Tissues all need oxygen and
other nutrients in order to stay healthy. If the oxygen is compromised it is
not getting to the tissues in a high enough concentration, the tissues will turn
blue or purple and become ischemic (which means lack of oxygen). If this lack of
oxygen goes on for a long enough time period, necrosis or tissue death may
Necrosis is not a concern in
many plastic surgery procedures, however in the surgeries where the blood supply
is compromised, the risk of circulation problems increase. Most of the time
with surgery there is another alternate blood circulation to supply the tissues
with the proper oxygen and nutrients.
In general necrosis is rare and doesn’t
occur very often.
How Necrosis Happens:
The risk of necrosis increases dramatically with the following:
Health conditions that increase the risk of necrosis are Diabetes, Peripheral
vascular disease and smoking. Patients who smoke are at a higher risk of
necrosis occurring after abdominoplasty.
Abdominoplasty involves your
plastic surgeon takes the lower abdominal tissue and pulling it to it's
capacity, so that you end up with a flat tight tummy. To have the
best result from this procedure the tissue has to resilient and healthy.
Sometimes, excessive tension on the wound edges, wound suturing and undermining,
and superficial undermining all contribute to a decreased blood flow to the
distal wound margins.
With smokers or patients who have smoked in the past, even under the best of
circumstances - do not generally have the most tolerant tissue to work with.
Smoking does decrease the oxygenated blood flow to the surgical site. This
oxygenated blood flow is necessary in order to heal from having this surgery
properly, otherwise portions of the tissue may "die" or turn necrotic. If
you are going to have an issue with blood supply to an area it usually shows up
relatively soon after the procedure.
Having necrosis means months and months of
delayed healing from this deep wound
- which can eventually lead to larger more noticeable scarring. The most
common place for necrosis to happen with abdominoplasty is near the pubic
region. The tissue will become discolored and then it will blister
causing some drainage from the area. The tissue starts turning a dark or
black color within a few weeks, as it is dying off. The underlying fat
that lies beneath the epidermis will begin to show and can also breakdown.
The size of necrotic tissue can end up ranging to several inches.
Recovering from necrosis with abdominoplasty procedure can take anywhere from
one to three months to fully heal.
Patient had necrosis with a full abdominoplasty procedure:
Necrosis is a very bad complication; however it is one that is not seen
that often with breast surgery. But if you see your wound
re-opening at all, it is best to contact your plastic surgeon
immediately. Early intervention in this complication is
Full Thickness Skin
Necrosis is death of the affected skin. This complication can
result from excess superficial
liposuction that injures the vascular
supply of the overlying skin. Deliberate trauma to skin can injure
the vascular supply to the skin and cause partial of full thickness
necrosis of the skin.
Causes of Full
Thickness Dermal Necrosis following liposuction:
blood vessel thrombosis
(clotting inside a blood vessel)
injury to a blood vessel
vasculitis (blood vessel
disease known as cryoglobulinemia
(cold-induced blood clots)
Signs of tissue death
(necrosis) are a blue, purple, or gray cast to the skin. This should not be
confused with the blue purple coloration from a bruise. Pain is also a sign of
necrosis and could be the only sign if the tissue death or necrosis is deep.
The tissue turns gray or black in the later stages of necrosis, and also may
smell if it becomes infected.
Treating necrosis or ischemia
needs to begin at its earliest stages. Possible therapies include releasing the
sutures to relieve compression from swelling or hyperbaric oxygen therapy. If
the necrosis is small, the tissue can be allowed to slough off by itself and
heal on its own.
The healing process goes
through many stages and it will take a long time depending on how extensive the
necrosis is. It can take up to three to six months depending on the severity of
the necrosis, and sometimes it can take longer. The wound turns black in color
and tend to feel like leather.
If the patient has a small
wound that has turned into necrosis, the wound will eventually go through the debridement process; but this should be watched carefully by trained medical
personal. The issue to be concerned about with necrosis is infection. Some
patients with necrosis tend to get a deep
infection, and this is when medical
intervention should be required – requiring either oral or IV antibiotics.
Larger necrosis normally
requires that the necrotic tissue be removed with surgical debridement, and then
let the wound heal by itself. This approach is better in as much that the
area will heal quicker since you are not waiting for the body to go through the
natural process of debridement. Once the wound has been debrided it is ready to
Every physician will have
their own philosophy in treating these open wounds. There are many
wound-healing ointments, solutions, dressing changes and devices that can
accelerate the healing process. All of these will help tremendously. The only
time the body stops’ healing is when there is an infection present. If there is
poor nutrition or not enough blood supply the healing will stop.
Sometimes surgeons will
suggest a skin graft to cover the open area. This type of procedure is varying
opinions mainly because this means that the surgeon will be placing another scar
on a different part of the body to close a wound that would eventually close
anyways. Most surgeons agree that a skin graft is only used in extreme
Tertiary Closure of the
Once the wound is debrided
the wound will start healing with healthy granulation tissue, the surgeon can
try and close the wound surgically again. This is caller tertiary closure.
This type of closure offers a much quicker recovery; however, there is a
slightly higher chance of developing an infection. If an infection starts with
a tertiary closure, then this means the surgeon will have to reopen the wound
Serial Closures of the Wound
In larger wounds can
sometimes require several debridements. And once the wound has started healing
the surgeon can close the wound in several stages. This is called serial
closures. Since the wound may be too large to close in one surgery then the
surgeon uses approximation with how many sutures or devices to maintain the
tension. Once the skin has stretched, then the surgeon goes back in again
repeating the process.
This is a new study that is
out in hopes of closing large wounds with necrosis faster. So far is has seen
some amazing results. It seems to have increased healing time by almost
50-60%. Wounds that would normally take 4 to 5 months to close are only taking
1 to 2 months. This device is not available nationwide just yet.
No matter what method is used
to treat necrosis and closing a wound, it will almost always require a scar
revision. Once the healing process has taken place the scar is revised and the
results are normally very good.