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Figure 3. Patient with a genetic predisposition for breast cancer (Images 1 and 2) who underwent bilateral skin- sparing mastectomies and immediate reconstruction with a left DIEP flap and a right SIEA flap. Three weeks postoperatively, she presented with a discoloration of the right flap skin paddle, brisk capillary refill, and firmness at the inferolateral quadrant of the breast (Images 3 and 4). While not frankly necrotic, the entire breast ultimately was very firm (Images 5 and 6). The right SIEA flap was debrided and replaced with a PAP flap using a more proximal portion of the same antegrade internal mammary vessels (Images 7 and 8).