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Journal of Surgical Case Reports, 2025, 5, rjae511
https://doi.org/10.1093/jscr/rjae511
Case Report
Case Report
Abdominal-based free flap reconstruction of the breast
in a patient with prior cryolipolysis: a case report and
literature review
Steven L. Zhang 1,†, Sofeah Samsuddin2,†, Lee Chee Meng3, Sabrina Ngaserin3, Allen Wei-Jiat Wong 2,
*
1Section of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, Woodlands Health, 17 Woodlands Dr 17, Singapore 737628
2Plastic, Reconstructive and Aesthetic Surgery Service, Sengkang General Hospital, 110 Sengkang E Wy, Singapore 544886
3Breast Service, Department of Surgery, Sengkang General Hospital, 110 Sengkang E Wy, Singapore 544886
*Corresponding author. Plastic, Reconstructive and Aesthetic Surgery Service, Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886.
E-mail: allen.wong.wei.jiat@gmail.com
†Steven L. Zhang and Sofeah Samsuddin are co-first authors and contributed equally to the writing of this paper.
Abstract
Abdominal-based flaps, including deep inferior epigastric artery perforator and transverse rectus abdominis myocutaneous flaps, are
workhorse flaps for autologous breast reconstruction. These f laps are vascularized by perforators originating from the deep inferior
epigastric vessels and traversing through the rectus abdominis muscle and subcutaneous tissue to supply the skin. As such, previous
abdominal procedures, such as liposuction, may compromise flap perfusion and affect the choice of reconstruction. While there are
numerous studies investigating the impact of liposuction on abdominal-based flaps, there is limited data on the implications of
cryolipolysis, which is a relatively newer modality of non-invasive body contouring that is gaining increasing popularity. We describe
a case of autologous breast reconstruction in a patient who had undergone cryolipolysis, where a free transverse rectus abdominis
myocutaneous flap was used as the perforators were too small for reliable perfusion of a deep inferior epigastric artery perforator flap.
Keywords: plastic surgery; reconstructive surgery; breast reconstruction; cryolipolysis; microsurgery
Introduction
Breast cancer is a leading cause of cancer among women globally
[1]. Breast reconstruction following mastectomy is becoming more
common due to increasing awareness of its psychosocial benefits
and availability of plastic surgery services [2]. Abdominal-based
flaps, including deep inferior epigastric artery perforator (DIEP)
and transverse rectus abdominis myocutaneous (TRAM) flaps,
are workhorse flaps for autologous breast reconstruction and
are vascularized by perforators originating from the deep inferior
epigastric vessels and traversing through the rectus abdominis
muscle and subcutaneous tissue to supply the skin. As such,
previous abdominal procedures, such as liposuction, may com-
promise flap perfusion and increase the risk of complications,
such as flap loss and fat necrosis, and are considered by many to
be a relative contraindication to the use of a free DIEP flap [3–5].
As compared to liposuction, cryolipolysis is a non-invasive
modality for localized fat reduction and body contouring, which
is gaining increasing popularity in recent years [6]. It is based
on the concept of controlled cooling or ‘cold panniculitis’, which
leads to selective apoptosis of adipocytes, theoretically without
damaging surrounding tissues and overlying skin [6, 7]. In clinical
practice, however, severe frostbites and cold burns have been
reported, likely attributed to vasoconstriction, tissue hypoxia, and
thrombosis [6, 7]. While there are numerous studies investigating
the impact of liposuction on abdominal-based flaps, there is
limited data on the similar implications of cryolipolysis [2].
We describe a case of autologous breast reconstruction in a
patient who had undergone cryolipolysis, where a free TRAM flap
was used as the perforators were too small for reliable perfusion
of a DIEP flap.
Case report
A 53-year-old female patient with right breast cancer was referred
to the Plastic Surgery service for breast reconstruction. She had
a past medical history of ankylosing spondylitis, which was
well controlled with non-steroidal anti-inflammatory drugs and
sulfasalazine. She had undergone one session of cryolipolysis
(CoolScupting treatment) 2 weeks prior to the consult. There was
no history of previous abdominal surgery.
On pre-operative evaluation, the patient had ecchymoses of
bilateral flanks, which was attributed to cryolipolysis. Breast
reconstruction options were discussed, and she was keen for
2|Zhang et al.
Figure 1. Preoperative CT angiography showing small maximum
perforator diameter of 1 mm (arrow).
Figure 2. Preoperative markings of perforator locations.
autologous reconstruction with a free DIEP flap. She was
counseled regarding the risks of flap failure and possible
conversion to a free TRAM flap. Surgery was scheduled at a date
2 months after her cryolipolysis treatment.
Computed tomography angiography (CTA) of the abdomen was
performed, which demonstrated three perforators on each side,
with a maximum diameter of 1 mm (Fig. 1). The perforator loca-
tions were marked following corroboration with bedside doppler
ultrasound (Fig. 2).
Reconstruction proceeded following nipple-sparing mastec-
tomy by the breast surgeon (Fig. 3). The abdominal flap was
divided in the midline, and the right side was chosen as the
donor site for the free flap as it had the largest perforator on
CTA. Exploration confirmed that the largest perforator was 1 mm
in diameter (Fig. 4), which was deemed to be insufficient for
reliable perfusion of a free DIEP flap. Hence, a muscle-sparing
TRAM flap was used instead, incorporatingthe segment of muscle
between the lateral and medial row perforators to maximize flap
perfusion (Fig. 5). Flap perfusion was checked to be adequate prior
to pedicle ligation. Microvascular anastomosis was performed on
the internal mammary artery and veins with ethilon 9/0 sutures.
Flap inset was completed, and the donor site was repaired with a
prolene mesh and closed in layers over suction drains.
Postoperatively, the patient was monitored in the general ward.
Flap monitoring was performed using clinical assessment and
near-infrared spectroscopy (NIRS) [8]. Intermittent f luctuations
of NIRS readings were noted during the first 2 days, which were
attributed to likely vasospasm. The flap remained stable on sub-
sequent monitoring, and the patient was discharged on postoper-
ative day eight with no complications.
Discussion
Previous studies investigating the effect of liposuction on per-
forators have demonstrated a decrease in both perforator size
Figure 3. Right nipple sparing mastectomy specimen.
Figure 4. Largest perforator with diameter of 1 mm.
Figure 5. Right muscle-sparing TRAM flap.
and number on doppler ultrasonography following liposuction [ 4,
9, 10]. In a prospective study of six patients, Salgarello et al. [9]
reported a decrease in the diameter of the two largest abdomi-
nal wall perforators of each patient following liposuction, from
1.0 to 3.3 mm preliposuction, to 1.0–1.8 mm postliposuction.
In contrast, the largest perforator in our patient was 1 mm in
diameter, both on preoperative CTA as well as direct visualization
intraoperatively. This unusually small size is possibly due to prior
cryolipolysis. Further studies measuring the perforator size before
and after cryolipolysis would be useful to confirm our hypothesis.
To our understanding, there have only been two case reports
of breast reconstruction using abdominal-based free flaps in
the setting of prior cryolipolysis [2, 11]. Hyland et al. reported
successful reconstruction with a free DIEP flap in a patient who
had undergone cryolipolysis 5 years prior to surgery, where pre-
operative CTA showed 6–7 viable perforators with no abnormali-
ties [2]. Kankam et al. [11] reported successful reconstruction with
a muscle-sparing TRAM flap in a patient who had undergone
cryolipolysis <1 year prior to surgery, with no vessel abnormalities
on preoperative CTA. In contrast, our patient had abnormally
small perforator sizes. This could be related to a shorter time
interval from cryolipolysis to surgery (2 months), although this
is difficult to interpret given limited patient numbers.
The factors affecting the decision to convert from a DIEP flap
to a free TRAM f lap vary between surgeons. Nahabedian et al. [12]
Abdominal-based free flap reconstruction |3
reported that reconstruction with a DIEP flap is usually possible
after identification of 1–2 perforators with a minimum diameter
of 1.5 mm. We find this to be a reliable guide, as perforators
smaller than 1.5 mm in size are unlikely to provide reliable
perfusion for the entire flap. In such cases, a free TRAM flap would
be more reliable.
In conclusion, this case highlights potential challenges of per-
forming autologous breast reconstruction using abdominal-based
flaps in the setting of prior cryolipolysis. Careful preoperative
assessment and counseling is important, ideally with CTA to
evaluate for perforator course and size. If the perforators are not
suitable for a DIEP flap, the free TRAM flap is a useful backup
option.
Conflict of interest statement
None declared.
Funding
None declared.
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Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2025. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which
permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
For commercial re-use, please contact journals.permissions@oup.com
Journal of Surgical Case Reports, 2025, 5, rjae511
https://doi.org/10.1093/jscr/rjae511
Case Report
