Does tumescent infiltration have a deleterious effect on undermined skin flaps?

In summary, we think that the intradermal injection of the tumescent solution with epinephrine, which produced a peau d'orange appearance of the overlying skin, resulted in superficial flap loss secondary to the vasoconstrictive property of epinephrine combined with the hydrostatic pressure of the injection in this patient within a superficial plane and flap elevation. This delayed the clearance of epinephrine from the flaps. In this case, removal of the sutures did not result in any improvement in the flap, and this maneuver was performed too late. If a peau d'orange appearance is observed after injection, we recommend waiting until the fluid has time to recirculate (15 to 30 minutes, at a minimum) and avoid immediate incising or undermining of the flap.