“…(Ali et al, 2010;Sbitany, Mirzabeigi, Kovach, Wu, & Serletti, 2012;Wechselberger et al, 2001) Indeed, if the cause of congestion was a technical issue at the primary venous anastomosis, it is implausible that additional venous anastomoses within the flap would resolve congestion. Salvage options may follow treatment algorithms, (Davies et al, 2014;Galanis et al, 2014) with options including using a contralateral TRAM or additional venous anastomoses utilizing the SIEV lifeboat (Villafane, Gahankari, & Webster, 1999) via cephalic switch, vein graft, interposition of the SIEV to the IMV (Blondeel, 1999;Blondeel et al, 2000) or alternative vessels, (Wechselberger et al, 2001) reverse flow venous anastomosis, (Liu, Ashjian, & Festekjian, 2007) There is likely to be a link between venous congestion and fat necrosis. Fat necrosis incidence ranges from 5% to 35% (Kroll, 2000;Peeters, Nanhekhan, Van Ongeval, Fabre, & Vandevoort, 2009) and non-standardized definitions based combinations of clinical symptoms, signs, or imaging findings remain a challenge.…”