Development of Skin Tags After Heart Surgery: Causes and Mechanisms
Skin tags that develop after heart surgery are primarily caused by radiation exposure during fluoroscopic procedures, pressure-related injuries during surgery, and compromised skin integrity due to poor perfusion during cardiopulmonary bypass.
Radiation-Induced Skin Changes
Radiation exposure during fluoroscopically guided cardiac procedures is a significant contributor to skin changes post-surgery:
- The skin at the site where the fluoroscopic beam enters the patient receives the largest radiation dose and is at greatest risk for injury 1
- When skin doses exceed certain thresholds, radiation injures numerous cells, leading to biological responses in the skin 1
- Radiation-induced skin injury is the most common deterministic effect from fluoroscopic procedures 1
- Proposed thresholds for various skin effects include:
- Early transient erythema: 2 Gy
- Temporary epilation: 3 Gy
- Permanent epilation: 7 Gy
- Dermal atrophy: 10 Gy
- Telangiectasia: 10 Gy 1
Risk Factors for Radiation Sensitivity
Certain patient factors increase susceptibility to radiation-induced skin changes:
- Collagen vascular disease (particularly scleroderma, discoid lupus erythematosus)
- Diabetes mellitus
- Hyperthyroidism
- Previous fluoroscopically guided procedures or radiation therapy 1
Pressure-Related Skin Injuries
Direct pressure during surgery is another major cause of skin changes:
- In a study of open heart surgery patients, 2.9% developed skin defects of varying magnitude remote from the incision site within 24 hours following surgery 2
- Eight out of 14 patients in this study had skin loss at sites of pressure on the head, back, buttocks, or arm 2
- Pressure points during positioning and subsequent skin trauma must be meticulously avoided in any patient undergoing cardiopulmonary bypass 2
Thermal and Perfusion-Related Mechanisms
Temperature and perfusion changes during cardiopulmonary bypass contribute to skin vulnerability:
- During active cooling and rewarming, skin temperature lags behind core temperature (by approximately 4°C) 2
- The skin develops a relative oxygen debt during cardiopulmonary bypass, decreasing the threshold for skin injury 2
- This effect is particularly pronounced in older patients with predisposing factors such as:
- Obesity
- Generalized atherosclerosis
- Diabetes
- Friable skin 2
Postoperative Complications and Management
Skin integrity disorders are common after cardiac surgery:
- Children undergoing cardiac surgery are at increased risk of experiencing skin integrity disorders and pressure ulcers 3
- In a study of pediatric patients, specialized skin care programs reduced the incidence of skin damage from 62.5% to 45% 3
- For adult cardiac surgery patients, 7% experienced skin breakdown in one study, with 71% of breakdowns occurring during the first 4 days after surgery 4
Prevention Strategies
To prevent skin tags and other skin integrity issues:
- Increase skin assessments and nursing interventions on the day of surgery and the first to fifth postoperative days 4
- Implement specialized care programs focused on maintaining skin integrity 3
- Carefully monitor radiation exposure during fluoroscopic procedures, as the median cumulative dose at the interventional reference point was found to be 0.64 Gy in one study 5
Special Considerations
Age, sex, and comorbidities affect risk:
- Age, female sex, and heart failure are statistically significant risk factors for skin breakdown (P < .001, .02, and .02, respectively) 4
- The Braden Scale scores can help identify patients at higher risk of skin breakdown 4
Management of Existing Skin Tags
While not specific to post-cardiac surgery skin tags, management options for skin tags include:
- For preauricular skin tags, Ligaclip application has been shown to be rapid, safe, and effective with the tag falling off between days 7-10 6
- For Crohn's disease-related skin tags, excision is not recommended due to high rates of postoperative complications 1, though this may not directly apply to post-cardiac surgery skin tags
Conclusion
The development of skin tags after heart surgery is multifactorial, involving radiation exposure, pressure injuries, and compromised skin perfusion during cardiopulmonary bypass. Preventive measures should focus on careful monitoring of radiation exposure, meticulous attention to pressure points during surgery, and specialized postoperative skin care.