the insertion of a 4-mm Mercedes cannula with three side holes (Fig. 1). The cannula was connected to the Hercules liposuction machine. Suction was initiated only when the tip of the cannula was within the area concerned. Each time the cannula was repositioned within the indurated area, suction was paused until the cannula was in place. During suction, the cannula was kept more or less stationary.4 No motorized or ultrasonic assistance was utilized. Tumescent infiltration was not used here, and we did not encounter much bleeding. Suction was carried out until the area of fullness and induration had flattened out and the return was minimal. We managed to remove about 100 ml of liquefied necrosed fat. Our patient tolerated the entire procedure without requiring any intravenous injection of analgesics or sedative. She was able to return home the same day after the procedure. On follow-up in the outpatient clinic during the next 2 weeks, the area of fat necrosis and distortion was noted to have subsided.
Liposuction is a frequently used procedure in the plastic surgeon’s armamentarium. It has also been described as an adjunct procedure in reduction mammaplasty5 for fine contouring of adjacent areas to achieve aesthetic balance, and also for suction curettage in the treatment of axillary hyperhidrosis.6 To our knowledge, its use in suction débridement of fat necrosis in reconstructed breasts has not been described. We believe that liposuction offers a minimally invasive yet effective method of débridement. It can be performed under local anesthesia using just a small incision.
