Livor Mortis and Forensic Dermatology: A Review of Death-Related Gravity-Dependent Lividity and Postmortem Hypostasis

Abstract

Livor mortis is an early postmortem change; it is also referred to as dependent lividity or postmortem hypostasis. This is a narrative review; the PubMed search engine was used to obtain citations of relevant articles. The following terms, by themselves and in combination, were used to screen for appropriate published manuscripts that described the features of livor mortis: color, cutaneous, dermatology, fatal, forensic, hypostasis, lividity, livor, mortis, and postmortem. The articles obtained from those searches were reviewed, and the relevant references cited by the articles were evaluated. Lividity typically presents as small blanchable red-purple macules and patches on the dependent areas of the decedent; it is usually observed within two hours after the person has died; however, it can be noted as early as 20 minutes after death. After four to six hours, hypostasis becomes more readily apparent; the smaller lesions become confluent and occur in larger regions of the body. However, contact pallor is observed in the dependent areas affected by direct pressure; these sites do not become red-purple. Livor mortis is usually "fixed," and not blanchable, after eight to 12 hours. A bruise is the most common condition in the clinical differential diagnosis of lividity. The onset and duration until fixation of postmortem hypostasis are variable; lividity is also influenced not only by temperature but also by other factors. Livor mortis has at least three potential applications in forensic medicine. The first is that lividity, usually in combination with information from other postmortem changes, can be used to estimate the time since death; however, livor mortis is not reliable as an independent observation for establishing a range for the postmortem interval. The second is that livor mortis, when fixed, can be very helpful to establish that a decedent has been moved after death. The third is that the color of the lividity may possibly provide information regarding the cause of death; for example, carbon monoxide intoxication, hypothermia, or cyanide poisoning can be associated with cherry-red or pink lividity. New discoveries in medical technology have provided the ability to incorporate the use of spectrophotometric analysis of lividity to provide an objective assessment of postmortem hypostasis and correlate the information to more accurately estimate the postmortem interval.

Keywords: color; cutaneous; dermatology; fatal; forensic; hypostasis; lividity; livor; mortis; postmortem.

Figure 1. Livor mortis on the back and buttocks of a woman

The lividity is red and fixed (black stars). The decedent was lying on her back and there is sparing of redness (contact pallor) in the areas that had pressure against them (blue triangles) that were located not only on her upper back (bilaterally overlying the scapular regions in a butterfly distribution) but also on her buttocks. The solid black rectangles are covering tattoos. Source: Author

Figure 2. Postmortem hypostasis on the buttocks and legs of a female decedent

The buttocks and posterior legs show fixed livor mortis that appears as diffuse, non-blanchable red lividity (black stars). The livor mortis spared the buttocks; the contact pallor (blue triangles) occurred in the buttock area since that location was exposed to pressure when she was lying on her back. The solid black rectangle is covering a tattoo. Source: Author

Figure 3. Contact pallor of the lower chest of a man

A middle-aged man was lying face down. When he was found his livor mortis was fixed (black stars). He had been in a prone position; his left distal arm and hand were between his lower chest and the floor he was lying against (A). When he was turned over to a supine position, an absence of lividity (contact pallor) was observed on his lower chest (blue triangles) that corresponded to the location that his forearm and hand had covered which resulted in pressure that prevented the development of postmortem hypostasis (B). Source: Author

Figure 4. A young woman with confluent livor mortis on her lower back and contact pallor on the upper back

Postmortem hypostasis presenting as diffuse redness from the mid back and extending to the lower back and proximal buttocks (black stars); the woman was lying on her back. She was wearing a bra which pressed firmly against her upper back; contact pallor (an absence of the lividity) developed in the areas of her back which were covered by the bra (blue triangles). Source: Author

Figure 5. The blanching test to evaluate whether livor mortis is fixed

The lower back and buttocks of a decedent who was found lying supine show confluent red lividity (black stars); the investigator used a gloved hand to press against the confluent red lividity (A). Livor mortis is not yet fixed since the area of confluent lividity demonstrates blanching of the redness (blue triangles) where pressure was applied (B). Source: Author

Figure 6. Tardieu spots on a man’s abdomen

Purple petechiae and minute hemorrhages (black arrows) have developed on the periumbilical area the abdomen of a man who was lying prone after dying. Some of the smaller lesions have enlarged. The increased pressure of the blood on the blood vessel walls causes them to rupture. Source: Author