What is Fat Necrosis and Should I Be Concerned About It?

The below question is answered by Dr. James Craigie of The Center for Natural Breast Reconstruction.

Dr. James Craigie

After my stage one DIEP surgery, I have some lumpy areas that I am told are fat necrosis.  Do they go away or what can you do about them? I am due to have stage two of my surgery soon.

Fat necrosis is a generalized term that results following injury or surgery when fat no longer has an adequate blood supply to survive. When fat does not survive and is in the breast the body develops scar or firmness as part of the healing process. A small amount of fat necrosis may go away on its own and larger amounts may persist indefinitely making the breast feel hard.

Following a DIEP or other muscle sparing breast reconstruction some of the fat transferred to the breast may not receive enough blood supply to survive the healing process. When this happens you may feel small lumps in the new breast about 1 – 2 months after the first surgery, sometimes sooner depending on where the lump is. These are usually small areas that can be removed at the second stage without affecting the end result. This is the most common situation we encounter.

On a larger scale, if something has occurred during the course of surgery and the tissue was transferred with an inadequate blood supply, the entire breast or a major portion of it could develop into fat necrosis. This is the most severe situation and would be considered a major complication or even failure of the procedure. Fortunately, in our experience, this situation is rare and the surgeon will know this has happened and should discuss options for correction.

If someone has a new breast lump and has a history of breast cancer, they are likely to undergo biopsies or have some concern over the area. Lumps that are fat necrosis may make breast exams more difficult or confusing and increase the chance that a new cancer or recurrence goes undetected. So anytime there is obvious fat necrosis after the first stage of surgery, we would make attempts to remove it. Initially, when a patient states they feel a firm area, I always remind them that what they feel on the outside will feel larger than the actual amount of fat necrosis tissue because the body is creating a reaction to the tissue trying to dissolve it.

It should be stressed that even patients who have undergone breast reconstruction should continue to do breast self-examinations. Any surgery on the breast will cause swelling and scarring. In many women who undergo reconstruction with breast implants, the body creates a capsule in response to these implants and all of these scars, capsules, or post surgical changes can feel like lumps and bumps following surgery. Therefore, it is important to know that fat necrosis may become apparent soon after surgery and should stay the same and not enlarge as time goes by. Alert your doctor regarding any breast lump that seems to enlarge. It is also important to know that breast exams will not be useful until after stage one and two are completed and the breast has had several months to recover from the surgery.

Once the reconstructive process is complete, things should not be changing. Patients should become familiar with any area that feels firm. If there are scars remaining after surgery, the patient should keep track of where they are and monitor them for changes. Changes in size or significant changes of any type should always be brought to the attention of your physician even in a reconstructed breast.

—James Craigie, M.D.

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  1. Carolyn Bohannon says:

    I had a unilateral tram 10 years ago and about 3 weeks ago for no reason the tram got real red and hot. They put me in the hospital with 2 IV antibiotics. I stayed 6 days and was discharged on 2 oral antibiotics. The reddness is better but the tram is hard and painful about half of it. They did a biopsy and said it was fat necrosis. The plastic surgeon said if he removed it now it would not heal good. He has no reason as to why it happened. Have you ever heard of this?

    Also had other breast removed 3 years ago and had implant. The skin died 3 days later and had it removed. Now the fat necrosis is even going to that side.

    Any ideas?

    • Shirley Boeninghaus says:

      I had a tram flap in dec of 2001…. This just happened to me…. So far I have the same story…. It’s been a month since this started, test, biopsies….and yes fat necrosis after 12 years! It’s soar …but yes … I see this is from a few years ago, would like to know what has happened since…

  2. Hi there. I had a double mastectomy with tram flap reconstruction on April 14, 2017. My right breast has had a large lump since the day of surgery and the left has turned very hard, about half of it. My doctor finally told me that it was fat necrosis and he will need to remove it and over the next several months he will slowly liposuction fat to insert into my breasts. Has this happened to anyone else and what was your result?

  3. Michelle says:

    Had a bilateral DIEP procedure in 2014. My left breast has had several fat necrosis areas postop. I continue to have pain. It seems to be in the tissue, skin and chest wall of the breast. It is annoyingly sore. It is bothersome. Has anyone experienced this? CT was normal. Physical therapy did nothing.

  4. I had necrosis right away. My blood pressure dropped drastically in surgery. Single flap, 11 hrs on table, 2 rounds of epinephrine. I continued low blood pressure and lost at least half of flap. He removed it 3 weeks later and could not close. I had wound vac for 7 weeks. I continue to create hard lumps especially in upper area that gets bigger and bigger. He has tried to remove it during phase 2 and 3. It comes back and I feel it like a pressure in that area. I am afraid it will become even larger as time goes. I am fortunate I did not loose it all. But now having reduction again on right breast July 29. I am hoping he can just remove it 100% but not sure he will. Love my surgeon but getting frustrated. I also had cellulitis in the flap and it spread like mad. Strep in blood as well. Jan 2020 spent 6 days on IV antibiotic., Vancomiacin. Now he really wants to stay clear of surgery on the flap. I go to Ohio State, The James.