Causes and Management of Skin Necrosis After Breast Surgery: A Case Study

The causes and management of progressively expanding skin necrosis following breast surgery?

A patient with stage II breast cancer [without lymph node involvement] underwent total mastectomy and the day after surgery, approximately 0.4 cm of hematoma was observed at both incision sites, which gradually expanded to about 0.7 cm [on postoperative day 11, the color changed to dark brown and there was a possibility of necrosis].
After evaluation by a wound care specialist, necrosis was confirmed, and approximately half of the wound showed signs of infection [around postoperative day 14].
The total length of the wound was approximately 21 cm, with a semi-circular hard mass at the axillary incision site measuring about 0.8 cm.

What are the necessary follow-up treatment methods and potential causes for the necrosis, mass, and infection? After discharge, the wound was maintained with follow-up treatments every 2-3 days, and daily cleaning and disinfection were performed using saline solution, along with dressing changes as prescribed by the physician.
During this period, the patient underwent hyperbaric oxygen therapy five times.
The necrotic areas have all formed scabs, and the physician confirmed there was no necrotizing fasciitis.
Other areas are still pending examination and confirmation for treatment.

An Dong Ni, 50~59 year old female. Ask Date: 2011/05/30

Dr. Zhou Jiazhen reply Breast and Thyroid

Dear Anthony,
1.
One of the postoperative complications of total mastectomy is flap necrosis, which can occur due to excessive wound tension (often seen when the tumor is large, more skin is excised, or when the breast is smaller) or due to inadequate circulation from a flap that is too thin, leading to partial skin necrosis.
If flap necrosis is observed postoperatively, depending on the severity, it may require debridement surgery or skin grafting.
Most wounds will heal over time.
2.
As for the axillary wound, whether it is caused by skin folds or protrusions in the axilla can only be determined by a physician's examination.
3.
After a mastectomy, further treatments such as chemotherapy may still be necessary.
Wishing you peace and health.
Sincerely,
Dr.
Chou Chia-Cheng
Director of Surgery, Taoyuan Hospital, Ministry of Health and Welfare

Reply Date: 2011/05/30

More Info

Skin necrosis following breast surgery, particularly in the context of breast cancer treatment, can be a significant complication that requires careful management. In the case presented, the patient underwent a total mastectomy for early-stage breast cancer and experienced skin necrosis and infection shortly after the procedure. Understanding the causes, implications, and management strategies for such complications is crucial for optimal patient care.

Causes of Skin Necrosis
1. Surgical Technique: Skin necrosis can occur due to excessive tension on the skin flaps during surgery, especially if a large tumor is removed or if the patient has a smaller breast size. If the skin flaps are too thin or if there is inadequate blood supply, necrosis can develop.

2. Infection: Postoperative infections can compromise the integrity of the skin and underlying tissues, leading to necrosis. The presence of infection can also exacerbate any existing ischemia (lack of blood flow) to the area.

3. Hematoma Formation: The initial observation of hematoma (the collection of blood outside of blood vessels) can indicate bleeding under the skin, which can lead to increased pressure and reduced blood flow, contributing to necrosis.

4. Patient Factors: Factors such as smoking, diabetes, obesity, and poor nutritional status can impair wound healing and increase the risk of necrosis.

5. Allergic Reactions: As noted in other cases, allergic reactions to dressings or topical agents can lead to skin irritation and subsequent necrosis.

Management Strategies
1. Wound Care: Regular cleaning and dressing changes are essential. The use of saline for cleaning is appropriate, but it is also crucial to ensure that the dressing is suitable for the wound type and does not cause further irritation.

2. Debridement: If necrosis is confirmed, surgical debridement may be necessary to remove dead tissue and promote healing. This procedure helps to reduce the risk of infection and allows for better healing of the surrounding healthy tissue.

3. Antibiotic Therapy: If there is evidence of infection, appropriate antibiotic therapy should be initiated based on culture results and sensitivity patterns. This is vital to control the infection and prevent further tissue loss.

4. Hyperbaric Oxygen Therapy: As mentioned, the patient received hyperbaric oxygen therapy, which can enhance oxygen delivery to hypoxic tissues and promote healing. This therapy is particularly beneficial in cases of compromised blood flow.

5. Monitoring and Follow-Up: Continuous monitoring of the wound is essential. Regular follow-up appointments every 2-3 days, as the patient is doing, allow for timely interventions if the condition worsens.

6. Nutritional Support: Ensuring adequate nutrition can significantly impact wound healing. Nutritional supplements, particularly those rich in protein and vitamins (like Vitamin B12), may be beneficial.

7. Physical Therapy: If there is swelling or limited mobility due to the surgical site, physical therapy may help improve circulation and reduce the risk of lymphedema, especially since the patient has undergone lymph node removal.

Conclusion
In summary, skin necrosis after breast surgery is a multifactorial issue that requires a comprehensive approach to management. The combination of surgical intervention, wound care, infection control, and supportive therapies like hyperbaric oxygen can significantly improve outcomes. It is essential for healthcare providers to remain vigilant in monitoring for complications and to educate patients on signs of infection or necrosis to ensure prompt treatment. Regular follow-ups and a multidisciplinary approach involving surgeons, wound care specialists, and nutritionists can optimize recovery and enhance the quality of life for patients undergoing breast cancer treatment.

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