Seroma and Quilting Suture at the Donor Site of the TRAM Flap in Breast Reconstruction: A Prospective Randomized Double-Blind Clinical Trial

A systematic review of randomised controlled trials in breast reconstruction

BACKGROUND

For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field.

METHODS

Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done.

RESULTS

A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction.

CONCLUSIONS

A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.

Effectiveness of 5-Fluorouracil and Hypertonic Glucose in the Prevention of Post-mastectomy Seroma in an Experimental Animal Model

INTRODUCTION

Seroma is a frequent complication that can affect the final result of reconstructive and cosmetic surgeries.

METHODOLOGY

This study evaluated the effectiveness of 5-Fluorouracil and 75% hypertonic glucose in preventing seroma in a mastectomy rat model, as well as cellular and vascular events in adjacent tissues. A left mastectomy with lymphadenectomy was performed in 60 Wistar-Albino female rats. Animals randomly allocated to the control group (Group I; n = 20) were sutured right after mastectomy. The intervention groups received 1.0 mL of 75% hypertonic glucose (Group II; n = 20) or 1.0 mL of 5-Fluorouracil (Group III; n = 20) at the surgical site before suturing. The assessment of the presence of seroma was performed in all animals at 24, 48, and 72 h and on the 7th and 12th postoperative day. After the 12th day, a tissue sample was taken from the surgical site and sent for histological analysis. The occurrence of seroma was assessed using GEE. A significance level of 5% was adopted.

RESULTS

Differences in seroma formation over time were observed for both Control Group I (p=0.041) and Intervention Group II (p<0.001). In Intervention Group III, there was no difference in the percentage and volume of seroma across the assessment points (p=0.627). When both the Control and Intervention Group II were compared to Intervention Group III, we found a reduction in seroma formation in the last group. The reduction in the inflammatory process was more regular to Intervention Group III.

CONCLUSION

In this animal model, 5-Fluorouracil was more effective in preventing seroma formation than 75% Hypertonic Glucose. No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Fascia turnover procedure at breast reconstruction using free TRAM flap for decreasing umbilical migration

BACKGROUND

The ideal umbilical position is midway between the two iliac crests. Some patients complained that the umbilicus position shifted from the midline after the breast reconstruction with a free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flap. We considered that the fascia of the external oblique muscle could be applied to the rectus abdominis fascia defect. This study aimed to introduce this "fascia turnover procedure" and compare the umbilical position in this procedure with that in primary fascial closure for the MS-TRAM flap of breast reconstruction.

METHODS

A total of 152 patients were enrolled (80 patients with fascia turnover (+) vs. 72 patients (-)). The patients' demographics were compared. Horizontal distances (right side: a; left side: b) were measured bilaterally from the lateral abdominal wall to the center of the umbilicus. Frontal abdominal photographs were taken preoperatively (a1, b1) and postoperatively (a2, b2). The rate of umbilical migration (= | (a1 - b1) / (a1 + b1) - (a2 - b2) / (a2 + b2) | × 100%) was calculated. Because the aponeurosis of the external oblique muscle is confirmed in front of the lateral side of the anterior rectus sheath, this procedure could be performed in cases with a medial defect.

RESULTS

No significant differences in the patients' demographics, including abdominal bulging rates and abdominal wall defect widths were observed between the two groups. The rate of umbilical migration showed a significant difference (median 1.78% vs. 3.70%, P < 0.001).

CONCLUSIONS

This procedure could decrease the rate of umbilical migration.

Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: A cost-effectiveness Markov decision analysis of prospective studies

BACKGROUND

Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer.

METHODS

Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000.

RESULTS

From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84.

CONCLUSIONS

All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.

Relationship between Preoperative Abdominal Wall Strength and Bulging at the Abdominal Free Flap Donor Site for Breast Reconstruction

BACKGROUND

Abdominal bulging at the donor site of free abdominal flaps for breast reconstruction is a common postoperative complication. In addition to the thickness of abdominal muscles, the authors identified the rectus abdominis diastasis as an important factor that compromises abdominal wall strength. This study aimed to assess the relationship between preoperative abdominal wall strength and postoperative abdominal bulging.

METHODS

A total of 224 patients were enrolled in this study. Patient demographics, the rectus and lateral abdominis muscle thicknesses, and the rate of rectus abdominis diastasis were compared (with versus without bulging). Muscle thickness and rectus abdominis diastasis were investigated by preoperative computed tomography.

RESULTS

The group with bulging consisted of 32 patients (14.3 percent), whereas the group without bulging consisted of 192 patients. The group with bulging had a significantly higher gestational history rate. The thickness of the rectus abdominis muscle in the group with bulging was significantly thinner (median, 8.6 mm versus 10.5 mm; p < 0.001) and the rate of rectus abdominis diastasis was significantly higher (78.1 percent versus 32.3 percent; p < 0.001). There were no significant differences with respect to the thickness of the lateral abdominal muscle and the other factors (i.e., age, body mass index, history of laparotomy. and operative details).

CONCLUSIONS

Because the diagnosis of abdominal bulging was based on severity, the rate may be high compared to that reported from previous studies. Because the factor of gestational history correlated to thickness of the rectus abdominis muscle and rectus abdominis diastasis, this factor influenced the occurrence of abdominal bulging. Patients with a thin rectus abdominis muscle and rectus abdominis diastasis were at higher risk of abdominal bulging.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Randomised controlled study of seroma rates after mastectomy with and without quilting the skin flap to pectoralis muscle

Aims

The aim of this study was to determine whether seroma formation was affected by reduction of the potential dead space with the flap fixation method and obliteration of the axillary region in patients with breast cancer who underwent either mastectomy and axillary lymph node dissection or sentinel lymph node biopsy. A total of 105 patients with breast cancer were divided into two groups according to wound closure patterns.

Patients and Methods

The operating time, postoperative pain and complications, time to drain removal, seroma formation, amount of fluid aspirated and number of aspirations were recorded prospectively.

Results

No significant difference was found between groups in the rates of seroma development (P = 0.7), complication rates (P = 0.6), time to drain removal (P = 0.5), length of hospital stay (P = 0.3) or numbers of aspiration (P = 0.7). The operating time for fixation was determined to be longer than that of the classic procedure (P = 0.02).

Conclusions

Reducing potential dead space with flap fixation and obliteration of the axillary region may be useful in decreasing the development of seroma in patients who have undergone mastectomy because of breast cancer. However, surgical technique must be careful, and appropriate patient follow-up must be conducted.

The Drain Dilemma: A Systematic Review and Meta-Analysis of Drain-Free Abdominal Closure With Progressive Tension Sutures Against Drain-Assisted Closure for Abdominal Flaps in Breast Reconstruction

The use of abdominal drains in donor site closure following breast reconstruction with abdominal flaps is widespread. Our review aimed to compare the outcomes of donor site closure with and without the use of abdominal drains following breast reconstruction with abdominal flaps. Randomized, non-randomized, and observational studies that compared the use of drains vs. no drain in breast reconstruction were included by searching MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). Four studies enrolling 327 participants were identified. A statistically significant difference was found in terms of duration of hospital stay favouring abdominal closure without the use of drains (MD = -1.15, 95% CI = -1.88 tom-0.42, P=0.002), with a similar difference found in terms of overall complication rate (OR = 0.44, 95% CI = 0.23 to 0.83, p=0.01). Likewise, a statistically significant difference was found favouring abdominal closure without the use of drains for the secondary outcome of operative time (MD = -55.95, 95% CI = -107.19 to -4.74, p=0.03). Abdominal closure without drains following breast reconstructions with abdominal flaps is superior to closure with drains.

Effect of quilting on seroma formation in mastectomies: A meta-analysis

BACKGROUND

Seroma is the most common complication following mastectomy and can require several days of drainage and lead to delayed wound healing, longer hospital stays, and an increased financial and emotional burden. Seroma formation is not well understood and but there is good evidence that closing the dead space via quilting can help reduce seroma formation. This study assessed randomized controlled trials and reviewed current literature to elucidate if there is a strong association between quilting sutures and seroma formation.

METHODS

A systematic search of 5 databases using search terms similar to "seroma", "quilting", "flap fixation", "random", and "mastectomy". Data was extracted and Medcalc software used to perform a meta-analysis of the primary outcome: incidence of seroma formation, as well as secondary outcomes: volume and duration of drainage.

RESULTS

Eleven randomized controlled trials with 2009 patients were included. Quilting with sutures greatly reduced the incidence of seroma formation compared with conventional closure (p < 0.001, RR 0.367 [95% CI 0.25, 0.539]; I² = 63.56%) as well as duration of drainage (p = 0.015, SMD -1.657, SE 0.680 [95% CI -2.991, -0.324]; 8 studies, n = 1578; I² = 98.98%). Quilting did not significantly affect volume of drainage.

CONCLUSIONS

Quilting was found to be associated with lower seroma rates. Future studies should investigate the use of quilting in combination with other preventative techniques to search for a synergistic method that will further improve patient care.

Saline Load Test and Quilting Sutures to Treat Intractable Lateral Malleolar Bursitis

The purpose of this study was to evaluate the clinical outcomes of patients with intractable lateral malleolar bursitis who were treated using the intraoperative saline load test to find communication between the bursal sac and the ankle joint and the quilting sutures after bursectomy to reduce the dead space. We reviewed a total of 28 patients who had been treated with quilting sutures after bursectomy between April 2014 and June 2017. When there was capsular opening detected with the saline load test, it was closed with sutures or augmented with periosteum. On the final follow-up office visit, the lateral malleolus was examined for the recurrence of bursitis. Patient medical records were reviewed for postoperative wound dehiscence, skin necrosis, infections, and nerve symptoms. The saline load test was positive in 11 (42%) cases. The mean foot function index improved from 25.94 ± 20.46 to 11.73 ± 5.27 (p = .003). Fourteen (54%) patients were very satisfied with the results, 9 (35%) were satisfied, 2 (8%) rated their satisfaction as fair, and 1 (4%) was dissatisfied. No cases required skin graft or flap surgery. Intractable lateral malleolar bursitis was successfully treated using the saline load test and quilting sutures after bursectomy. Closure of the capsular opening prevented fluid drainage around the wound. Quilting sutures after bursectomy reduced dead space underneath the wound to prevent fluid accumulation and promoted healing of the skin on the underlying soft tissue.

Utility of autologous fibrin glue in the donor site of free abdominal flap for breast reconstruction: A randomized controlled study

BACKGROUND

Seroma formation at the donor site is a common complication of breast reconstruction using free abdominal flap. In this study, we assessed the benefits of use of autologous fibrin glue (AFG) at the donor site.

METHODS

This randomized controlled study compared AFG group (n = 61) with commercial fibrin glue (CFG) group (n = 79). Owing to the high volume of AFG (10 mL), AFG group received fibrin glue at both the anastomosis and the donor sites, whereas CFG group received fibrin glue only at the anastomosis site. Operative protocols and the criteria for postoperative drain removal were identical in both groups. Patient characteristics and abdominal discharge were compared between the two groups.

RESULTS

Since anemia was a contraindication for use of AFG, preoperative Hb in CFG group was significantly lower than that in AFG group; other factors were comparable in the two groups. The mean total abdominal drain volumes on first postoperative day (POD1) and POD2 was (AFG vs. CFG) 130.9 vs. 169.4 mL (P < 0.001) and 131.0 vs. 162.8 mL (P = 0.03), respectively. On POD3, there was no significant difference in this respect (116.2 vs. 128.4 mL, P = 0.19). The mean time for removal of all abdominal drains was significantly lower in AFG group (7.4 vs. 8.4 days; P = 0.01).

CONCLUSIONS

AFG reduced the discharge at the donor site of free abdominal flap, especially in the early postoperative period. AFG helped to reduce the abdominal drainage period.

No-drain Technique in Abdominal Closure for Breast Reconstruction: Lower Complication Rate, Shorter Hospitalization Stay

Background:

Progressive tension suture (PTS) technique in cosmetic abdominoplasty is safe in terms of seroma rates. This was extrapolated to deep inferior epigastric perforator (DIEP) flap donor site closure. No study to our knowledge has analyzed the PTS technique alone without drains in transverse rectus abdominis musculocutaneous (TRAM) flap donor sites. We aim to show that no-drain closure has similar complication rates and this may be applied to TRAM flaps safely even though they have higher drain output.

Methods:

A single-center, single-surgeon retrospective study was performed over 4 years. Patients undergoing breast reconstruction with an abdominal flap were included. Data collected included patient's demographics, type of flap, usage of drains or PTS technique, drain output, date of fitness for discharge, date of discharge, and seroma rates. The outcomes studied were drain volumes, seroma rates, and duration of hospital stay.

Results:

Fifty patients were recruited. The first 25 patients (13 DIEP and 12 TRAM) underwent conventional closure. The subsequent 25 patients (17 DIEP and 8 TRAM) underwent PTS technique. TRAM flaps had higher drain volume (785.6 mL) compared to DIEP flaps (366.2 mL) (P = 0.047). No patients developed a seroma. Patients who underwent the PTS technique had lower abdominal-specific complications (P = 0.021). Patients without drains were discharged faster at 5.4 versus 8.2 days (P ≤ 0.001).

Conclusions:

Patients who underwent the PTS technique had lower complication rates, faster time to fitness for discharge and shorter hospitalization stay. The PTS technique may be applied to TRAM flaps safely.

Effects of hydrochlorothiazide on drainage volume and seroma formation in deep inferior epigastric perforator flap breast reconstruction: Randomized controlled trial

BACKGROUND

Seroma is a recognized complication encountered at the reconstructed breast and donor site after abdominal-based breast reconstruction. Seroma is caused by lymphatic channel disruption and the formation of a large space between the deep fascia during flap elevation. Surgical techniques to preserve the lymphatics and secure the closure of the donor site can reduce seroma formation. This study investigated the safety and effectiveness of the diuretic hydrochlorothiazide at reducing interstitial fluid accumulation and seroma formation during deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

Sixty patients with breast cancer who underwent skin- or nipple-sparing mastectomy and DIEP flap reconstruction were enrolled between August 2016 and June 2017. The patients were randomly assigned to receive either 25 mg per day of hydrochlorothiazide from the second to the twentieth day after surgery (treatment) or no diuretic (control). The clinicopathological characteristics, drainage time, and drainage volume were statistically compared between the two groups.

RESULTS

The average total drainage volume at the donor site was 291 mL in the treatment group and 434 mL in the control group (p = 0.003). The differences in body mass index and flap weight between the two groups were not statistically significant (p = 0.879 and p = 0.963, respectively). No hypotension or electrolyte imbalance was noted during the follow-up.

CONCLUSIONS

Intake of 25 mg per day of hydrochlorothiazide tablets effectively reduced the total abdominal drainage volume and removal time of indwelling drains. However, the adverse effects should be further investigated in a large population and multiracial cohort before using hydrochlorothiazide for seroma prevention.

The use of surgical site drains in breast reconstruction: A systematic review

BACKGROUND

Use of drains has been advocated in order to prevent seroma and hematoma; however, specific recommendations vary widely. The goal is to perform a systematic analysis of published literature on the use of drains for breast reconstruction.

METHODS

The literature search was performed according to the PRISMA guidelines. The search included the Cochrane Library, Embase, and Pubmed databases using the terms "breast reconstruction" and "breast flap" combined with "drain", "seroma," and "seroma prevention". The references were appraised in two rounds, by two independent reviewers; studies were included/excluded based on relevance of title and subsequently by the content of their abstracts/manuscripts. Outcomes regarding seroma, infection rate, length of stay (LOS), drainage, reconstruction type and complications were analyzed.

RESULTS

Of 2252 studies identified via search, 64 were relevant and 21 met inclusion criteria. Most of the study designs were case series or retrospective cohort studies (Level of Evidence III or IV), with the exception of one prospective randomized-controlled trial. Seroma rate was given in 18 studies, infection rate in 11, and criteria for drain removal in 19. Reoperation rate was available in 7 and LOS in 18 studies. The majority of studies (13) agreed to remove the drain when the output was less than 30 ml/24 h. Drain output was reported in 11, and 20 reported drain type used.

CONCLUSION

There is sparse literature available with which to make evidence-based guidelines. A standardized guideline for reporting drain use is crucial to providing a better understanding of complications in breast reconstruction related to surgical drains.

Using quilting sutures in decreasing seroma formation after managing large ventral hernias: a comparative study

PURPOSE

The aim of this study was to evaluate using quilting sutures in a prospective randomized controlled manner the decrease in the incidence of seroma formation among patients subjected to ventral hernia repair.

METHODS

The study was a prospective randomized controlled study. 370 patients with large ventral hernias were randomly distributed among two groups. Group A (control group) included 180 patients in whom the repair was done without quilting sutures. Group B (quilting group) included 190 patients, all performed with quilting. Method of dissection was unified as far as possible. All cases had an attached closed suction drain that was removed after two successive days of output ≤ 50 cc. The output of the suction drain was recorded; accumulation of clinically detected seroma after 1, 2 and 4 weeks of removal of the drain was monitored.

RESULTS

There was no statistical difference between both groups as regards the demographic data and the hernia characteristics. There was significantly smaller amount of output of the drains in every day of the first five postoperative days as well as the total amount of the output before drain removal in favor of the quilting group. Drains were removed earlier in group B. The incidence of clinically detected seroma was less in group B as well.

CONCLUSIONS

Quilting sutures is an effective and easy technique to reduce post-ventral hernia seroma accumulation.

Can Abdominal Wall Reconstruction be Safely Performed without Drains?

The use of closed suction drains in the abdominal wall is a common practice in abdominal wall reconstruction (AWR) operations. Drains can be a conduit for bacteria and can cause pain and discomfort for patients after surgery. A single hernia program has implemented the principles of clinical quality improvement in an attempt to improve outcomes for hernia patients. An attempt at a process improvement was implemented to eliminate the use of drains in AWR by adapting the technique. A total of 102 patients undergoing AWR were included between 8/11 and 9/15 (49 months). Compared with the group before the attempt at eliminating the use of abdominal wall drains (8/11–9/13), the group of patients after the implementation of the attempted process improvement (9/13–9/15) had less wound and pulmonary complications, a shorter hospital stay, less time in the postanesthesia care unit, and less opioid use in the postanesthesia care unit as well as for the entire hospital stay. In this group of AWR patients, an attempt at process improvement that eliminated the use of drains led to improved outcomes. Abdominal wall drains may be able to be safely eliminated with appropriate technique adaptation for AWR.

Prevention of postoperative seromas with dead space obliteration: A case-control study

INTRODUCTION

Excision of soft tissue masses in the subcutaneous space is a common surgical procedure. Postoperative seromas may occur and often result in additional visits, procedures, and impaired wound healing.

METHODS

A retrospective chart review (2001-2011) identified patients who underwent resection of a soft tissue mass in the subcutaneous tissues. Patients undergoing breast surgery, head and neck surgery, and lymph node dissections were excluded. Patients (n = 100) with seromas were identified. These patients were matched to patients not having postoperative seroma (n = 100).

RESULTS

We identified 100 patients with seroma and 100 controls without seroma after soft tissue resection. Patients had no difference in wound characteristics. Patients with a dead space obliterating stitch were less likely to have a postoperative seroma (26% vs 74%, P < 0.001).

CONCLUSIONS

Dead space closure was associated with a decreased rate of postoperative seroma in subcutaneous resections. Postoperative seroma was associated with increased cost and provider visits.

Fibrin Sealants and Quilting Suture for Prevention of Seroma Formation Following Latissimus Dorsi Muscle Harvest: A Systematic Review and Meta-analysis

PURPOSE

Despite popular use of fibrin sealants and quilting sutures for prevention of seroma formation at the donor site of the latissimus dorsi (LD) muscle flap, there is still no consensus regarding their efficacy. The present review estimates the potential benefits of fibrin and quilting suture for reducing seroma-related morbidity following LD muscle harvest.

METHODS

Using Medline, Ovid, and Cochrane databases, two-arm studies evaluating the efficacy of fibrin sealants, quilting suture, or their combination for prevention of seroma formation following LD muscle transfer were searched. The outcome measure was the incidence of seroma, total drainage volume from the back, periods of drainage in situ, volume of seroma, and frequency of aspiration for treatment of seroma. The efficacy on reducing the seroma-related morbidity for each procedure was estimated by meta-analytic methodology.

RESULTS

Fourteen studies were analyzed. Fibrin alone failed to reduce seroma-related morbidities compared with no intervention, while fibrin instillation combined with quilting suture halved the risk of seroma formation (relative risk (RR): 0.51, 95 % CI 0.12-2.16) and significantly reduced total drainage volume (mean difference (MD); -320.80, 95 % CI -389.92 to -251.68) and drain indwelling periods (MD -1.62, 95 % CI -2.91 to -0.33) compared with quilting suture alone. Quilting suture had significant protective effects on reducing the risk of seroma formation (RR 0.38, 95 % CI 0.19-0.75), total drainage volume (MD -284.10, 95 % CI -474.61 to -93.60), and drain indwelling periods (MD -3.65, 95 % CI -5.43 to -1.87), and its efficacy was enhanced by combining with fibrin.

CONCLUSIONS

According to this review, both fibrin and quilting sutures contributed in varying degrees to reducing seroma-related morbidity following LD muscle transfer, and their combination can have a synergistic effect. Although large-scaled, randomized studies are needed, the combination of both procedures may be considered an effective option for minimizing the risk of seroma.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Quilting Sutures Reduces Seroma in Mastectomy

BACKGROUND

Drainage duration and seroma formation occurring after mastectomy with or without axillary surgery lengthens hospitalization and delays adjuvant treatment. The aim of the study was to evaluate the effect of quilting in the prevention of seroma after mastectomy for breast cancer.

PATIENTS AND METHODS

Eighty-two breast cancer patients about to undergo mastectomy with or without axillary surgery lymphadenectomy were enrolled in the study. We conducted an observational comparison between 41 patients in whom quilting with closed suction drainage was used and 41 patients in whom drainage only was used.

RESULTS

The mean drained volume was significantly lower in the quilting group compared with the control group on days 1 and 2 (day 1: 107.1 mL vs. 156.5 mL; P = .02; day 2: 108.4 mL vs. 162.8 mL; P = .01). The mean drainage period was shorter in the quilting group (4.6 vs. 5.3 days; P = .046). There were fewer needle aspirations for seroma in the padding group (n = 14, 34.1% vs. n = 24, 58.5%; P = .03).

CONCLUSION

The use of padding after mastectomy seems to reduce seroma formation, volume drained, and length of drainage time.