Wound Breakdown After Tummy Tuck? Infection or Fat Necrosis

May 29, 2020 Tags: ,

We all know cosmetic surgery is on the rise. Do we know what scale it is growing?

A whopping more than 17.7 million surgical and minimally invasive cosmetic procedures were performed in the United States in 2018. Tummy Tuck or Abdominoplasty ranks the 5th on the list for now, but an increasing trend seen in body-shaping procedures, according to a report by the American Society of Plastic Surgeons (ASPS). Australians follow the same trend and don’t seem to be fazed by the fact that Private Health funds have stopped paying for the cosmetic Tummy Tucks.

Tummy Tuck is the only permanent way to get your pre pregnancy flat tummy in the best possible way. As regulators and advances in surgical techniques have made it much more safer for patients, there are some inherent postoperative complications that come in a package even with the best surgeon. At Esmée Clinics, Dr Mahadik endeavours to educate his patients by providing evidence and research based data to guide them through this unforeseen aspect of their cosmetic journey.

Lets briefly outline some facts on complication rates after a Tummy Tuck procedure (1). We believe that patients should be aware of them before signing up. The numbers reflect only those needing hospitalisation and those complications managed from clinics were excluded.

  1. Abdominoplasty accounts to higher major complication rate of 8-10% (4) compared to other cosmetic surgery procedures
  2. When combined with multiple procedures like other body contouring procedures the rate spiked higher(1)
  3. Seroma, Fat Necrosis and Infection were the top 3 complications
  4. They pose a significant financial burden on the surgeon and the patient as most expenses are out of pocket, uncovered by private funds.

WHAT IS FAT NECROSIS?

Fat necrosis is the death of fat cells due to shortage of or a disruption of blood flow to the abdominal fat and skin. Fat necrosis causes wound breakdown and delayed healing.

The signs are similar to wound infection. Infection,however is caused by bugs while fat necrosis is tissue death which can then be a good medium to get colonized by bugs.

HOW DO I KNOW, I HAVE FAT NECROSIS?

After an uneventful surgery patients are usually followed up day 7 to 10 to check sutures and dressing changes. The signs of fat necrosis usually take 5-7 days or sometimes 2 weeks to appear.

They appear to be similar to infection, but infection is due to bugs while fat necrosis is a death of fat cells under the skin due shortage of or a disruption of blood flow to the abdominal fat and skin.

Signs of fat necrosis
  1. Skin next to incision site is discoloured, bluish- black or scabby
  2. The area becomes lumpy, firm, swollen and warm.
  3. Small red patchy areas may develop on the upper skin flap below the umbilicus
  4. The skin may break into tiny 3-4 mm areas at one or more locations along the scar
  5. Discharge of think reddish yellow fluid from the scar.

Although it might appear to be superficial infection that can settle with antibiotics, more often than not, it is more sinister than this.

It is FAT NECROSIS of the abdominal skin flap that will cause a wound breakdown.

WHAT CAUSES FAT NECROSIS?

The primary cause is shortage of blood supply to keep the fat alive.

Sir Harold Gillies wrote that “Plastic Surgery is a constant battle between blood supply and beauty’* (Gillies and Millard, 1957)-a struggle which has not yet been resolved.

These fat cells typically located in the middle portion of the abdominoplasty scar are at the farthest point of the blood supply, may die causing the wound to break and dehise. The size of breakdown is proportional to the amount of fat death secondary to ischemia (lack of blood supply).

Skin is more tolerant than fat to ischaemia. Hence it survives and the underlying fat dies.

There are a few other contributing factors –

  1. Tension closure – Over zealous cut out of the skin apron often leads to tight closure of the skin which contributes to fat necrosis. The heavy sutures cut like a cheese wire through the fat layers
  2. Diabetes and Smoking – reduce the baseline blood flow to tissues. Smoking ideally should be ceased 4 weeks before the procedure.
  3. Infection – Surgical site infections can cause wound breakdown and fat necrosis
  4. Obesity in general and patients with massive weight reduction are high risk for fat necrosis.
  5. In a small percentage of patients it can happen without an identifiable cause

WHAT TO EXPECT & HOW DOES FAT NECROSIS HEAL?

Mild cases – The inflammation, induration and lumpiness settles over time and the skin may not breakdown

Moderate to Severe cases – Small areas of skin breakdown will continue to ooze thin fluid. Gradually, the broken down areas will grow into a bigger wound with more discharge. This may progress depending on how much of the fat is subject to slow death.

Fat Necrosis Treatment

1. Yellow Dots – Perforators (Blood supply to the skin flaps) 2. Blue Arrows – Indicate the pull of the upper skin flap to achieve a fine line bikini scar. 3. Broken White Line – Mid line dissections allowed 4. Fat Necrosis – increases if Critical Zone is breached

Treatments may include :

  1. Surgical debridement procedures – This is usually the first step to excise dead tissues, up to bleeding healthy tissue. This will create an environment for faster healing from healthy viable tissue. The wound is left open for dressings and to be healed by secondary intention.
  2. Short period of hospitalization – should be expected after debridement for a couple dressing changes till the wound is stable and suitable to be managed in the clinic setting.
  3. Regular dressings over a period of 4 -10 wks on average. Frequency of dressings depend on the wound size and the amount of wound discharge.
  4. Dressings that are offered :-

    a) VAC (vacuum assisted closure) dressings gold standard that heal the wound faster, help the wounds to contract in size and are patient friendly. They work on the principle of negative pressure therapy and are quite expensive, unless funded by public health. VAC is to be changed twice a week.

    b) Gauze dressings – The wounds may be packed with guaze soaked with an antiseptic with some tapes to hold it in place. They need more frequent changing than VAC and could be managed by wound nurses or GP’s.

  5. Skin graft or Secondary closure – Once the wound is clean and healthy, the surgeon may decide to cover it with a split skin graft or close it with sutures. Skin graft – can be quite unsightly with a darker color tone and a visible indentation. It is however a good means to cover and close a large wound that otherwise may take ages to heal. The unsightly graft can be later excised and converted into a good scar.

TAKE HOME MESSAGE

Medicine is a science and there are no fixed answers for all questions as science still continue to unlock new things every day.

Esmée Clinics would like to summarize this a small take home message for those considering an abdominoplasty procedure. As long as patients are educated, they are better prepared mentally and financially to face any odds.

  1. Tummy Tuck has a higher complication rate of 8-10%
  2. Certain surgical principles should be followed to minimize fat necrosis, but some patient factors play an important contribution
  3. Most cases of fat necrosis can drag the healing process over 4-10 weeks
  4. Delayed healing can be resource intensive and cause a significant mental and financial stress to the surgeon and the patient.

References

  1. Science daily .’Tummy Tuck’ Complications—Study Looks at Rates and risk factors. October 28, 2015
  2. Matarasso A. Abdominolipoplasty. Clin Plast Surg 1989; 16: 289–303.

  3. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg 1977; 59: 513–17.

  4. Abdominoplasty wound-healing complications: assisted closure using foam suction dressing. C. H. Fenn and P. E. M. Butler,Department of Plastic Surgery, St George’s Hospital, London, UK
  5. Patient Care & Health Information Tests & Procedures Tummy tuck
  6. Minimising complications in abdominoplasty: An approach based on the root cause analysis and focused preventive steps, Mohan Rangaswamy

Plastic Surgery Department, American Academy of Cosmetic Surgery Hospital, Dubai Healthcare City, Dubai, U.A.E


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