Late-onset Total Necrosis in Deep Inferior Epigastric Perforator Flap after Contrast Enhanced Computed Tomography

There seems to be an incessant debate regarding the duration of dependency of free flaps on pedicle vessels and the extent to which neovascularization from surrounding tissue contributes to the fortification of the free flaps. Although animal studies have suggested that pedicle vessels can be safely divided 5-8 days postoperatively without flap failure in fasciocutaneous flaps, recent clinical reports, particularly concerning the deep inferior epigastric perforator (DIEP) flap, cast doubt on this assumption. This report highlights a singular case of delayed-onset total necrosis in a DIEP flap following a contrast enhanced computed tomography (CECT) scan conducted 48 days post reconstructive surgery. The patient, a 56-year-old woman, had undergone a mastectomy for right breast cancer followed by immediate tissue expander placement. Subsequently, 6 months later, she underwent delayed reconstructive surgery with a DIEP flap. The postoperative course was uneventful, except that she had a CECT scan as part of follow-up care 48 days postoperatively and developed an abrupt yellow exudate from the right breast wound 2 days later, eventually leading to aggressive debridement of the totally necrotized flap 60 days postoperatively. This case marks the first instance of late-onset total necrosis of a DIEP flap following a CECT. The intensified endothelial damage induced by contrast media, in the context of the high dependency of the DIEP flap on the pedicle vessels with marginal blood supply from the surrounding wound bed, could be ascribed as the cause of this total loss of the flap.