COMPLICATIONS & RISKS: SKIN NECROSIS
What Is Skin Necrosis?
A potential, but rare, complication that may cross the path of a facelifter is skin necrosis. Skin necrosis is a complication that results in the death of the skin tissue. Skin necrosis occurs when not enough blood and oxygen are supplied to a given skin region. The main causes of skin necrosis are extensive hematomas and seromas that are left undetected and untreated for a period of time, cigarette smoking, and infections. Once necrosis has taken shape in an area, the complication is not reversible because there is nothing that can be done for skin that has undergone the necrotic process. Yet, the earlier skin necrosis is detected the better because steps can be taken to prevent further damage. In a good many cases, when skin necrosis occurs after a facelift it is confined to small areas that heal without serious consequences. In certain cases, however, skin necrosis leads to unsightly scarring.
Why Does Skin Necrosis Happen?
In the case of a facelift, skin necrosis is due to the lack of blood and oxygen coming to a particular tissue of the body. During a facelift, the skin is separated from up to 80% of its blood supply. If the skin flap that has been detached from its underlying structures is deprived of blood supply for a long period of time, then necrosis can occur. Of course, a competent surgeon should perform the facelift in a way that will not expose the patient to this risk. During the procedure, the extent the surgeon will pull the skin may be a factor that causes skin necrosis. As a matter of fact, the tightness of the skin in certain areas can cause a decrease of the blood circulation and even in some rare cases to loss. During surgery, skin necrosis can occur if a surgeon pulls the skin too tightly to the point that circulation is lost and an inadequate blood reaches the skin cells.
The risk of skin necrosis is significantly heightened when one smokes during the few weeks before surgery or by smoking during the initial weeks of post-op. Skin necrosis may even be caused as a result of secondhand smoke. This is because nicotine can cause the blood vessels beneath the skin to become constricted, thus blocking the flow of blood and oxygen to the skin. Because these blood vessels sometimes represent the only blood supply to certain skin tissues, the tightening of these vessels that results from smoking can have severe consequences. Moreover, the carbon monoxide that is produced during smoking may further decrease oxygen levels flowing to the skin, increasing your chances of getting skin necrosis. For this reason, it is important to stop smoking for 2-3 weeks before surgery and for 2-3 weeks following surgery.
Skin necrosis may also be caused by Hematomas or Seromas that may form after surgery beneath the skin which are left untreated for a period of time. If you have not yet read about these complications, a hematoma is a collection of blood that forms under the skin, whereas a seroma is a collection of fluid that forms under the skin. When a hematoma or a seroma form, they may put pressure on the tiny blood vessels underneath the skin surface and thus decrease circulation to the affected tissues. If a hematoma is detected and treated early enough, skin necrosis should not occur. However, if a hematoma or seroma is left untreated for a certain period of time, skin necrosis may take shape. The reason being that often in a hematoma, blood pools underneath the skin and then it often coagulates and hardens. Blood clots are usually a good sign of recovery in relation to wounds. However, blood clots can prevent or hinder blood flow to the surface of the skin if formed underneath the skin. Because of this (but this is by no means a definite outcome), it is important to know how to identify the warning signs of a hematoma or seroma so that you may be able to report it immediately to your doctor. We discuss these warning signs shortly below, as well as in the discussions on hematomas and seromas that appear in their own individual areas in this room.
Finally, an infection that occurs during post-op may also cause skin necrosis. Indeed, the infection stimulates the swelling and tightness in the area causing the vessel to constrict. This occurs when an infection causes the blood vessels to block up by stimulating swelling and tightness in the area that leads to vessel constriction. After surgery, your immune system can be down and it is not unusual for you to contract such infections, which can cause inflammation, thereby causing blockage in the regular blood circulation. In rare cases, skin necrosis can occur if a surgeon pulls the skin too tightly to the point that circulation is lost. For this reason, it is important to do significant research on the surgeon with whom you have decided to partner on your journey.
It is important to note that skin is more prone to skin necrosis after a surgery, because after a surgery skin tissues, blood vessels and the entire body works collectively towards the healing process. At this time, the skin needs more blood and oxygen, its nutrients to repair the damaged tissues and replace the dead skin tissues. However, if the skin does not receive the needed nutrients, it cannot properly repair, leading to accumulation of dead skin tissues and even skin necrosis. Beside the blockage of blood supply, the bacteria can cause the skin to swell and become discolored, usually purple or black.
Why Is Skin Necrosis Bad For Me?
Because skin necrosis literally represents the death of the skin cells, the affected skin tissue is irreversibly damaged. In a considerable number of cases, skin necrosis resulting from a facelift is limited in its severity so long as it is treated early enough so that the necrosis doesn’t spread to other areas. Whenever necrosis occurs, the affected area turns black, dies and a scab forms thereafter. The real harm that is done to you is the scarring that can result in the affected area. In a good number of cases, the scar will be minimal and superficial. Yet, scarring can be considerable and the degree of its severity will depend on how early the skin necrosis was detected and treated, as well as on individual factors such as your body’s individual response to the complication and how well it heals the affected area. Many times, Hypertrophic scars develop at the site because of excess collagen synthesis. Ultimately, skin necrosis is not a life and death issue. Yet, skin necrosis can cause scarring that can be aesthetically unattractive or so unsightly to the point of requiring you to have further surgery done such as through a scar revision procedure.
What Are My Chances Of Getting Skin Necrosis?
Facelifters should bear in mind that skin necrosis is a very rare post-op complication. Studies have shown that the incidence of skin necrosis after a facelift ranges between 2% to 3%. But, certain factors can increase this risk. The main factor of skin necrosis is the cigarette smoke. Studies have revealed that it happens in about one in ten smokers who have a facelift (studies reveal figures of anything from 7.5% to 19%). This makes it the most common complication of a facelift for smokers. Remember: This risk of skin loss is 12-20 times higher in smokers than nonsmokers. As a matter of fact, it has been shown that nicotine interferes with wound healing and slows down the circulation of the blood into the body. Smokers must be advised to cease all smoking, including secondary, at least 2-3 weeks before surgery and 2-3 weeks after surgery. Do not forget to tell your PS the absolute truth and mention any cigarette you smoked before the surgery. Indeed, they can us a more conservative procedure, using a short flap technique, to promote better healing.
Other than smokers, patients with protein C or S deficiency are also at risk of developing skin necrosis. Protein C is a Vitamin K-dependent protein. It is an inhibitor of the coagulation process and it interferes with the formation of clots. Similarly, diabetics are also at an increased risk of developing this complication.
When Can Skin Necrosis Occur On The Journey?
Skin necrosis can pretty much develop at anytime during the first few weeks of post-op, after which the risks of developing skin necrosis lessen. Yet the factors that cause necrosis to develop can be the result of your smoking before surgery, your surgeon pulling the skin too tightly during surgery, or a hematoma, seroma, or infection developing sometime during post-op. For this reason, the onset of skin necrosis can occur during the first few weeks of post-op and then lessen as you continue to heal beyond this timeframe.
Where Can Skin Necrosis Occur?
After a facelift, skin necrosis may occur in any area where there is a loss of blood flow and oxygen supply to a tissue. The most common area where skin necrosis occurs is the area right behind the ears (post auricular region). The reason why skin necrosis occurs in this area more frequently is due to the fact that this region is the farthest away from the regular blood supply. Also, because the incision lines are closed with tension around the ears, this can compromise the circulation to the surrounding skin tissues. Finally, it is worthwhile to mention that it is possible for skin necrosis to affect more than one area.
What Are the Warning Signs?
A decreasing blood flow in a particular area is a good way to detect skin necrosis. Usually, you will notice this decrease in blood supply because the area is pale. An increasing blood flow is also another warning sign. You will notice in this case some kind of blood congestion as if the blood was accumulating in a localized area without any way to escape. This excess accumulation of blood often happens in the case of a hematoma, and beside other reasons, thinning of blood can be a cause of such excess blood flow. Usually because skin necrosis is a result or occurs after an old hematoma or seroma in the skin, the skin in that area is usually red and can very easily bleed and usually the fat underneath the skin is yellow. Usually, the symptoms of skin loss start with blistering that progress to a purplish mark. A rough and dry sensation, a darker and black discoloration are also signs of skin necrosis. With time as the blood circulation to the affected area decreases, the skin becomes black and usually with time this skin may also fall off.
Another warning sign that may indicate the onset of necrosis is if you see a clear liquid with a yellow or brownish color flowing out of your drains placed in your incision areas. This occurrence may possibly mean that skin necrosis has begun.
Because a hematoma can lead to skin necrosis, understanding the warning signs for this complication will also be helpful in detecting skin necrosis in its early formation. You may have a hematoma if you experience a sudden pain or swelling developing in a localized region, or if the skin in a small area turns into a bluish-purplish color, or if you feel a tender, burning sensation, or if a small region feels appreciably warmer than the rest of our face and neck. As a result, if you experience any of these symptoms, you should immediately contact your doctor who shall then decide how to proceed. A detailed discussion of this complication is found in the Hematoma area of this room.
A seroma can have the same effect as a hematoma and need to be also detected. You may have a seroma if you feel a particular area to be lumpy. You may also monitor any irritation of the skin tissue especially next to the wounds because it can cause the formation of a seroma. A detailed discussion of this complication is found in the Seroma area of this room.
How Does Skin Necrosis Change And Heal Over Time?
An area that is affected by skin necrosis usually starts out looking purplish and then it turns into a darker discoloration, ultimately becoming black. The texture of the area can be rough and dry. During the weeks following the onset of skin necrosis, the area turns into a scab that can be quite hard. Once the area heals, the scab turns into a scar. It takes around 5 to 7 days for the black area to detach form the healthy skin. Then, the period it takes for an area affected by skin necrosis to heal is usually several weeks.
In many cases, if skin necrosis is treated early on, the affected tissue usually heals well. However, if the damage from skin necrosis is more considerable, then noticeable scars can form. Fortunately, a good number of cases of skin necrosis occur in areas behind the ears so the damage that occurs is not detectable to the eye in such instances.
Healing 101: What Are The Healing Tips?
What Can I Do To Lessen/Prevent The Possibility Of Skin Necrosis?
If you smoke, you should quit for at least 2-3 weeks before and 2-3 weeks after surgery. Similarly, you should try to avoid secondhand smoke during these periods. You should remember that you multiply the risk of having skin necrosis anywhere from a factor of 12-20 times if you continue smoking during these periods. If you are a diabetic or have a protein C or S deficiency, be sure to disclose your condition to your surgeon in advance of surgery so they may decide how to proceed. An additional safety measure that you can take during your recovery is to wear loose-fitting clothes that do not put pressure on your skin (such as tight collars) and refrain from activities that can put significant pressure on the skin and interfere with the circulation.
What Should I Do If I Detect Skin Necrosis?
If you believe that you have the signs that typify skin necrosis, the first thing that you should do is go back to your bed and prop yourself above pillows and then proceed to call your doctor immediately. Keeping your head in elevation will help the circulation. Moreover, you should avoid applying pressure to the affected area. You might have to release the sutures if you believe that the tension is too high. By intervening in a timely fashion, you can impede the expansion of the necrotic process.
What Are The Surgical Treatments?
Once skin necrosis has taken shape, the affected tissue is definitely dead. However, the earlier skin necrosis is detected the less damage that occurs. A surgical procedure called debridement may be necessary to remove the necrotic tissue. It is an operation by which the surgeon will cut away the dead skin with a scalpel. Usually, this procedure does not require any anesthesia because the tissue removed is dead and you don’t have any sensation. In some very rare and severe case, a more invasive debridement technique involving coming back to the operating room might be required. But, this occurrence is really rare.
Since an unrecognized hematoma may be the culprit behind skin necrosis, if a hematoma occurs the surgeon may elect to have the hematoma drained by a needle or with compression. Less frequently, the surgeon may need to open the incisions and operate again. For a full discussion on this complication, take a walk to the Hematoma discussion in this room.
What Are The Non-Surgical Treatments?
As far as non-surgical treatments for skin necrosis, you may ask your doctor if he/she would prescribe you topical and oral antibiotics that can help the healing of the necrotic tissue. However, it seems that this non-surgical treatment is not as effective as a surgical one especially because tissue removal can be important if you want to prevent skin necrosis from spreading to other skin areas.
What Can I Do To Improve The Appearance Of Necrotic Tissue?
After the necrotic tissue has healed, a scar can be left. In many cases, the scar is superficial. Yet, in some cases the scar may be unattractive that you may want to consider having a scar revision to improve its appearance. The scar revision technique that is most often used is skin grafting that can soften, smoothen, and lessen the appearance of the scar. Skin grafting involves taking a thin layer of skin from another part of the body and placing it over the scarred area. You may also consider using scar healing products such as silicone gels that can further help in improving the appearance of the scar. A detailed discussion about various scar healing products is found in the Scar Healing Solutions area of the Hygiene & Personal Care tab.
If you have an area of your face or neck that is affected by skin necrosis, you can effectively conceal it with the use of camouflage makeup. Of course, before applying makeup to the affected area it should be properly healed (you should consult with your surgeon). A detailed discussion about camouflage makeup, including tried-and-tested tips and techniques, as well as product recommendations, may be found in the Makeup & Camouflaging Techniques section of the Beauty Secrets, Potions & Techniques Room.
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