Wound Separation After Plastic Surgery

Wound Separation After Plastic Surgery: Factors, Symptoms & Treatments

April 13, 2018

Wound dehiscence or separation in reconstructive plastic surgery after massive weight loss is unfortunately common. Some sources quote the incidence of wound openings may be as high as 15 - 20%. Several factors influence the occurrence of wound separation. Multiple factors influence the chances of wound breakdown.

There are some factors for wound separation after plastic surgery that you can change and some factors that you cannot change.

Factors For Wound Breakdown That You Can Change

Smoking

Cigarette smoke contains nicotine and releases nitric oxide. These cause vasoconstriction and decreased delivery of oxygen. Smoking is particularly harmful because it affects not only the lungs (increasing your chances of post-operative pneumonia), but also changes the delivery of oxygen to the skin (increasing your chances of wound breakdown). After plastic surgery, tissues are incredibly dependent on oxygen delivery. Any subtle decrease in oxygen delivery can cause tissue death and wound separation. Whether you are smoking cigarettes, hookah, or electronic cigarettes, all deliver nicotine that causes decreased oxygen and increases the chances of wound separation.

Type of Procedure

Anecdotally, I see a higher incidence of wound separation and healing problems in patients who have had a partial gastrectomy or a duodenal switch. This increased incidence may be due to the severe loss of micronutrients and dumping. Patients with Roux-en-Y, lap bands, and gastric sleeve procedures have less occurrence of wound separation. Patients who have lost weight naturally have the least amount of wound healing problems.

Poor Nutrition

Adequate nutrition before and after plastic surgery is essential for healing. High-quality food is especially important for weight loss patients. Your body needs a certain number of calories just to go about your daily activities.

After surgery, your body’s daily caloric requirement increases to assist in healing, sometimes as high as 35 calories/kg body weight. If there are not enough nutrients to meet the caloric and metabolic demands of the body after a plastic surgery procedure, your body will not heal.

Plastic surgeons and dietitians who specialize in reconstructive plastic surgery after massive weight loss recommend that you eat/drink at least 100 g of protein a day. For optimum healing, this 100g of protein is recommended for one week before and two to three weeks after your procedure.

Low Vitamins Levels (esp. Vitamin B12)

Micro-nutrients and vitamin are essential for wound healing. Unfortunately, many vitamins levels are low and poorly absorbed in patients who have had stomach surgeries. Before and after your plastic surgery procedures, please be sure you are taking a multivitamin every day and check your vitamin B12 levels.

Anemia and Low Iron

Many gastric bypass procedures result in anemia (low hemoglobin) and low iron.  If your hemoglobin is sufficiently low, you may require a blood transfusion. Iron essential in that it helps transport oxygen to your tissue. If your iron is low, your oxygen delivery may also be low. Before surgery, be sure your iron levels are normal.  You may require oral iron supplements or even iron transfusion. With every surgical procedure, there is some blood loss. It is better to optimize your hemoglobin and iron levels before surgery than to have a risky surgery/recovery.

Increased Tension Due to Too Much Post-Operative Activity

Wounds separate because there is too much tension in the incision. Too much activity can place undue strain on the incision. I suggest bed rest for at least several days. Blood clot prevention can be minimized with Lovenox injections.

Poor Glucose Control

High and low glucose and subsequent insulin levels have a significant impact on wound healing. With the stress of surgery, glucose levels often rise. High glucose levels can have a negative effect on the incision. Uncontrolled diabetes increases the chances of wound breakdown.

Inexperienced Plastic Surgeon

Experience in performing plastic surgery counts. Though anyone can have wound complications, plastic surgeons with more experience often have fewer complications. When deciding on a plastic surgeon, choose one with the most experience in weight loss patients. Skin tension and wound healing issues are significantly different in massive weight loss patients compared to patients who have not undergone gastric procedures.

Factors For Wound Breakdown That You Cannot Change

Underlying Infection

Infections can lead to wound breakdown. Sometimes infections can be from the skin surface, or they can be deep inside the wound. Whether the infection is superficial or deep, the body tries to get rid of it by opening the wound.

Certain areas of the body are more prone to break down. Due to their complex anatomy and lymphatic structures, the armpit and the groin have a much higher incidence of wound breakdown. Thus, arm lifts and thigh lifts have an increased rate of breakdown compared to other body parts.

Suture Rejection

Sometimes your body rejects the suture. When this happens, surrounding tissue liquefies, and the suture is ejected through the wound. This leads to a wound opening. If enough sutures are rejected, a significant portion of the incision can open.

Compression Garment

If your compression garment is too tight, this can decrease oxygen delivery. Also, the garment can dig into the incision line. Garment compression can lead to wound breakdown.

Constipation

Constipation is almost expected after any surgical procedure. Straining to have a bowel movement can put undue pressure on incisions. To minimize tension exerted by constipation, begin taking a stool softener the day after surgery.

Symptoms of Wound Separation

Symptoms of wound separation vary.  Wound separation may start as an area of redness. This reddened area may swell slightly. There may be associated discoloration.  After this inflammatory response, the wound may open. In some patients, a single suture is rejected resulting in wound breakdown. Sometimes multiple sutures are rejected.  In some patients, fluid under the wound accumulates and comes through the wound. The fluid can be serous fluid, blood, or purulent (think pus) material.   Sometimes wounds are small and deep. These small, deep wounds often drain fluid. Sometimes, wounds are large and shallow.

Treatments for Wound Separation

Wound dehiscence and separation treatment depend on the type and size of the wound.  Wound treatment also depends on your provider's practice. There is no one way to treat a wound. Instead, there are many medically acceptable ways to heal surgical wounds. The treatment of an open wound involves several factors.

Antibiotics

Oral or IV antibiotics are used to combat infection within the wound.

Wound Debridement

There are several ways to clean or debride a wound. Santyl is an enzymatic debriding cream which acts like a little “Pac-man” to clean up the wound. “Wet to dry dressing” are sometimes placed in the wound. As the wet dressing dries, it sticks to the tissue. When the dressing is changed, the dead tissue sticks to the dressing and thus, the wound is cleaned.

Sometimes the wound separation is so severe that you may require surgical debridement with specialized surgical instruments to remove infected or dead tissue. This can be done bedside or in the operating room. Fortunately, this is usually painless for the patient. Often, the wound is left open and covered with dressings.

Wound VAC

The wound VAC is a relatively new plastic surgery tool.  The VAC consists of a sterile sponge hooked to a negative pressure suction canister. The negative pressure removes unwanted fluid, increases blood flow, and stimulates wound closure.

Diet

If you developed wound separation, I highly advised you try to ingest at least 100 g of protein or more a day.

Oral Supplements

If you developed wound separation, I suggest you take the following once a day: 220mg of Zinc, 500mg of Magnesium, and Vitamin B complex. I would suggest you take a probiotic twice a day as well as 1000mg of arginine and 500mg glutamine three times a day. Also, I would suggest 500mg of Vitamin C every six hours.

Hyperbaric Oxygen

To increase oxygen delivery, minimize infection, and increase wound healing, I often suggest hyperbaric oxygen. You sit in a pressurized chamber for an hour or more, while oxygen seeps into your body.

Conclusion

Maximize your chances of an event-free recovery. Before surgery, stop smoking, get your diabetes under control, take daily vitamins, correct your iron and hemoglobin, and choose an experienced, board-certified plastic surgeon.

Fortunately, most wound separations heal well with conservative treatment. It is rare that surgery needs to be performed on wound openings and revisions are rare.

timothy katzen

ABOUT THE AUTHOR

Dr. J. Timothy Katzen is certified by the American Board of Plastic Surgery. Dr. Katzen specializes in reconstructive plastic surgery after massive weight loss. He has written many articles and given lectures around the world about how to perform plastic surgery on patients who have undergone massive weight loss. He is performed tens of thousands of procedures on weight loss patients. Dr. Katzen has offices in Beverly Hills and Las Vegas.

Read more articles from Dr. Katzen!