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Necrosis or "Tissue Death"

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 happen.

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:

Smokers have a high incidence of necrosis due to blood vessel constriction and a decreased oxygen supply to the surgical area.

 

The higher risk surgeries include the following:

These surgeries hold a higher increase of necrosis because flaps are created separating the skin and its blood supply from your primary structures. 

 

 

 

 

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:

 

                   

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Factors associated with increased necrosis with breast augmentation include:

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 imperative.

 

 

 

 

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:

  • Infection

  • blood vessel thrombosis (clotting inside a blood vessel)

  • injury to a blood vessel

  • vasculitis (blood vessel inflammation)

  • 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.

Read more about the Hyperbaric Oxygen Therapy

 

 

 

 

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 start healing.

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.

 

 

 

 

Surgical Procedures to help Necrosis

  • Skin Graft

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 circumstances.

 

  • Tertiary Closure of the Wound

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 again.

 

  • 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.

 

 

 

 

Other Therapies for Necrosis

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.

 

Hyperbaric oxygen therapy treatments may also be ordered by your physician if appropriate for your specific wound issues.  It has seen great results with patients who do have necrosis. 

 

The benefits of Hyperbaric Oxygen Therapy 

 

 

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