The deep inferior epigastric artery (DIEP) perforator flap is the primary reconstructive approach for autologous breast reconstruction. It is associated with minimal donor site complications and acceptable aesthetic outcomes for both the abdomen and breast. This meta-analysis evaluated the impact of radiotherapy on the DIEP flap for patients with autologous breast reconstruction. All clinical studies involving patients who underwent DIEP flap breast reconstruction and compared the outcomes of irradiated and non-irradiated breasts were included. A comprehensive literature search was performed across 12 databases up to May 18, 2025. Eight studies including 4,447 patients (4478 flaps) were analyzed, of whom 1,624 received radiotherapy. Radiotherapy was associated with higher risks of partial flap loss (RR 1.69; 95% CI 0.99-2.90; P=0.05) and wound revisions (RR 1.23; 95% CI 1.01-1.50; P = 0.04). Pre-DIEP radiotherapy significantly increased the risk of wound healing disturbances (RR 1.62; 95% CI 1.06-2.49; P = 0.03). No statistically significant differences were observed in flap volume change, total flap loss, flap contracture, fat necrosis, recipient-site infection, or the need for reconstructive adjustments. There was a significant lower total breast satisfaction score among irradiated breasts (MD - 6.49; 95% CI - 11.79 to - 1.19; P = 0.02). Radiotherapy adversely affects surgical and patient-reported outcomes following DIEP flap autologous breast reconstruction, with pre-DIEP radiotherapy significantly increasing the risk of wound healing disturbances and post-DIEP radiotherapy associated with reduced overall breast satisfaction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

At our breast reconstruction center we have over time developed a focused program to increase access to care for low resource patients. This program includes outreach clinics, physician extenders, care coordinators, and telehealth utilization. A retrospective review of all free flap breast reconstruction patients between 2017 and 2022 at our center was performed. Specific criteria including insurance carrier, educational attainment and zip code median household income, language barriers, and distance to hospital were used to create favorably-resourced (FR) and unfavorably-resourced (UR) cohorts. Propensity score matching was then used to control for clinical factors and comorbidities. 49 and 52 patients met inclusion criteria for FR and UR cohorts, respectively, producing 33 matched pairs. FR was associated with a greater average number of donor site revisions (0.73 vs. 0.45, p=0.05). Other statistically significant differences included average zip code household income ($109,477 FR vs. $71,996 UR, p<0.01), bachelor's degree education level (26% FR vs. 16% UR, p<0.01), and average distance to hospital (25 miles FR vs. 82 miles UR, p< 0.01). No significant differences were detected between groups regarding mastectomy skin flap necrosis, recipient site infection, recipient site wound, breast revisions, donor site infection, donor site wound, seroma, fat necrosis, hernia/bulge, length of follow-up, or drain removal time. This study shows that through the utilization of access to care programs equivalent results can be achieved in autologous breast reconstruction in both favorably and unfavorably resourced patients.

Background: Venous congestion remains a major threat to deep inferior epigastric perforator (DIEP) flap survival. While superdrainage via the superficial inferior epigastric vein (SIEV) is an established strategy, few reports describe temporary controlled drainage as a salvage option when a second venous anastomosis is not feasible. Methods: We present two cases of bilateral DIEP flap breast reconstruction complicated by early venous congestion due to superficial venous dominance. In each, a trimmed angiocatheter was inserted into the SIEV and secured to allow controlled venous outflow. Drainage was titrated based on clinical findings and perfusion monitoring, and catheters were weaned and removed once congestion resolved. Results: In Case 1, congestion was identified intraoperatively and managed with intermittent drainage every 30 minutes, later spaced and discontinued by postoperative day (POD) 2. The catheter was removed on POD 3, and both flaps survived without fat necrosis. In Case 2, congestion was detected postoperatively with declining tissue oximetry readings. Controlled drainage improved perfusion, and the catheter was removed on POD 3. The patient experienced delayed wound healing and a small focus of fat necrosis excised at revision, but flap viability was preserved. Conclusion: Controlled drainage using a trimmed angiocatheter provides a simple, reproducible option to augment venous outflow in DIEP flaps with superficial dominance. This minimally invasive approach may serve as an alternative to formal superdrainage, enabling flap salvage while avoiding additional anastomoses or prolonged operative time.

Pancreatic panniculitis is a rare cutaneous manifestation affecting patients with pancreatic disease. This eruption is associated with acute pancreatitis, pancreatic malignancies, pancreatic pseudocysts, post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and pancreatic trauma. Increased efflux of pancreatic enzymes from the diseased pancreas appears to cause extra-abdominal fat necrosis and may manifest in the skin. We report a 59-year-old woman with cutaneous pancreatic panniculitis presenting after ERCP with elevated amylase levels but no symptoms of pancreatitis.

Ultrasonographic evaluation of cosmetic fillers: patterns and frequent complications - A literature review.

Erdheim-Chester disease (ECD) is a rare disease characterized by the accumulation of neoplastic histiocytes in various extra-nodal tissues. Tissue biopsies involved by ECD are difficult to distinguish from reactive inflammatory infiltrates given the bland appearance of the neoplastic histiocytes. Confirmation of the ECD diagnosis often relies on molecular studies to confirm BRAF V600E mutation or other activating mutations involving MAPK pathway genes. In this study, we examined the diagnostic utility of cyclin D1 and pERK as immunohistochemical markers of MAPK pathway activation in ECD compared with its histopathologic mimics. The cohort included 41 clinically confirmed ECD patients, most with known genetic alterations in MAPK pathway genes (n=38). In 3 cases no mutation was identified. 37 of 41 (90%) of ECD cases showed cyclin D1 overexpression, with frequent staining in the cytoplasm as well as the nucleus. pERK expression was observed in 32 of 39 (82%) cases. Cyclin D1 staining was negative in histopathologic mimics of ECD, apart from weak patchy staining in fat necrosis and uniform staining in a subset of cases of juvenile/adult xanthogranuloma. While not entirely sensitive or specific, in the proper clinical and radiologic context strong nuclear and cytoplasmic cyclin D1 expression within histiocytic infiltrates helps to support a diagnosis of ECD.

Predictors of postoperative complications following staged nipple-sparing mastectomy: A systematic review & meta-analysis.

Epipericardial fat necrosis (EFN) is a rare but benign cause of acute chest pain that can mimic life-threatening conditions such as myocardial infarction, pulmonary embolism, and aortic dissection. This case highlights the importance of recognizing EFN to prevent unnecessary interventions.

Abstract Background: Fat necrosis is one of the most common complications following autologous breast reconstruction. The clinical presentation of fat necrosis can mimic that of a cancerous recurrence, inducing patient anxiety and necessitating further imaging and biopsies. Furthermore, severe cases can compromise cosmetic outcomes, often requiring revisional surgery. Despite its prevalence and clinical significance, identification of specific risk factors for the development and severity of fat necrosis is poorly understood. This study, therefore, aims to identify and examine these risk factors to improve patient outcomes. Methods: We performed a retrospective review of patients who underwent autologous breast reconstruction with an abdominally based free flap at a single academic institution between September 2005 through January 2024. Data collected included demographics, surgical details, and post-operative complications (fat necrosis, infection, delayed wound healing, seroma, hematoma, necrosis, revision surgery). Chi-square and independent t-test analysis were performed to identify differences between groups, and multivariate logistic regressions were performed to assess predictors of fat necrosis. Results: A total of 434 patients (706 breasts) were included in this study. The median length of follow up after reconstruction was 4.2 years. 157 breasts (22%) developed fat necrosis, of which 68 breasts (43%) which underwent surgical excision. Average age (p=0.03) and BMI (p=0.01) were both significantly higher in the cohort that developed fat necrosis. Neither smoking status nor the presence of pre- or post-mastectomy radiation impacted rates of fat necrosis. Increased venous coupler size (p=0.01) and use of a bipedicled flap (p=0.000) were also significantly associated with the cohort that developed fat necrosis. Flap type (DIEP, msTRAM, SIEA) did not impact rates of fat necrosis. No significant differences in demographics or surgical details were found between patients that developed fat necrosis that did or did not warrant surgical management. On multivariate logistic regression, age (p=0.009, OR: 1.02), BMI (p=0.003, OR: 1.06), venous coupler size (p=0.04, OR: 1.58), and bipedicled flap reconstruction (p=0.00, OR: 6.05), were identified as independent predictors of developing fat necrosis. Conclusion: This study identifies advanced age, higher BMI, the use of larger venous couplers, and bipedicled flap as independent risk factors for the development of fat necrosis following autologous breast reconstruction. These findings can help guide preoperative patient counseling and intraoperative decision-making. Citation Format: M. Choi, A. J. Lopes, C. M. Vargas, P. Tewari, D. S. Rouhani, R. Behnam-Hanona, J. Brown, M. Lem, A. Gozali, N. Parmeshwar, M. L. Piper. Risk Factors for Fat Necrosis Following Abdominally Based Autologous Breast Reconstruction [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS2-01-21.

Abstract Objective: In a previous clinical study, we demonstrated that it is feasible to perform volume displacement using diced acellular dermal matrix (dADM) immediately after breast-conserving surgery (BCS) in patients with operable breast cancer. However, we realized that unexpected non-infectious erythema could present as a complication, which led us to develop a new approach to address this issue. Summary Background Data: Previous study proved dADM was effective to fill the defect in the breast after BCS, however, some patients showed intramammary fat necrosis during adjuvant chemotherapy or postoperatively following non-infectious erythema on the skin over the cavity filled with dADM. We take into consideration of embryological characteristics of breast to minimize this complication by changing approach route through retromammary plane, while maintaining its proven advantage. Methods: After institutional review board approval, we prospectively recruited 530 breast cancer patients requiring BCS from August 2019 to June 2022. Incision was made along the periphery of breast mound including axilla or inframammary fold, where the minimum distance was expected from the incision to the index tumor. After breast cancer removal, cavity was filled with dADM. After surgery, all patients received adjuvant local irradiation treatment, systemic chemotherapy, targeted agent or endocrine treatment according to the recommendations of international treatment guidelines according to the type of molecular subtype. All enrolled patients were followed up at 2 months after completion of both chemotherapy and external radiation treatment and up to 3 years from the date of surgery, including systemic evaluation to assess the occurrence of any complications, including non-infectious erythema, and oncologic outcome related to locoregional recurrence or systemic metastasis. Results: Of 530 patients enrolled, only 5 patients showed intramammary fat necrosis. Locoregional recurrence and systemic metastasis rates were also not statistically different from previous results not included in this study. Conclusions: Retromammary BCS and volume displacement with dADM for operable breast cancer is effective for reducing fat necrosis postoperatively, even after repetitive episodes of neutropenia during systemic chemotherapy, and is easy to preserve preoperative breast mound volume and shape. Although further clinical studies are needed in a larger number of patients, we believe that this surgical method could be another oncoplastic BCS that can overcome the limitations of conventional BCS. Citation Format: J. Schneider, Y. An, H. Choi, Y. Suh. Retromamamry breast-conserving surgery and volume displacement with diced acellular dermal matrix for operable breast cancer [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS2-03-22.

Abstract Background: There is concern from in-vitro studies that adipose-derived stem cells could promote cancer recurrence through their proliferative properties. The impact of immediate lipofilling (ILF) in the setting of breast conserving surgery on oncological outcomes, complications and patient-reported outcomes are unknown. Methods: A systematic search of Medline, Embase and Cochrane Central was conducted for studies investigating the impact of ILF in patients undergoing BCS. Random-effects meta-analysis were conducted for oncological outcomes (local [LR], regional [RR], distant [DR] and overall recurrence). Results: Six studies fulfilled the inclusion criteria including 252 patients. The pooled LR, RR, DR and overall recurrence rates were 2.38%, 1.52%, 3.03% and 5.95%, respectively (median follow-up, 39 months). A meta-analysis of studies comparing ILF (n=170) with no-ILF (n=362) found no difference in LR (OR, 0.77; 95%CI, 0.19-3.17; p=0.714), RR (OR 1.73, 95%CI 0.36-8.21, p=0.686), DR (OR 1.37, 95%CI, 0.51-3.63; p=0.627) or overall recurrence (OR 1.23, 95%CI, 0.60-2.52; p=0.569). Cancer-specific survival in the ILF group was 100% compared to 98.7% with no ILF. Post-operative calcifications (12.9% [21/163] vs. 0%; [0/72], p=0.002) and fat necrosis (7.8% (17/217] vs. 2.8% [8/283], p=0.011) were significantly more common with ILF, but early complications (e.g haematoma and infection) showed no difference (p&amp;gt;0.05). Three studies reported superior Breast-Q scores in ILF compared to no-ILF. No randomised controlled trials have been conducted. Conclusion: Immediate lipofilling following BCS is oncologically safe, enhances aesthetic outcomes and causes minimal morbidity. Citation Format: J. Lucocq, H. Baig, J. Dixon. The impact of immediate lipofilling on oncological outcomes, complication rates and patient reported outcomes in breast conserving surgery: a systematic review and meta-analysis [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS3-13-08.

Abstract Background: For many women with early-stage breast cancer, accelerated partial breast irradiation (APBI) offers comparable tumor control to whole-breast radiation with a shorter treatment course. However, cosmetic outcomes vary by technique. Stereotactic body radiotherapy (SBRT) is a promising external beam method allowing highly conformal dose delivery with tight margins, potentially improving cosmesis by sparing normal tissue. We present final three-year results from a prospective trial evaluating a five-fraction SBRT regimen for APBI, focusing on long-term safety, cosmesis, functional status, and local-regional control. Methods: Twenty-three patients with early-stage breast cancer (24 treatment plans) received 30 Gy in five daily fractions. A bioabsorbable 3D tissue marker (BioZorb™) was placed at lumpectomy for cavity delineation. Clinical target volume (CTV) included the cavity plus 1-cm margin; planning target volume (PTV) added 3 mm and was limited to ≤124 cc. Median PTV volume was 76.0 cm3 (range, 50.3–211.7). Treatment was delivered using 10-MV flattening filter-free beams on a Varian Edge system with VMAT planning and daily cone-beam CT. Positioning was prone or supine per anatomy; two patients had 9- and 11-day courses due to non-clinical delays. Zubrod status, patient- and nurse-reported cosmesis (4-point scale), adverse events, and imaging (mammography, ultrasound, MRI) were evaluated through 36 months. Results: At 36 months, 20 of 23 patients remained on protocol. One experienced biopsy-confirmed nodal recurrence at 6 months; two were lost to follow-up with benign or stable imaging. No ipsilateral breast tumor recurrences were observed. Zubrod status remained 0 in 90% at 36 months, with no grade ≥2 functional decline. Patient-reported cosmesis was excellent or good in 75% at 36 months (down from 85% baseline); nurse-reported was 80%, with stability across intervals. Poor cosmesis was reported by ≤2 patients at any timepoint. Fat necrosis affecting cosmesis occurred at 18 months but resolved. Erythema, pigment change, retraction, and volume loss were noted at 24 months but were typically non-cosmetic. Excellent/good cosmesis was maintained in ≥75% of patients across all intervals. Conclusion: This five-fraction SBRT approach to APBI was safe, well-tolerated, and preserved long-term cosmesis and function. Among patients completing 36-month follow-up, no ipsilateral breast tumor recurrences occurred. SBRT is a promising, efficient alternative to whole-breast radiation in carefully selected early-stage patients. Citation Format: M. Gevorgian, V. Reddy, T. Mathew, Y. Liu, C. Veale, D. Hablitz, H. Krontiras, A. Dalton, K. Meyers, M. Dobelbower, R. Lancaster, M. Bredel, C. Parker, K. Keene, E. Thomas, D. H. Boggs. Three-year outcomes following five-fraction sbrt for apbi in early-stage breast cancer: cosmesis, functional status, and local control [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS1-08-03.

Abstract Background: External beam accelerated partial breast irradiation (APBI) has emerged as a convenient alternative to the conventional 4-6 weeks of whole breast irradiation following breast-conserving surgery. This study presents 2.5-year follow-up data assessing the feasibility, safety, and efficacy of the 5-fraction APBI Florence trial regimen in select patients with early-stage breast cancer. Methods and Materials: A retrospective analysis was conducted on patients who received an ultra-hypofractionated external beam APBI regimen of 30 Gy delivered in 5-fractions. Eligible patients were women aged ≥40 years with early-stage breast cancer (pTis or pT1-2), no axillary lymph node involvement, tumor size ≤30 mm, and no distant metastases. All had undergone breast-conserving surgery, had histologically confirmed invasive carcinoma or pure ductal carcinoma in situ (DCIS), and had tumor bed clips placed. Clinical data collected included patient and tumor characteristics, treatment parameters, oncologic outcomes, and acute and late toxicities assessed using CTCAE v5.0. Adverse events occurring within 90 days post-APBI were categorized as acute; those occurring thereafter were considered late toxicities. Results: Between April 2021 and December 2022, 54 female patients most commonly with pTis tumors (29.6%) underwent external beam APBI. The median age was 68.0 years (range, 50.0-85.0) and 98.1% had an ECOG performance status of 0-1. A body mass index ≥30.0 mg/kg2 was reported in 40.7% of patients. Tumor laterality was nearly evenly distributed, with 29 (53.7%) patients having left-sided and 25 (46.3%) right-sided breast cancer. The majority of tumors were localized in the upper outer quadrant (42.6%). Median pathological tumor size was 6.5 mm (range, 1.0-29.0). Histological subtypes included invasive ductal carcinoma (55.6%), DCIS (33.3%), and invasive lobular carcinoma (11.1%). Pathological staging was available for 52 of 54 patients: 16 (29.6%) were grade 1, 33 (61.1%) grade 2, and 3 (5.6%) grade 3. Estrogen receptor positivity was observed in 98.1%, progesterone receptor in 77.8%, and Her2Neu positivity in 1.9% of tumors. During the median follow-up of 37.7 months from diagnosis (range, 5.4-49.6) and 34.7 months from APBI (range, 0.6-46.8), majority of patients (87.0%) received adjuvant hormonal therapy post-APBI. Acute grade 1 toxicities were observed in 24.1% of patients, including breast pain (11.1%), dermatitis radiation (7.4%), and fatigue (7.4%). Late grade 1 toxicities were reported in 7.4% of patients, with breast pain (3.7%), and fatigue (3.7%) being the most common. No toxicities of grade 2 or higher have been reported. Breast tissue fibrosis occurred in 1 patient, while 3 patients developed fat necrosis at a median 18.9 months post-APBI (range, 4.3-21.2); all of which were asymptomatic and required no intervention. At the most recent follow-up, all patients remained alive, with no cases of locoregional recurrence or distant metastasis observed. Conclusion: External beam APBI after breast conservation surgery is a feasible treatment approach resulting in excellent tumor control and with minimal toxicities. The outcomes of this study are consistent with those of the external beam APBI Florence trial, further supporting its use as a standard treatment option for appropriately selected patients with early-stage breast cancer. Citation Format: R. A. Herrera, N. Strusberg Fernandez, Y. Weiss, A. Botero, C. Lopez-Penalver, S. Mautner, J. Mendez, G. Giron, J. Panoff, M. M. Rodrigues. 2.5-year follow-up results of a five-fraction external beam radiotherapy accelerated partial breast irradiation for early-stage breast cancer after breast-conserving surgery [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS1-07-05.

We define "BBL blowout deformity" as a soft tissue deformity after autologous gluteal fat transfer. It is caused by a loss of integrity of the fascia and ligaments in the buttocks, resulting in an undesirable convexity and weakening of the lower buttock skin. A fat necrosis cyst is often found within the deformity that must be addressed for correction. Treatment guidelines are not currently defined; thus, we have created a treatment algorithm that may serve as a preliminary guide. Generally, patients with favorable factors such as younger age (<35), good skin quality, and a smaller deformity of <20% buttock surface area can tolerate a more conservative approach. For these patients, a liposuction cannula can be used to evacuate the fat necrosis cyst, fenestrate the cyst capsule, and perform a wide soft tissue release, which can achieve good correction of the deformity. Those with older age (>35), poor skin quality, or larger deformity of >20% buttock surface area are recommended to be treated with direct skin and fat necrosis cyst removal through a direct buttock-lift incision. Invasive radiofrequency skin tightening may be added in all cases to improve results. These single-surgeon clinical observations informed our proposed treatment algorithm.

Oral contraceptive pills and reduction mammoplasty: A retrospective cohort analysis.

Histopathologic characterization of Morel-Lavallée lesion: Report of 6 cases and review of the literature.

Subcutaneous fat necrosis with extensive hematoma following therapeutic hypothermia

Total pancreatectomy and islet autotransplantation (TPIAT) is a complex surgical procedure performed in transplant centers throughout the United States, with increasing prevalence over the last 2 decades. The goals of TPIAT are to alleviate pain caused by debilitating chronic pancreatitis or acute recurrent pancreatitis by removing the pancreas and to prevent the development of brittle diabetes by infusion of pancreatic islet cells to replace the function of the surgically absent pancreas. Imaging plays a key role in evaluating patients who have undergone TPIAT. Radiologists must be aware of the surgical procedure and its variations, expected postoperative imaging findings, and potential complications for accurate diagnosis. The authors review the background of TPIAT and the indications for and goals of the procedure. The surgical procedure, expected postsurgical anatomy, imaging findings, and spectrum of complications are described. Imaging findings of postoperative complications and sequelae of TPIAT may include bowel or bile leak, anastomotic breakdown, abscess, hematoma, biliary stricture, bowel obstruction due to anastomotic stricture, adhesions, incisional or internal hernia, delayed gastric emptying, bezoar, vascular abnormalities (eg, thrombosis, pseudoaneurysm), omental infarct and/or asymptomatic fat necrosis, and atypical patterns of hepatic steatosis, including nodular hepatic steatosis. ©RSNA, 2026.

We report a 5-week-old female infant who developed firm, erythematous nodules over the buttocks one week after discharge from the neonatal intensive care unit following perinatal hypoxia managed with therapeutic hypothermia. Clinical examination and imaging confirmed the diagnosis of subcutaneous fat necrosis of the newborn.

Reduction mammoplasty is an established treatment for symptomatic macromastia. Understanding risk factors associated with complications is essential for counseling and patient selection. The modified frailty index (mFI-5) has been proposed as a simple tool to assess risk in surgical candidates. We sought to determine if the mFI-5 can accurately predict wound healing complications following reduction mammoplasty. A retrospective review was performed of primary bilateral reduction mammoplasty cases between 2017 and 2019 at one institution. MFI-5 scores were calculated for each patient. 30-day wound healing complications were defined as incisional dehiscence, T-point breakdown, nipple-areolar complex necrosis, and fat necrosis. Univariate and multivariate logistic regression were used to evaluate predictive value. 474 patients were stratified into three age groups: 15-30, 31-50, and over 51. Twenty-six percent of patients developed 1 wound healing problem. On univariate analysis, ages 31-50 and 51+ (OR 2.75 and 3.16) and mFI score of 1 (OR 2.07) were associated with an increased risk of wound healing complications. Adjusted multivariate analysis indicated that age greater than 51 years significantly predicted wound healing issues (OR 2.89; p=0.001) when controlled for American Society of Anesthesiologists (ASA) score, smoking, and body mass index (BMI). The mFI-5 did not significantly predict wound healing issues when controlled for age, ASA, BMI, or smoking. In our population, the mFI-5 was not a statistically significant predictor of wound healing complications following reduction mammoplasty. When controlling for confounders, advanced age alone seems to place patients at higher risk for wound healing complications.