Necrosis, or tissue death, is a serious potential complication following a mastectomy, particularly when immediate breast reconstruction is performed. This complication affects the thin skin flaps remaining after the removal of the breast tissue, occurring when the blood supply to these flaps is compromised. Without adequate blood flow and oxygen, the skin tissue can wither and die. While the incidence of skin flap necrosis can be significant, ranging from 5% to over 30% in some reports, careful planning and management can often prevent its occurrence. This guide provides an overview of the preventative measures, from pre-surgical optimization to post-operative care, aimed at preserving the health and viability of the mastectomy skin flaps.
Identifying Patient-Specific Risk Factors
A patient’s health and lifestyle choices significantly influence the probability of developing skin flap necrosis. Smoking is the most substantial modifiable risk factor. Nicotine acts as a powerful vasoconstrictor, narrowing blood vessels, while carbon monoxide reduces the blood’s oxygen-carrying capacity. Both severely impair the small vessel circulation needed for skin flap survival.
Obesity (high BMI) also increases risk, as do pre-existing conditions like diabetes mellitus and hypertension. These conditions often involve underlying microvascular dysfunction, making the skin flaps vulnerable to reduced blood flow. A history of previous radiation therapy or prior breast surgeries can also negatively impact the existing vascular network, making the remaining skin tissue more fragile.
Patients should take proactive steps to mitigate these risks before the operation. The surgical team advises complete cessation of smoking, ideally for several weeks before and after the procedure, to allow circulatory function to recover. For those with diabetes, maintaining strict blood glucose control improves overall tissue health and microcirculation for better healing. Addressing these patient-specific factors is the first layer of prevention against post-mastectomy necrosis.
Surgical Techniques and Intraoperative Measures
The surgeon’s technique during the operation plays a direct role in preserving the skin flap’s blood supply. This involves maintaining an optimal skin flap thickness, typically 5 to 8 millimeters, ensuring enough subcutaneous tissue remains to carry a viable blood supply. If the flap is thinned too much, vessels are damaged, and blood flow is compromised.
The surgical team also minimizes tension on the wound closure. Excessive pulling can compress small vessels and block blood flow, especially if a large implant is placed. Precise incision placement, such as using a lateral inframammary fold approach in nipple-sparing cases, helps preserve important vessels, like the second intercostal perforator.
Modern technology allows surgeons to assess tissue viability in real-time. Indocyanine green (ICG) angiography uses a fluorescent dye and a specialized camera to map blood flow through the skin flaps. This imaging provides objective data, helping the surgeon identify areas of poor perfusion. These areas can then be trimmed or managed with post-operative treatments like topical vasodilators.
Optimizing Post-Surgical Circulation and Care
Immediate post-operative care focuses on maximizing blood flow and minimizing mechanical stress on the healing tissues. Meticulous management of surgical drains is essential to remove fluid accumulation. If fluid (seroma) or a blood clot (hematoma) builds up under the skin flaps, the resulting pressure compresses the delicate microvasculature, compromising circulation and leading to tissue death.
Patients must strictly follow activity restrictions to prevent strain on the incision site. Strenuous movements that stretch or pull the skin can create tension, causing vessel compression and subsequent necrosis. This means avoiding lifting anything heavy and refraining from activities that significantly raise the heart rate for several weeks.
Choosing the right post-operative garments is also important. Specific surgical bras or compression garments provide gentle, even support without causing localized pressure points that constrict blood flow. Patients must also avoid sleeping in positions that put direct, sustained pressure on the surgical sites, which can temporarily occlude vessels.
Temperature control influences circulation; extreme cold causes vasoconstriction, reducing blood flow to the skin flaps. Maintaining a comfortable, warm body temperature is recommended. In high-risk cases, the surgeon may prescribe topical treatments like nitroglycerin paste. This medication acts as a potent vasodilator, widening small blood vessels to encourage better perfusion and oxygen delivery.
Recognizing the Early Warning Signs
Early detection of reduced blood flow, or ischemia, is the final line of defense against full-thickness tissue death. Patients and caregivers must be vigilant in monitoring the skin flaps for any change from the healthy, pink appearance. The first visual sign of compromised circulation is often a change in color, where the skin may appear dusky, mottled, or take on a dark purple or grayish hue.
Along with discoloration, the temperature of the skin flap will change compared to the surrounding, healthy skin. An area experiencing ischemia will often feel notably cooler to the touch because of the reduced volume of warm blood flowing through the tissue. This temperature difference is an important physical sign that the tissue is struggling to survive.
As ischemia progresses, the skin may begin to show signs of blistering, or it may feel hardened and non-pliable, indicating a loss of normal tissue turgor. The appearance of small, superficial blisters often precedes full-thickness necrosis and is an urgent indicator of a perfusion problem. Any observation of these signs—dusky color, coolness, or blistering—requires immediate communication with the surgical team. Prompt notification allows the medical professionals to implement interventions, such as adjusting garments, managing fluid collections, or initiating topical treatments, potentially reversing the process before irreversible tissue death occurs.