Skin Necrosis after Pedicled Tram Flap reconstruction

I had my reconstruction on March 22 2013. 7 hours in surgery and lost units of blood. Surgeon was concerned with the sluggish response to cappillary refil after the operation and I was kept under close observation for 4 hours. Today 11 days after surgery, I have an area to the reconstruction (closest to my arm) that is black, hard and in one area oozes a smelly discharge. I have seen my surgeon today and district nurses come every day to change the dressing. My surgeon is talking of further surgery to remove the necrotic area.

I was wondering if anyone else has had experience of this with a good outcome. I am worried that I could end up with a permanent disfigurment.

Apologies if I have double posted. I did post, but it looks to have disappeared.

I was due Mx with immediate reconstruction, but had change of plan. Plastic surgeon I saw said he expected me to get some skin necrosis because of my previous rads and breast surgeries. I got the impression he thought it wasn’t a huge problem: he told me he was prepared to wait it out.

I’m sure someone will come along with some more relevant input, but hope this helps in the meantime.

Hugs,

Margaret

Hiya
I had this with my reconstruction, which I had in November 12. I had to have a vac pump to clear it up. I still have 2 dents, but PS assured me that I can have a skin graft later if I am not happy with how it looks, but Im fed up with surgery so will see how it goes next year. It takes a long time to heal when they try to do naturally. I had dressings for 5 weeks and nothing as they have to keep cleaning it out . They cut that bit out in dressing clinic (one of the surgeons) I did not feel anything because it is dead, but was surprised when I looked in the mirror how deep he went, and how much was cut out. If they cut it out you want a KCI pump as this is the better one, and healed me in a week compared to the other pump which they were going to give me until the sister that I know stepped in as the other pump would taje 4 weeks.
I hope this helps

Best wishes
Norma

Hi Supertrouper,
So sorry to hear you are having problems. I had been going to message you to ask how your op went in a couple of weeks. You kindly replied to my post about good news stories about pedicled tram flap. Hope you get it all sorted out soon and that you are not too uncomfortable.
All the very best and hope you will be feeling better soon.
Gaynor xx

Thanks for the replies. I went to the breast clinic yesterday morning and saw the two surgeons that operated on me. They want to see me again on Thursday morning to discuss what the next stage of treatment is. Yesterday they we still talking about surgery to remove the necrotic area. The area is not small, if I describe my new boob as a half sphere then the necrtotic area is a full 1/7 crescent from top to the bottom, thankfully it is on the side closest to my arm. The outer “skin” is black and hard, like a shell. at the top there is a softer area and this is where the fat necrosis is oozing out of. It is a discoloured watery fluid with a strong ammonia smell to it. very unpleasant and of course right under my nose! I change the dressings four times and quite often my vest top at the same time. When I try to do my physio exercises as instructed, I feel that the hard area is being put under a lot of strain and worry that it will crack.

I must admit to feeling a little sorry for myself today. Not quite the beginning of the return to normality that I was hoping for. I also has words with one of the nurses yesterday who spotted my compression sleeve and said something along the lines of “oh poor you, you are having a rough time of it.”. I pointed out that at least I was here to tell the tale.

Anyway, if anyone else has an experience to add on to this I would be very grateful.

Just a quick update to this. I was back at the hospital this morning and my surgeon took one look at the reconstruction and told be that he wants to do a surgical debridement tomorrow. I had to go through pre-op assessment again and have to be on the ward for 7:30 tomorrow morning. I am worried about waking up and finding nothing there again!

Hugs supertrooper. I can’t offer any words of wisdom, but just want to say stay strong, the road may be long and twisty, but I you will get there!
Sue xx

Hi Supertrouper,
Hope everything went well for you yesterday, been thinking of you.
Gaynor x

I also had necrosis, but following a mastectomy with immediate silicone implant reconstruction, which was on my left breast in September 2012 - fortunately no need for radiotherapy or chemotherapy. A few weeks after surgery my skin (in the area where the nipple had been) became necrotic - black and hard, and was discharging. I went back to the consultant many times, who just monitored it and kept telling me to put on dry dressings. The black skin eventually healed (after 3-4 months), except for a small hole in the middle, and has been discharging all the time. In the last few weeks this hole has become much larger and discharging more, and now I can see the implant. I suspect that the skin died because it was too thin, being pulled too tight over the implant, but despite going back to the surgeon many times over the last 6 months he has allowed this to continue. I have now developed another “hole” in the scar line under the breast, which is also discharging. I saw the cosmetic nurse last week who said she can see the implant, so it will have to be replaced, but my surgeon is away until the end of this week. I am now resigned to having to have the implant removed, having a flat breast for a while whilst it heals up, and then having a new implant inserted. I am less than happy with this, due to the fact that I will not want to be without an implant and do not want to have a flat breast, even for a short time (I would not have opted for the reconstruction if I did), and now face further surgery, pain and healing, and more time off work, just when I have got my life back on track and am feeling fit and well again. I feel that my surgeon should have spotted the signs long ago - possibly at the time that the skin became necrotic, and not allowed this to get to this stage and for me to have suffered for so many months. I had this done privately, but I had to contribute £1500 towards the cost as my insurance company would not pay the full cost. I am wondering if I have a right to claim for medical negligence, and if so, how to go about this - should I wait until the treatment is complete, or start something now. I would like this surgeon to finish what he started - he is highly respected, but does not seem to have done a very good job with me. I have been very positive throughout since I was diagnosed, and never let it get me down, but this is now testing me and I am beginning to feel quite down about it.

Thanks positive thinker for your post.

I had more surgery on Friday and before going to theatre I asked if they were hopeful That they could save the reconstruction. They said they were. When I woke up I was told that they had managed to close the wound with metal clips. Once back on the ward I managed to inspect what they had done and could see that all that was left of the reconstruction was the skin, all the tissue and muscle had gone. So I am back to flatness on one side. All the pain but none of the promised gain. I shall be asking for copies of all the theatre and ward observations as I think something must have gone wrong somewhere. I certainly dont think I should have been sent home before Easter when there were obvious problems. I was discharged from hospital again today after another five nights. I still have two drains in place and a few dozen staples holding my chest together. An open wound area has been packed and my instructions are to return to the breast clinic on Monday. It will be weeks before I can return to work and months before I recover from such major surgery. The thought of reconstruction kept me going through some of the darkest times over the past two years, today I am not sure how I feel.

Supertrouper, your user name seems very apt as you really seem to be having to pull out all the stops at the moment So sorry to hear you have had / are having such a horrid time. I’m seeing my ps next week to have further discussion about this procedure. I just want him to be honest about complications and failure rates. I know everyone is different but I know I’ll blame myself if it doesn’t go to plan.
Hope you start to feel better soon. It sounds like you need some questions answered from your ps.
take care
Gaynor xx

GMT from the information I have seen, there is a 5% failure rate for the type of reconstruction that I had. I think my surgeon was a little over ambitious and tried to get rid of a lot of the skin that had been damaged by radiotherapy. I am seeing him on Monday and I have a list of questions. I am concerned about the restricted level of movement in my left arm. I cannot do many of the recommended exercises due to the number of staples holding everything together. My physio says “try and do what you can” my surgeon tells me light movements only.

And I HATE these drains. So difficult getting comfy in bed with two drains coming out of my side. Grrrrr

Saw my surgeon again on Monday - had both surgical drains removed and 20 (about half) of the metal staples removed. There is a small open wound that needs packing every day so I have district nurses coming out to me every day. So far my surgeon has said nothing about what the next step should be. I am still signed off work and spend most of my days resting as I am still in quite a lot of pain both from my hip to hip abdominal cut and also from where the staples are. When I go to bed I feel like there is a tight band around my chest.

I have two appointments at the hospital next monday - one at 8am with my surgeon, presumably to have the rest of the clips removed and then one at 1pm with my physiotherapist who will no doubt have a go at me about not doing the exercises I should have been doing. Even though my surgeon told me not to do them and the lymphoedema in my affected arm makes it very painful to do any arm movements.

Hopefully I will see improvements soon. It will be good to be able to drive again and then I am not having to ask my husband to ferry me to and from the hospital appointments.

Supertrouper, thanks for the update. Sorry you are in pain but after seeing surgeon next week perhaps some of that will be alleviated if he takes out the staples. Hope you will be feeling a bit brighter soon. Keep us posted of your progress.
big hug,
Gaynor xx

Really sad to hear that you’ve been going through all this agony, hugs st.
I truly hope that your surgeon has a plan to restore/replace the ‘lost’ tissue.

Sue xx

Quick update - now that all the staples have been removed, a larger section of the surgical wound has now re-opened and is now about 6 inches long. District nurses come each day to pack and dress this wound that so far is showing no signs of healing. I have to sleep on my back in one position as any movements are painful and wake me up. I am back at the breast clinic on Monday and will see what my surgeon says. Bad enough that I don’t have the promised new breast but to have this to deal with on a daily basis is even worse.

Hopefully things will start to improve soon.

Oh dear, this is just rubbish isn’t it! I wish there was something I could say or do that would help, but sadly there isn’t.
But I can give you a hug, and send you some virtual support, and I hope come Monday they can work some magic for you.
Stay strong st, we can et through this!
Sue xx

Hi ST,
Hope you get on ok tomorrow with your surgeon. So sorry it is still not much better, thinking of you.

Gaynor xx

Thanks for the messages of support. I was at the breast clinic on Monday and saw my surgeon. He said the open wound is going to take weeks to heal and I will need daily visits from the district nurses. Yesterday was my first day back at my voluntary job and I left messages on the district nurse’s answering machine starting at 8:30 am asking for a morning visit. What time did they come? 7:30pm. I shall ask about going to the clinic at a set time each day as I am not prepared to put up with the randomness of their visiting times.

I also asked my surgeon about what could be done in the future and he made it quite clear that he wasn’t prepared to attempt another reconstruction as my blood supply and skin to that area has been too badly damaged by the radiation treatments that i had. So, I will have to accept life with one breast and make up some fancy story about a shark attack to explain the quite extensive scaring that I now have following both the mx and now the failed tram flap. Tattoos look like they may be the way forward although my surgeon would probably warn me that it could make my lympaeodema worse!

Hello Supertrouper,
Just wanted to send you a message of support really as you have been through such a tough time.
I am recovering afer having ovaries removed on Monday, but last year had bilatermastecomies and immiediate reconstruction.It was a different method as had implants but I suffered necrosis about 4 months after the orginal op while I was on chemo again and had a debridement like you- ie radical mastecomy. I had had previous rads to that breast and like you was told it was likely to be due to rads damage. It took a long time to completely heal, but it did, so hang on in there. I found it very tough emotionally as I felt I went to hell, for nothing! Like you was told the failure rate is very low-not much consolation when you find you are one of the unlucky 5 per cent!
Take good care, Rattles x