IntroductionMastectomy skin flap necrosis (MSFN) has a reported incidence of 5%–30% in the literature. It is often a significant and underappreciated problem. The aim of this article was to review the associated challenges and possible solutions.MethodsA MEDLINE search was performed using the search term “mastectomy skin flap necrosis”. Titles and abstracts from peer-reviewed publications were screened for relevance.ResultsMSFN is a common complication and may present as partial- or full-thickness necrosis. Predictive patient risk factors include smoking, diabetes, obesity, radiotherapy, previous scars and severe medical comorbidity. MSFN leads to a number of challenges, including wound management problems, delays to adjuvant therapy, esthetic compromise, implant extrusion, patient distress and financial loss. Careful preoperative planning and meticulous surgical technique may reduce the incidence of MSFN. A number of intraoperative techniques are available to try and predict skin flaps at risk of MSFN. MSFN may be managed operatively or nonoperatively. Early intervention may reduce the morbidity of MSFN in selected cases. Topical nitroglycerin ointment may be beneficial in reducing MSFN following immediate reconstruction, but the evidence base is still limited.ConclusionMSFN can result in considerable challenges for the patient and the health care service. This review discusses the management options for this problem.

The variable and unpredictable thickness of the breast subcutaneous layer means that a single specific universal thickness for mastectomy skin flaps cannot be recommended. It may be that the plane between the subdermal fat and breast parenchyma is a reasonable guide for mastectomy flap thickness, but this may not always correspond to a subcutaneous fascial layer.

Patients undergoing oesophageal resection can be safely managed on a surgical HDU without routine postoperative ventilation. Although ventilation and ICU will be required in a significant number due to postoperative complications, this is unlikely to occur in the first 48 h. The requirement for an ICU bed to be available on the day of surgery should, therefore, no longer be considered necessary. This has important implications for the scheduling of elective oesophageal surgery.