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Spiekerman van Weezelenburg MA, de Rooij L, Aldenhoven L, van Kuijk SMJ, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Drain-free mastectomy and flap fixation: The interim analysis of a randomized controlled noninferiority trial. J Surg Oncol 2024; 129:975-980. [PMID: 38173366 DOI: 10.1002/jso.27577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Flap fixation after mastectomy has proven to be one of the most promising solutions to reduce seroma formation. Drain placement remains standard practice in many clinics, even though this may be redundant after flap fixation. METHODS This is a prospective randomized controlled trial comparing mastectomy and wound closure using flap fixation with or without drain placement. The primary outcome measure was clinically significant seroma (CSS) incidence. The aim of this interim analysis was to assess the assumptions for the sample size calculation and to provide preliminary results. RESULTS Between July 2020 and January 2023, 112 patients were included. CSS incidence was 9.1% in the drain group and 21% in the no-drain group. In total, 10 patients were lost to follow-up. These numbers are similar to the ones used for the sample size calculation. In the drain group, three patients required interventions for wound complications compared to nine in the no-drain group (odds ratio: 3.612 [95% confidence interval: 0.898-14.537]). CONCLUSION The sample size calculation seems to be correct and no protocol amendments are necessary. Current preliminary results show no significant differences in CSS incidence. Complete results should be awaited to draw a well-powered conclusion regarding drain policy after mastectomy.
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Affiliation(s)
| | - Lisa de Rooij
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
| | - Loeki Aldenhoven
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - James van Bastelaar
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
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Fairhurst K, Roberts K, Fairbrother P, Potter S. Current use of drains and management of seroma following mastectomy and axillary surgery: results of a United Kingdom national practice survey. Breast Cancer Res Treat 2024; 203:187-196. [PMID: 37878150 PMCID: PMC10787912 DOI: 10.1007/s10549-023-07042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/06/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Up to 40% of the 56,000 women diagnosed with breast cancer each year in the UK undergo mastectomy. Seroma formation following surgery is common, may delay wound healing, and be uncomfortable or delay the start of adjuvant treatment. Multiple strategies to reduce seroma formation include surgical drains, flap fixation and external compression exist but evidence to support best practice is lacking. We aimed to survey UK breast surgeons to determine current practice to inform the feasibility of undertaking a future trial. METHODS An online survey was developed and circulated to UK breast surgeons via professional and trainee associations and social media to explore current attitudes to drain use and management of post-operative seroma. Simple descriptive statistics were used to summarise the results. RESULTS The majority of surgeons (82/97, 85%) reported using drains either routinely (38, 39%) or in certain circumstances (44, 45%). Other methods for reducing seroma such as flap fixation were less commonly used. Wide variation was reported in the assessment and management of post-operative seromas. Over half (47/91, 52%) of respondents felt there was some uncertainty about drain use after mastectomy and axillary surgery and two-thirds (59/91, 65%) felt that a trial evaluating the use of drains vs no drains after simple breast cancer surgery was needed. CONCLUSIONS There is a need for a large-scale UK-based RCT to determine if, when and in whom drains are necessary following mastectomy and axillary surgery. This work will inform the design and conduct of a future trial.
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Affiliation(s)
- K Fairhurst
- Centre for Surgical Research, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England.
| | - K Roberts
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - P Fairbrother
- Independent Cancer Patient Voice (ICPV), London, England
| | - S Potter
- Centre for Surgical Research, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
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Zeelst LJV, Ten Wolde B, Plate JDJ, Volders JH, van Eekeren RRJP, Doeksen A, Hoven-Gondrie ML, Olieman AFT, van Riet YEA, van der Velden APS, Vijfhuize S, Witjes HHG, de Wilt JHW, Strobbe LJA. The QUILT study: quilting sutures in patients undergoing breast cancer surgery: a stepped wedge cluster randomized trial study. BMC Cancer 2023; 23:667. [PMID: 37460983 DOI: 10.1186/s12885-023-11154-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/04/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Seroma is the most common complication following breast cancer surgery, with reported incidence up to 90%. Seroma causes patient discomfort, is associated with surgical site infections (SSI), often requires treatment and increases healthcare consumption. The quilting suture technique, in which the skin flaps are sutured to the pectoralis muscle, leads to a significant reduction of seroma with a decrease in the number of aspirations and surgical site infections. However, implementation is lagging due to unknown side effects, increase in operation time and cost effectiveness. Main objective of this study is to assess the impact of large scale implementation of the quilting suture technique in patients undergoing mastectomy and/or axillary lymph node dissection (ALND). METHODS The QUILT study is a stepped wedge design study performed among nine teaching hospitals in the Netherlands. The study consists of nine steps, with each step one hospital will implement the quilting suture technique. Allocation of the order of implementation will be randomization-based. Primary outcome is 'textbook outcome', i.e.no wound complications, no re-admission, re-operation or unscheduled visit to the outpatient clinic and no increased use of postoperative analgesics. A total of 113 patients is required based on a sample size calculation. Secondary outcomes are shoulder function, cosmetic outcome, satisfaction with thoracic wall and health care consumption. Follow-up lasts for 6 months. DISCUSSION This will be one of the first multicentre prospective studies in which quilting without postoperative wound drain is compared with conventional wound closure. We hypothesize that quilting is a simple technique to increase textbook outcome, enhance patient comfort and reduce health care consumption.
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Affiliation(s)
- L J van Zeelst
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands.
| | - B Ten Wolde
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - J D J Plate
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - J H Volders
- Department of Surgical Oncology, Diakonessenhuis, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - R R J P van Eekeren
- Department of Surgical Oncology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - A Doeksen
- Department of Surgical Oncology, St. Antonius Hospital, Soestwetering 1, 3543 AZ, Nieuwegein, Netherlands
| | - M L Hoven-Gondrie
- Deparment of Surgical Oncology, Hospital Gelderse Vallei, Willy Brandtlaan 10, 6716 RP, Ede, Netherlands
| | - A F T Olieman
- Department of Surgical Oncology, Martini Hospital, Van Swietenplein 1, 9728 NT, Groningen, Netherlands
| | - Y E A van Riet
- Department of Surgical Oncology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, Netherlands
| | - A P Schouten van der Velden
- Department of Surgical Oncology, St. Jansdal Hospital, Wethouder Jansenlaan 90, 3844 DG, Harderwijk, Netherlands
| | - S Vijfhuize
- Deparment of Surgical Oncology, Bravis Hospital, Boerhaavelaan 25, 4708 AE, Roosendaal, Netherlands
| | - H H G Witjes
- Department of Surgical Oncology, Onze Lieve Vrouwe Gasthuis, Jan Tooropstraat 164, 1061 AE, Amsterdam, Netherlands
| | - J H W de Wilt
- Radboudumc Department of Surgical Oncology, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, Netherlands
| | - L J A Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
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Jeibouei S, Shams F, Mohebichamkhorami F, Sanooghi D, Faal B, Akbari ME, Zali H. Biological and clinical review of IORT-induced wound fluid in breast cancer patients. Front Oncol 2022; 12:980513. [DOI: 10.3389/fonc.2022.980513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/19/2022] [Indexed: 11/22/2022] Open
Abstract
Intraoperative radiotherapy (IORT) has become a growing therapy for early-stage breast cancer (BC). Some studies claim that wound fluid (seroma), a common consequence of surgical excision in the tumor cavity, can reflect the effects of IORT on cancer inhibition. However, further research by our team and other researchers, such as analysis of seroma composition, affected cell lines, and primary tissues in two-dimensional (2D) and three-dimensional (3D) culture systems, clarified that seroma could not address the questions about IORT effectiveness in the surgical site. In this review, we mention the factors involved in tumor recurrence, direct or indirect effects of IORT on BC, and all the studies associated with BC seroma to attain more information about the impact of IORT-induced seroma to make a better decision to remove or remain after surgery and IORT. Finally, we suggest that seroma studies cannot decipher the mechanisms underlying the effectiveness of IORT in BC patients. The question of whether IORT-seroma has a beneficial effect can only be answered in a trial with a clinical endpoint, which is not even ongoing.
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Wainwright D, Weinstein B, Tavares T, Panetta NJ. Relationship of Adjuvant Radiation and the Lymphedema Index: A Valuable Trend to Follow Subclinical Lymphedema in Patients After Immediate Lymphatic Reconstruction. Ann Plast Surg 2022; 88:S512-S516. [PMID: 35690948 DOI: 10.1097/sap.0000000000003252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer-related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature. METHODS After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX). RESULTS Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation. CONCLUSIONS These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.
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Affiliation(s)
- D'Arcy Wainwright
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
| | - Brielle Weinstein
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
| | - Tina Tavares
- Department of Surgery, Moffitt Cancer Center, Tampa, FL
| | - Nicholas J Panetta
- From the Department of Plastic and Reconstructive Surgery, University of South Florida, Morsani College of Medicine
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van Zeelst LJ, Ten Wolde B, van Eekeren RRJP, Volders JH, de Wilt JHW, Strobbe LJA. Quilting following mastectomy reduces seroma, associated complications and health care consumption without impairing patient comfort. J Surg Oncol 2021; 125:369-376. [PMID: 34786726 PMCID: PMC9298805 DOI: 10.1002/jso.26739] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/05/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022]
Abstract
Background An important complication following mastectomy is seroma formation. Quilting, in which skin flaps are sutured to the underlying muscle, is reported to reduce seroma incidence, but might induce pain and impair shoulder function. Main objective is to compare quilting with conventional wound closure, regarding seroma incidence, health care consumption, and patient discomfort. Methods In a combined prospective and retrospective study, 254 patients undergoing mastectomy and/or axillary lymph node dissection (ALND) were included. Patients received quilting sutures or conventional closure. Primary outcome was clinical significant seroma (CSS). In prospectively included patients shoulder function and analgesic use was observed. Results CSS incidence was 12.9% in the quilted versus 62.3% in the nonquilted cohort (p < 0.001). Surgical site infections were reported significantly less in the quilted cohort. Duration of hospital stay was shorter and outpatient clinic visits were less in the quilted cohort. Surgical procedure required 10 additional minutes for quilting. No significant differences were observed in postoperative shoulder function and analgesic use. Conclusion Quilting following mastectomy reduces CSS incidence. Quilting requires 10 additional minutes during surgery. It facilitates day treatment and results in less additional outpatient clinic visits culminating in reduced health care consumption. Shoulder function and pain are not affected by quilting.
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Affiliation(s)
- Lotte J van Zeelst
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Britt Ten Wolde
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - José H Volders
- Department of Surgical Oncology, Gelre Hospital, Apeldoorn, The Netherlands
| | | | - Luc J A Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Effect of quilting on seroma formation in mastectomies: A meta-analysis. Surg Oncol 2021; 39:101665. [PMID: 34563996 DOI: 10.1016/j.suronc.2021.101665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/15/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
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.
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O'Connor RÍ, Kiely PA, Dunne CP. The relationship between post-surgery infection and breast cancer recurrence. J Hosp Infect 2020; 106:522-535. [PMID: 32800825 DOI: 10.1016/j.jhin.2020.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023]
Abstract
Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.
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Affiliation(s)
- R Í O'Connor
- School of Medicine, University of Limerick, Ireland; Health Research Institute, University of Limerick, Ireland; Bernal Institute, University of Limerick, Ireland
| | - P A Kiely
- School of Medicine, University of Limerick, Ireland; Health Research Institute, University of Limerick, Ireland; Bernal Institute, University of Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - C P Dunne
- School of Medicine, University of Limerick, Ireland; Health Research Institute, University of Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland.
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Wu Y, Wang S, Hai J, Mao J, Dong X, Xiao Z. Quilting suture is better than conventional suture with drain in preventing seroma formation at pectoral area after mastectomy. BMC Surg 2020; 20:65. [PMID: 32252732 PMCID: PMC7137264 DOI: 10.1186/s12893-020-00725-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/24/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to compare quilting suture with conventional suture on the formation of seroma at pectoral area after mastectomy (ME) with sentinel lymph nodes biopsy (SLN) or axillary lymph nodes dissection (ALND) for breast cancer. METHODS Two hundred thirty-five consecutive breast cancer patients were retrospectively analyzed. The primary outcome was the incidence of Grade 2 or Grade 3 seroma at anterior pectoral area within 1 month postoperatively. We categorized seroma into early or late seroma according to the drainage removal time. Cox regression was used for analysis. RESULTS The incidence of Grade 2 and 3 seroma was significantly higher in the conventional suture group compared with that in the quilting suture group (19.3% vs. 9.5%, p = 0.032), which was attributed to the late seroma in Grade 2 and 3. Quilting suture was associated with longer time for fixing flaps compared with that of conventional suture (504.7 s vs. 109.1 s, p < 0.001), but with less volume of drainage. Old age, high body mass index and conventional suture were independently risk factors for Grade 2 and 3 seroma. CONCLUSIONS Quilting suture decreased the incidence of Grade 2 and 3 seroma at pectoral area within 1 month after mastectomy, especially the late seroma in Grade 2 and 3.
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Affiliation(s)
- Yuhui Wu
- Department of Breast Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, P. R. China, 410008
| | - Shouman Wang
- Department of Breast Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, P. R. China, 410008
| | - Jian Hai
- Department of Breast Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, P. R. China, 410008
| | - Jie Mao
- Department of Breast Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, P. R. China, 410008
| | - Xue Dong
- Department of Breast Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, P. R. China, 410008
| | - Zhi Xiao
- Department of Breast Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, P. R. China, 410008. .,Clinical Research Center For Breast Cancer Control and Prevention In Human Province, Changsha, P. R. China.
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