Skin Necrosis After a Tummy Tuck: Why It Happens and How We Treat It

Let's talk about skin necrosis in tummy tuck, why it happens, how to avoid it, and what we actually do about it when it does. This is one of the more feared complications, and understanding the blood supply makes the whole thing make sense.

In a tummy tuck, we make a low incision from hip to hip, elevate the abdominal wall off the muscle layer, pull everything down, and remove the extra. That's how we tighten things up and get rid of excess skin and tissue.

Here's the critical part. The blood supply to that tissue comes up from the muscle wall, and we have to cut it in the process of elevating everything. So after a tummy tuck, all of that abdominal wall tissue is living off an alternate blood supply. Its normal, major supply has been deliberately altered.

That's why the tissue is more prone to trouble healing, and why, unfortunately, you can lose some of the skin. That's what necrosis is.

Because the remaining blood supply comes in from the sides, the area farthest away from it is the most vulnerable. That's the triangle of tissue just underneath your belly button.

Some of us call it the triangle of doom. It's the classic location for tummy tuck skin necrosis, and it's the spot we're all watching in the early post-op period. (It's distinct from belly button necrosis, which involves the belly button skin itself.)

Prevention happens in the operating room, and it comes down to protecting those remaining vessels.

Be very gentle in handling the tissue. And critically: don't pull things too tight. If you pull the abdomen too tight, you stretch those tiny blood vessels, which can cause them to kink and clot off. That is not a good thing.

A tummy tuck that's over-tightened for a flatter result on the table can cost you the skin afterward.

You want to avoid anything that could damage that blood supply. This is exactly why a lot of surgeons completely avoid liposuction of the abdominal tissue during a tummy tuck.

But say your abdominal wall is thicker than you'd like and you want it thinner. There's a right way to do it:

• We remove fatty tissue underneath Scarpa's fascia. Think of it as two pockets of fat with a dividing layer between them, we want to stay below that divider.
• We remove fat from that deep layer and not too close to the skin, because the vessels keeping everything alive run in the more superficial layer.
• This can be done directly (visualizing and removing it with our instruments) or with liposuction, but either way you must stay deep.

Another population that has trouble losing skin after tummy tucks: patients with clotting disorders. Those tiny vessels keeping the flap alive are more likely to clot off if you have a clotting disorder, so this is important history to share before surgery.

The first sign in most patients is discoloration. That little triangle underneath the belly button tends to look bruised or purple.

It might just be normal bruising. But it might be something worse, and this is exactly the kind of thing where early attention matters. Don't sit on it, tell your surgical team.

If we think there's a problem, there's a clear escalation of things we do to improve blood flow.

First, look for anything mechanical impeding blood flow, and it's often the garment. We make sure whatever garment you're in fits properly and isn't choking off circulation. If we're genuinely concerned, we'll often get rid of the garment altogether. (Related: a compression garment worn too high can cause its own problems.)

We use topicals that improve perfusion, most commonly:

• Nitroglycerin paste (nitropaste)
• DMSO

Often we'll add hyperbaric oxygen therapy to supercharge the oxygen in whatever blood is reaching the area.

Then it's watchful waiting to see what happens. And here's the encouraging part:

If it doesn't recover, we watch it for a week or two to let things declare themselves. It often looks like a much larger area than it ends up being, so early appearances are genuinely misleading in a good way.

Once we've figured out exactly what tissue didn't survive, we can remove it. What happens next depends on how much:

• Smaller area: we can simply close it, leaving you with a small vertical incision
• Larger area: we can use tools like a wound vac to help the area heal faster (here's how those work)

And I know this sounds crazy, but even if you lose a decent area of tissue and have to heal with a wound vac, it often looks pretty good once you're completely healed. We can also do some fancy footwork rotating tissue in to close the area.

• Tummy tuck necrosis happens because we cut the main blood supply when elevating the abdominal wall, leaving the tissue on a backup supply.
• The most vulnerable spot is the triangle just below the belly button, the "triangle of doom", because it's farthest from the vessels coming in from the sides.
• Prevention: gentle handling, don't over-tighten, and either avoid abdominal liposuction or stay deep to Scarpa's fascia. Clotting disorders raise the risk.
• First sign: purple or bruised discoloration below the belly button. Tell your surgeon.
• Treatment ladder: fix the garment, nitropaste or DMSO, hyperbaric oxygen, then watchful waiting, most of it usually recovers.
• If tissue is lost, we remove it and close it, or heal it with a wound vac, and the final result is often surprisingly good.

That's tummy tuck necrosis in a nutshell. Scary to look at, but usually far better in the end than it appears in week one.