In this case, a 45-year-old woman with right breast cancer (Panel A) requested expander insertion to maintain domain during chemotherapy and radiation therapy prior to autologous conversion. SPY image (Panel B) identified poor perfusion in an extensive area around the incision. Clinically, the skin appeared well perfused and was preserved based on clinical judgment. Postoperative ischemia ensued, leading to full-thickness necrosis (Panel C). Two attempts at salvage with debridement and expander deflation failed to achieve successful closure, and the expander was removed to allow the patient to proceed with chemotherapy and radiation therapy. The resulting healed, radiated mastectomy site prior to free TRAM reconstruction is shown in Panel D.