Pathophysiology of seroma in breast cancer

Efficacy of axillary dead space closure after mastectomy, axillary clearance and prosthetic reconstruction: a single-center preliminary experience

Background

Postoperative seroma is most frequent after mastectomy (ME) in combination with axillary lymph node dissection (ALND), and its reported incidence varies from 15.5% up to 90%. Seromas can be responsible for discomfort, infections and can lead to reconstruction failure. Therefore, many ways of seroma prevention have been studied, although from a recent overview it has become clear that no single method is reliably successful. Mechanical closure of the dead space, however, was consistently found to be significantly effective. The aim of our study is to evaluate if quilting of the axilla, in patients undergoing ME, immediate prosthetic breast reconstruction and ALND reduces the duration of drain maintenance, the incidence of seromas that require aspiration (clinically significant seromas, CSS) and reconstruction failure rate.

Materials and methods

In our study population we analyzed a total of 81 patients divided into two groups: 27 consecutive patients undergoing mastectomy, axillary lymph node dissection (ALND), breast reconstruction and quilting of the axilla. We subsequently randomly picked up a double number of patients (54) undergoing the same oncological and reconstructive procedures without undergoing axillary quilting, matched for clinical characteristics in order to analyze efficacy of the procedure while reducing any bias. Our observational retrospective data was collected from October 2016 to July 2020 in one single high-volume center. Our median follow-up time was of 40.6 months.

Results

In the case group we observed a reduced time of drain maintenance: 16 vs. 20 days observed in the non-quilted group (p < 0.05). Incidence of seromas that required aspiration was 11% in the control group, while 3,7% in the case group. In addition to that, we observed 6 cases of implant removal in the control group, while in the quilted group we only observed a single case.

Conclusion

Previous literature and our results confirm that quilting of the axilla with flap fixation significantly decreases time of drain maintenance, allowing the earlier removal of the drains as well as decreasing the incidence of seroma, its eventual associated complications and related social costs. Moreover, our work suggests how quilting sutures decrease the incidence of seroma in patients undergoing immediate reconstruction, probably reducing the risk for implant removal.

Quality and readability of online information and materials on post-surgery breast seroma

Aims/Background Seroma formation is the most common complication following breast surgery. However, there is little evidence on the readability of online patient education materials on this issue. This study aimed to assess the accessibility and readability of the relevant online information. Methods This systematic review of the literature identified 37 relevant websites for further analysis. The readability of each online article was assessed through using a range of readability formulae. Results The average Flesch-Reading Ease score for all patient education materials was 53.9 (± 21.9) and the average Flesch-Kincaid reading grade level was 7.32 (± 3.1), suggesting they were 'fairly difficult' to read and is higher than the recommended reading level. Conclusion Online patient education materials regarding post-surgery breast seroma are at a higher-than-recommended reading grade level for the public. Improvement would allow all patients, regardless of literacy level, to access such resources to aid decision-making around undergoing breast surgery.

Separate axillary incision for surgery of axillary lymph node can decrease drain amount and days to drain removal of the breast in direct-to-implant breast reconstruction

PURPOSE

Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) can be performed either with a separate axillary incision or through the mastectomy incision. The authors hypothesized that after SLNB or ALND through a single incision, connection of the axilla with mastectomy pocket could increase drainage. This study investigated whether a separate incision decreases drainage amount and duration in implant-based breast reconstruction.

METHODS

Medical records of breast cancer patients who underwent nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction with prosthesis from March 2018 to February 2021 in a single tertiary center were reviewed. Demographic data, intraoperative details, and postoperative complications were reviewed. Breast drains were removed if the drain amount was less than 30cc for two consecutive days. Total breast drain amount, duration until removal, and prolonged drainage were compared with multivariate analysis.

RESULTS

A total of 206 patients were included in the study, with separate incisions placed in 145 breasts and a single breast incision placed in 70 breasts. Mean duration and amount until drain removal were 12.8 ± 4.9 days and 817 ± 520 cc in the single incision group, respectively, and 9.9 ± 3.1 days and 434 ± 228 cc in the separate incision group, respectively Separate incision placement (p < 0.001), lower mastectomy weight (p < 0.001), and prepectoral plane of insertion (p < 0.001) were significantly associated with less drain amount and duration. None-separate incision placement (p = 0.01) and preoperative radiation therapy (p = 0.023) were significant factors for prolonged drainage.

CONCLUSION

Placing a separate incision for axillary surgery during mastectomy and immediate implant-based reconstruction can decrease both drain amount and duration and reduce the risk of prolonged drainage.

Bioglass/ceria nanoparticle hybrids for the treatment of seroma: a comparative long-term study in rats

Background: Seroma formation is a common postoperative complication. Fibrin-based glues are typically employed in an attempt to seal the cavity. Recently, the first nanoparticle (NP)-based treatment approaches have emerged. Nanoparticle dispersions can be used as tissue glues, capitalizing on a phenomenon known as 'nanobridging'. In this process, macromolecules such as proteins physically adsorb onto the NP surface, leading to macroscopic adhesion. Although significant early seroma reduction has been shown, little is known about long-term efficacy of NPs. The aim of this study was to assess the long-term effects of NPs in reducing seroma formation, and to understand their underlying mechanism. Methods: Seroma was surgically induced bilaterally in 20 Lewis rats. On postoperative day (POD) 7, seromas were aspirated on both sides. In 10 rats, one side was treated with NPs, while the contralateral side received only NP carrier solution. In the other 10 rats, one side was treated with fibrin glue, while the other was left untreated. Seroma fluid, blood and tissue samples were obtained at defined time points. Biochemical, histopathological and immunohistochemical assessments were made. Results: NP-treated sides showed no macroscopically visible seroma formation after application on POD 7, in stark contrast to the fibrin-treated sides, where 60% of the rats had seromas on POD 14, and 50% on POD 21. At the endpoint (POD 42), sides treated with nanoparticles (NPs) exhibited significant macroscopic differences compared to other groups, including the absence of a cavity, and increased fibrous adhesions. Histologically, there were more macrophage groupings and collagen type 1 (COL1) deposits in the superficial capsule on NP-treated sides. Conclusion: NPs not only significantly reduced early manifestations of seroma and demonstrated an anti-inflammatory response, but they also led to increased adhesion formation over the long term, suggesting a decreased risk of seroma recurrence. These findings highlight both the adhesive properties of NPs and their potential for clinical therapy.

Outcomes and complications of postoperative seroma cavities following soft-tissue sarcoma resection

Introduction

Seroma development is a known complication following extremity and trunk soft-tissue sarcoma (STS) resection. The purpose of this study is to evaluate and characterize seroma outcomes and the development of associated complications.

Methods

A retrospective review of 123 patients who developed postoperative seromas following STS resection at a single institution was performed. Various patient and surgical factors were analyzed to determine their effect on overall seroma outcomes.

Results

77/123 seromas (62.6%) were uncomplicated, 30/123 (24.4%) developed infection, and 16/123 (13.0%) were symptomatic and required aspiration or drainage for symptom relief at an average of 12.2 months postoperatively. 65/123 (52.8%) seromas resolved spontaneously at an average time of 12.41 months. Seromas in the lower extremity (p=0.028), surgical resection volume >864 cm3, (p=<0.001) and initial seroma volume >42 cm3 (p=<0.001) increased the likelihood of infection. 90% of infected seromas developed the infection within the first three months following initial resection. No seromas which were aspirated or drained ultimately developed an infection following these procedures, though 50% recurred.

Discussion

Most seromas following STS resection are uncomplicated and do not require intervention, though a large resection cavity >864 cm3 and a large seroma volume >42 cm3 are risk factors for complications.

Current use of drains and management of seroma following mastectomy and axillary surgery: results of a United Kingdom national practice survey

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.

Early Seroma Treatment Protocol Based on US-Guided Aspiration in DTI Prepectoral Reconstruction: A Prospective Study

INTRODUCTION

Seroma is a common complication after prepectoral prosthetic breast reconstruction with ADM, leading to wound dehiscencse, infection, and even loss of reconstruction at last. A new ultrasound (US) guided follow-up protocol has been applied to compare primary and secondary complications incidence and their treatment, and evaluate the effect of precocious seroma detection and its evacuation in reducing secondary complications.

METHODS

We enrolled 406 patients from January 1st, 2021 to July 1st, 2023 who underwent mastectomy and 1-stage prepectoral reconstruction with ADM. Experimental group counted 96 patients, whom have been treated as protocol fashion, therefore with multiple US-guided evaluations and eventual evacuations along with postoperative period; control group (310 patients) has exclusively been clinically evaluated.

RESULTS

Seroma incidence detected rate among experimental group, after 1-year follow-up, was 32.2%, compared to 16.8% in control cohort, additionally no other secondary complications were detected in the first group. Referring to the wound dehiscence incidence, a statistically significant higher frequency was observed in control group compared with treatment 1 (21.2% vs. 0%; P = .0027).

CONCLUSIONS

Seroma and correlated secondary complications may lead to additional surgeries, higher sanitary costs and even reconstructive failure. With a seriated US follow-up protocol application, the surgeon could promptly manage and treat seroma, decreasing additional complications rate, particularly wound dehiscence.

LEVEL OF EVIDENCE

III.

Elderly and Patients with Large Breast Volume Have an Increased Risk of Seroma Formation after Mastectomy-Results of the SerMa Pilot Study

The collective of the SerMa pilot study included 100 cases of primary breast cancer or Carcinoma in situ who had undergone a mastectomy procedure with or without reconstruction of the breast using an implant or expander at Augsburg University Hospital between 12/2019 and 12/2022. The study aimed to investigate possible causes of seroma formation; reported here are the clinicopathological correlations between seroma formation and tumor biology and surgical procedures. Seroma occurred significantly more often in patients with older age (median patient age in cases with seroma was 73 years vs. 52 years without seroma; p < 0.001). In addition, patients with larger mastectomy specimen were significantly more likely to develop seroma (median ablation weight in cases with seroma 580 g vs. 330 g without seroma; p < 0.001). Other significant parameters for seroma formation were BMI (p = 0.005), grading (p = 0.015) and tumor size (p = 0.036). In addition, with insertion of implant or expander, a seroma occurred significantly less frequently (p < 0.001). In a binary logistic regression, age in particular was confirmed as a significant risk factor. In contrast, tumor biological characteristics, number of lymph nodes removed or affected showed no significant effect on seroma formation. The present study shows the need for patient education about the development of seroma in particular in older patients and patients with large breast volumes within the preoperative surgical clarification. These clinicopathological data support the previously published results hypothesizing that seroma formation is related to autoimmune/inflammatory processes and will be tested on a larger collective in the planned international multicenter SerMa study.

Efficacy and safety of surgical energy devices for axillary node dissection: a systematic review and network meta-analysis

Various surgical energy devices are used for axillary lymph-node dissection. However, those that reduce seroma during axillary lymph-node dissection are unknown. We aimed to determine the best surgical energy device for reducing seroma by performing a network meta-analysis to synthesize the current evidence on the effectiveness of surgical energy devices for axillary node dissection for breast cancer patients. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform Search Portal. Two reviewers independently selected randomized controlled trials (RCTs) comparing electrosurgical bipolar vessel sealing (EBVS), ultrasonic coagulation shears (UCS), and conventional techniques for axillary node dissection. Primary outcomes were seroma, drained fluid volume (mL), and drainage duration (days). We analyzed random-effects and Bayesian network meta-analyses. We evaluated the confidence of each outcome using the CINeMA tool. We registered with PROSPERO (CRD42022335434). We included 34 RCTs with 2916 participants. Compared to the conventional techniques, UCS likely reduces seroma (risk ratio [RR], 0.61; 95% credible interval [CrI], 0.49-0.73), the drained fluid volume (mean difference [MD], - 313 mL; 95% CrI - 496 to - 130), and drainage duration (MD - 1.79 days; 95% CrI - 2.91 to - 0.66). EBVS might have little effect on seroma, the drained fluid volume, and drainage duration compared to conventional techniques. UCS likely reduce seroma (RR 0.44; 95% CrI 0.28-0.69) compared to EBVS. Confidence levels were low to moderate. In conclusion, UCS are likely the best surgical energy device for seroma reduction during axillary node dissection for breast cancer patients.

Ethanol Sclerotherapy for Postoperative Seroma of the Breast and Axilla

OBJECTIVE

Evaluate the effectiveness of alcohol sclerotherapy in postoperative breast and axillary seromas.

METHODS

This was an IRB-approved retrospective review of consecutive patients from 2017 to 2021. The procedure involves aspiration of seroma fluid, injection of ethanol for 15 to 30 minutes, and then aspiration of the injected ethanol. Following review of the medical record, patient and procedure data were recorded. Success was defined as no recurrence of seroma. Statistical analysis was performed using a chi-square or t-test, as appropriate.

RESULTS

Twenty seromas were treated in 19 patients (mean age, 63 years; range, 49-79) following mastectomy (9/20, 45%), lumpectomy (25%, 5/20), axillary nodal dissection (5/20, 25%), or chest wall surgery (1/20, 5%). The mean seroma volume was 146 ± 165 mL. There was a mean of 1.4 prior aspiration attempts (range, 0-3). Mean injected ethanol volume was 39 mL (range, 8-60 mL) for a mean of 26 ± 5 minutes. Seromas recurred in 85% (17/20) of cases, and repeat aspiration was performed in 35% (6/17). The mean recurrence time was 34 ± 29 days. The recurrent seromas were 31% smaller (mean, 80 ± 48 mL). Only a smaller pre-ablation seroma was associated with successful ablation (P < 0.01), as the mean pre-ablation volume was 36 ± 24 mL for successful ablations and 119 ± 56 mL for unsuccessful ablations. There were no post-procedural complications.

CONCLUSION

Single-treatment ethanol sclerotherapy is typically unsuccessful in ablating breast and axillary seromas. Only a smaller pre-ablation seroma size was associated with successful ablation.

Indo-cyanine green administration to identify loss of lymph after axillary lymph node dissection

Background

Near infrared fluorescence imaging with Indocyanine Green (ICG) is now used for the imaging of lymph nodes and lymphatic vessels. In this work, we investigated the impact of its pre-operative and peri-operative administration on our ability to detect axillary lymphatic loss after breast cancer surgery.

Methods

One subcutaneous injection of ICG was administered in the ipsilateral hand of 109 women who were scheduled to have either a mastectomy with total axillary lymph node dissection (CALND) or a lumpectomy with selective lymphadenectomy (SLN) the day before (n = 53) or the same day of surgery (n = 56). The lymph leakages were assessed by means of the application of a compress in the operated armpit and by the presence or absence of fluorescence on it, as well as in the post-operative axillary drains.

Results

The compress was fluorescent in 28% of SLN patients and 71% of CALND patients. The liquids in the axillary drains were also fluorescent in 71% of patients with CALND. No statistical significance was observed between the ICG injection groups. The association between compressive fluorescent and the presence of fluorescence in the axillary drains is significant in the pre-operative subgroup and in the whole group.

Conclusion

Our research demonstrates that lymphatic leaks aid in the development of seromas and calls into question the effectiveness of the ligatures and/or cauterizations used during surgery. A prospective, multicentric, randomized trial should be conducted to verify the efficacy of this approach.

Effect of different quilting techniques on seroma formation after breast surgery: retrospective study

BACKGROUND

Quilting, a technique in which skin flaps are sutured to the underlying muscle, reduces seroma after mastectomy and/or axillary lymph node dissection. The aim of this study was to assess the effect of different quilting techniques on the formation of clinically significant seroma.

METHODS

This was a retrospective study including patients undergoing mastectomy and/or axillary lymph node dissection. Four breast surgeons applied the quilting technique based on their own discretion. Technique 1 was performed using Stratafix in 5-7 rows placed at 2-3 cm distance. Technique 2 was performed using Vicryl 2-0 in 4-8 rows placed at 1.5-2 cm distance. Technique 3 was performed using Vicryl 0/1 in 3 rows placed at 3-4 cm distance. Technique 4 was performed using Vicryl 0 in 4-5 rows placed at 1.5 cm distance. The primary outcome was clinically significant seroma.

RESULTS

A total of 445 patients were included. Clinically significant seroma incidence was 4.1 per cent (six of 147) for technique 1, which was significantly lower than that for the other techniques (25.0 per cent (29 of 116), 29.4 per cent (32 of 109), and 33 per cent (24 of 73) for techniques 2, 3, and 4 (P < 0.001) respectively). The duration of surgery was not significantly longer for technique 1 compared with the other three techniques. The length of hospital stay, number of additional visits to the outpatient clinic, and reoperations did not differ significantly between the four techniques.

CONCLUSION

Quilting using Stratafix and placing 5-7 rows with 2-3 cm distance between the stitches associates with low clinically significant seroma incidence without adverse effects.

Efficacy and aesthetic outcomes for quilting sutures in the prevention of seroma after mastectomy

Worldwide, mastectomy for breast cancer is one of the most frequently performed surgical procedures. As one of the main complications of mastectomy, seroma is associated with pain, infections and a prolonged hospital stay. We performed a prospective multicenter randomized trial to assess the efficacy and esthetic outcomes associated with quilting the skin flap. Eighty-seven patients were included. The proportion of patients with seroma on postoperative day 15 was significantly lower in the quilting group (12 out of 39 (30.8%)) than in a control group with conventional wound closure (21 out of 40 (52.5%); P = 0.05). The mean breast seroma volume was significantly lower in the quilting group (130.2 mL) than in the control group (236.8 mL; P = 0.02). There were no differences in the esthetic outcomes. The pain level on day 1 was similar in the quilting and control groups (mean visual analog scale score: 2.5 vs. 2.1, respectively; P = 0.3). Quilting the skin flap was associated with a lower prevalence of seroma and a lower seroma volume, and did not worsen the esthetic outcomes or pain levels. This technique is technically straightforward and should be offered to all patients scheduled for mastectomy.

Importance of Nutrition in the development of Seroma after Breast Surgery

Amaç: Meme cerrahisi sonrası seroma gelişiminde nütrisyonun önemini araştırmak. Seroma mastektomi sonrası görülen en sık komplikasyon olup, görülme sıklığı %10- 50 arasında değişmektedir. Seroma cilt nekrozu, enfeksiyon, yara iyileşmesini gecikmesi ve bunun sonucu olarak ek tedavilerin gecikmesine neden olabileceği için ciddiye alınması gereken bir komplikasyondur. Metod: Bu deneysel çalışmada 10’arlı gruplara ayrılan toplan 40 rat kullanıldı. Preoperatif 7 gün boyunca 1.gruba (kontrol) normal rat gıdası, 2. gruba kontrol grubunun %70’i kadar normal rat gıdası (malnütrisyon), 3. ve 4. gruba proteinden zengin diyet (Glutamin-Arjinin-Metil Bütirat) (10gr protein /kg/gün) verildi ve gruplara 7. gün tek taraflı (sağ) pektoral majör kas eksizyonu ve aksiler diseksiyon uygulandı. Postoperatif 10 gün boyunca 1. gruba normal rat gıdası, 2. gruba kontrol grubunun %70’ i kadar normal rat gıdası, 3. gruba normal rat gıdası ve 4. gruba proteinden zengin diyet verildi. Postoperatif 10. günde ratlardan seroma örneği alınarak sakrifiye edildi. Bulgular: Kontrol grubunun seroma miktarı 1,5 ml (1ml-2,5ml), malnütrüsyon grubunun seroma miktarı 1,5ml (1ml-2,75ml), preoperatif proteinden zengin diyetle beslenen 3.grubun seroma miktarı 1ml (0,5ml-1ml), preoperatif ve postoperatif proteinden zengin diyetle beslenen 4.grubun seroma miktarı 0,75ml (0,5ml-1ml) olarak bulundu. Seroma miktarları ortanca olarak verildi. Bu değerlere göre proteinden zengin diyetle beslenen grupların seroma miktarları anlamlı olarak düşük bulundu. (p=0,001 ) Sonuç: Çalışmamızda elde edilen veriler doğrultusunda deneysel mastektomi ve aksiller diseksiyon (AD) modelinde preoperatif ve postoperatif dönemde proteinden yüksek diyetle beslenmenin seroma oluşumunu azalttığı görülmüştür. Benzer şekilde klinik çalışmaların planlanması gerektiği kanaatindeyiz.

Seroma after Simple Mastectomy in Breast Cancer-The Role of CD4+ T Helper Cells and the Evidence as a Possible Specific Immune Process

Seroma development after breast cancer surgery is the most common postoperative complication seen after mastectomy but neither its origin nor its cellular composition is known. To investigate the assumption of immunological significance, one of the first aims of this pilot study is to describe the cellular content of collected seroma fluids and its corresponding serum in patients with simple mastectomy after needle aspiration, as well as the serum of healthy controls. The content of red blood cells (RBC) was measured by haemato-counter analyses, and the lymphocyte identification/quantification was conducted by flow cytometry analyses in seroma fluid (SFl) and the sera of patients (PBp) as well as controls (PBc). Significantly lower numbers of RBCs were measured in SFl. Cytotoxic T cells are significantly reduced in SFl, whereas T helper (Th) cells are significantly enriched compared to PBp. Significantly higher numbers of Th2 cells were found in SFl and PBp compared to PBc. The exact same pattern is seen when analyzing the Th17 subgroup. In conclusion, in contrast to healthy controls, significantly higher Th2 and Th17 cell subgroup-mediated immune responses were measured in seroma formations and were further confirmed in the peripheral blood of breast cancer (including DCIS) patients after simple mastectomy. This could lead to the assumption of a possible immunological cause for the origin of a seroma.

Comparison of Flap Fixation to Its Bed and Conventional Wound Closure with Drainage in Preventing Seroma Formation Following Mastectomy for Breast Cancer: Systematic Review and Meta-analysis

BACKGROUND

Seroma formation is a common complication following mastectomy. The objective of this systematic review and meta-analysis is to evaluate the impact of flap fixation techniques that omit drainage versus conventional closed drainage on seroma formation and related complications after mastectomy.

METHODS

Clinical studies of flap fixation techniques versus the conventional closure technique in patients undergoing mastectomy with or without axillary clearance were retrieved from the PubMed, Embase and Cochrane databases. Papers were eligible for inclusion if the outcome was described in terms of seroma formation. Studies older than 20 years, animal studies and studies involving patients undergoing direct breast reconstruction were excluded.

RESULTS

Four randomized controlled trials (RCTs) and four cohort studies were included in our examination. Compared with the conventional drainage group, the flap fixation group had a similar incidence of seroma formation (OR 0.76, 95% CI 0.30-1.93, p = 0.57).

CONCLUSION

Based on current evidence, mechanical flap fixation can replace conventional drainage without increasing seroma formation after mastectomy. Further well-designed RCTs are warranted to evaluate the effects of flap fixation.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. 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 .

Impact of Quilting Sutures on Surgical Outcomes After Mastectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Seroma after mastectomy and/or axillary lymph node dissection (ALND) is among the most common issue surgeons have to face in the early postoperative management of breast cancer. Using quilting sutures (QS) to aid in tissue approximation and decrease dead space is proposed as a simple technique to reduce seroma rate. We aimed to perform a systematic review, and analyse, in a meta-analytical model, the role of QS in improving wound outcomes and decrease volume, duration of drainage, and length of stay in hospital.

METHODS

The study was registered with PROSPERO. A systematic search of the PubMed, EMBASE, and SCOPUS databases was performed for all comparative studies examining surgical outcomes in patients who underwent QS versus conventional closure (CC) after mastectomy ± ALND.

RESULTS

Twenty-one studies with a total of 3473 patients (1736 in the study group and 1737 in the control group) were included based on the selection criteria. The study group showed significantly lower rates of seroma (p < 0.00001), total volume of drainage (p < 0.0001), days to drain removal (p < 0.00001), and length of stay (p < 0.00001) compared with the control group, while wound complication rates (surgical site infection, flap necrosis, hematoma, skin dimpling) were comparable between the two groups.

CONCLUSIONS

QS are a reliable intraoperative technique that decrease seroma formation, volume of postoperative drainage, duration of drainage and length of hospital stay, and should be considered in mastectomies with or without ALND.

Capsulectomy Can Successfully Treat Chronic Encapsulated Breast Seroma: A Case Report

Chronic encapsulated seroma following breast cancer surgery is a rare entity, and management is challenging. We present clinical and pathologic findings in a patient with previous node-negative breast cancer and an extensive history of chronic bilateral seromas, successfully treated with capsulectomy. This is the first report of fibrous encapsulated breast seroma with bilateral presentation and late onset, following mastectomy with no prior axillary dissection. When managing breast seroma refractory to conventional treatment, the diagnosis of encapsulated seroma should be considered, followed by prompt capsulectomy.

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.

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.

An Optimal Timing for Removing a Drain After Breast Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

In clinical practice, drains had been routinely used for reducing seroma formation after breast surgery. However, an optimal timing to remove drains does not identify yet.

METHODS

This study aimed to compare the clinical outcome, such as seroma formation, surgical site infection (SSI), and a length of hospital stay between early removal and late removal. A systematic review was performed using PubMed, MEDLINE, and the Cochrane Library. Breast cancer patients who received surgery using drains were eligible. Those parameters were compared between early vs late removal.

RESULTS

Eleven studies included in this meta-analysis. Seroma formation in the early removal group was significantly higher than the one in the late removal group (RR = 1.58: 95%CI [1.25-2.01], P = 0.0001), meanwhile no significant difference was found among the groups for SSI (RR = 0.82: 95%CI [0.51-1.31], P= 0.40). A length of hospital stay in the early removal group was also significantly shorter than late removal (RR -3.31: 95%CI [-5.13-1.49], P = 0.0004).

CONCLUSIONS

Seroma formation was significantly higher in patients who had early drain removal. Conversely, SSI incidence was low, and early removal did not increase SSI incidence. In conclusion, early drain removal has no proved clinical benefit in these settings besides reduction of hospital stays.

Mixed Metal Oxide Nanoparticle Formulations for the Treatment of Seroma

Seroma formation is a well-recognized postoperative complication for many plastic and general surgical procedures. Although various tissue adhesives and substances have been used in an effort to treat seroma formation, no therapies have been established clinically. Recently, the nano-bridging phenomenon has been introduced as a promising approach to achieve tissue adhesion and strong closure of deep skin wounds in rats. The present study seeks to assess the potential of nano-bridging beyond skin wounds in a rat model of seroma. Seromas were induced in 20 Lewis rats through bilateral axillary lymphadenectomy, excision of the latissimus dorsi and cutaneous maximus muscles, and disruption of dermal lymphatics. On postoperative day (POD) 7, the seroma was aspirated on both sides. A bioactive nanoparticle (NP) suspension based on zinc-doped strontium-substituted bioglass/ceria nanoparticles (NP group) or fibrin glue (fibrin group) was injected into the right seroma cavity, while the left side was left untreated. On POD 14, the NP group showed complete remission (no seromas at all), while the fibrin group recorded a reduction of only 63% in the seroma fluid volume. The NPs exerted local anti-inflammatory and neo-angiogenic effects, without any detectable systemic changes. Moreover, the ceria levels recorded in the organs did not surpass the background level, indicating that the nanoparticles stayed at the site of application. This study is a promising first example demonstrating the ability of inorganic nanoparticle formulations to reduce seroma formation in a rat model, without any detectable systemic adverse effects. These results emphasize the potential of nanotechnological solutions in the therapeutic management of seroma in the clinical setting.

Serial Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Scan Distinguishing Infected Seroma from Recurrence in a Necrotic Lymph Node in a Case of Squamous Cell Carcinoma of the Right Kidney

Seroma can occur as a complication following nephroureterectomy. We report a case of squamous cell carcinoma of the kidney, postnephroureterectomy where serial fluorodeoxyglucose positron emission tomography-computed tomography images helped in distinguishing the diagnostic dilemma between lymph node recurrence and infected seroma.

Effects of Different Applications on Postoperative Seroma Formation and Wound Healing Following Mastectomy and Axillary Dissection in Rats

The most frequent postoperative complication after breast surgery is seroma formation. Seroma occurs due to lymphatic and vascular fluid leakage into the dead space created by surgical dissection. The objective of the research was to evaluate the effects of local fibrin glue, tetracycline, talc applications, and flap fixation technique on reducing seroma formation after mastectomy and axillary dissection. In addition, we aimed to determine the level of efficacy for these applications, as well as to identify the most appropriate method to be used in operations with high risk of seroma formation. Materials and Methods. This experimental study was conducted using a total of 60 female Wistar albino rats. They were allocated into six groups and each comprised ten rats. Unilateral mastectomy and axillary dissection were performed on all the rats. Local applications of fibrin glue, tetracycline, talc, and alcoholic iodine were performed in four separate groups. Flap fixation technique was applied in one group and those rats that did not receive any intervention constituted the control group. On the 10th postoperative day, seroma was aspirated under anesthesia, and the amount of seroma fluid was recorded. Seroma fluid was analyzed for interleukin 1-β, vascular endothelial growth factor, and C-reactive protein levels. Tissue samples were obtained from the skin overlaying the dissection area, the axilla, and the thoracic wall. Wound healing was evaluated with histopathological examination. Results. Seroma volume was lower and the wound healing scores were the highest in the flap fixation group and the tetracycline group as compared to the control group. However, the alcoholic iodine group and the talc group had a greater amount of seroma (p < 0.05). There was no difference between the fibrin glue group and the control group. Conclusions. In our mastectomy model, local application of alcoholic iodine and talc substances caused more wound site problems and postoperative seroma formation. While fibrin glue did not cause wound site problems, it did increase seroma formation. These three substances were determined to be inefficacious in postoperative seroma formation. Local tetracycline application and flap fixation technique were found to reduce postoperative seroma and benefit wound healing.

Novel Use of a Porcine Bladder Extracellular Matrix Scaffold to Treat Postoperative Seroma in a Total Knee Arthroplasty Patient

Seroma formation in a knee arthroplasty surgery is a rare complication. When seromas occur, they act as a nidus for bacterial growth and create an optimal environment for surgical site infections. In this case report, a 52-year-old woman presented with a seroma after multiple revision operations on the left knee. Owing to multiple failures of standard irrigation and drainage procedures to resolve the seroma, an orthoplastic colleague was consulted. Over five-and-a-half months, the patient underwent multiple procedures that failed to treat the seroma. However, in a final exploratory procedure, 3000 mg of urinary bladder matrix and negative pressure wound vacuum were placed. Seven months after the intervention, the patient had complete resolution.

Effectiveness of Cyanoacrylate in Reducing Seroma Formation in Breast Cancer Patients Post-Axillary Dissection: A Randomized Controlled Trial

Background/Purpose

Seroma is a common complication after axillary dissection in women with node-positive breast cancer. We aim to determine the effect of Cyanoacrylate on reducing seroma formation in patients undergoing axillary dissection. This a randomized clinical trial.

Methods

This is a single-center, randomized, single-blinded, and two-arm parallel study. Women with node-positive breast cancer eligible for axillary dissection were enrolled. Patients with a Body Mass Index (BMI) greater than 35 kg/m², those who underwent immediate breast reconstruction, and/or received neoadjuvant chemotherapy were excluded. Patients were randomized in a 1:1 ratio, and were stratified according to their age, BMI, tumor size, and operation type. The primary endpoint was the total seroma volume (the total drained volume and the total aspirated volume after drain removal). Data presented as mean and range when applicable.

Results

111 patients were randomized (Cyanoacrylate 57; control 54). 105 patients were analyzed. Sixty-nine patients underwent breast conserving surgery, and 36 underwent modified radical mastectomy. There was no difference in the total seroma volume between the Cyanoacrylate vs. control arms (1,304 (60–4,950) vs. 1,446 (100–5,223) ml, p=0.458). Wound infection, flap necrosis, number of manual aspirates, and hematoma formation were not statistically different between the two groups. Time to drain removal was shorter in the Cyanoacrylate arm (11.04(3–23) vs. 13.84(3–37) days, p=0.015). The use of Cyanoacrylate was not cost effective ($586.93 (550–748) vs. $29.63 (0–198), p<0.001). Higher seroma volume was correlated with modified radical mastectomy, older age, and BMI more than 30 kg/m².

Conclusion

Cyanoacrylate did not reduce seroma formation and its use was not cost effective.

Clinical Trial Registration

clinicaltrials.gov, identifier NCT02141373.

Managing infected seroma post-lymphadenectomy; A retrospective cohort study and cost analysis in melanoma patients

BACKGROUND AND PURPOSE

Seromas are a common and unavoidable complication following lymphadenectomy, and often become clinically significant with superseded infection requiring re-admission for prompt intervention. However, there is no consensus as to whether a formal surgical incision and drainage (I&D), ultrasound (US)-guided aspiration or intravenous (IV) antibiotics alone is the most efficacious method of managing an infected seroma, the investigation of which formed the rationale for this study.

SUBJECTS AND METHODS

This retrospective cohort study included a consecutive series of patients readmitted for infected seroma following a lymphadenectomy for melanoma at Leeds Teaching Hospitals Trust (LTHT) from 2006 to 2017. Details on management, length of hospital stay, length of follow-up and number of clinical appointments required were examined.

FINDINGS

Seventy-one cases of infected seroma were identified from the cohort of 1691 lymphadenectomies. Initially, 21 patients (29.5%) were managed by IV antibiotics alone (failure rate of 52.4%); 18 (25.4%) with US-guided aspiration (failure rate 27.8%) and 32 (45.1%) with surgical I&D, which was 100% effective. Ultimately, 62.5% of the cohort required surgical management. Patients who underwent surgical I&D were discharged significantly faster following the procedure (3 versus 5 days for US-guided aspiration, p = 0.002) and spent fewer days in hospital overall (p = 0.022). The overall average cost was comparable across the three treatment groups.

CONCLUSIONS

Surgical management seemed preferential to conservative approaches in terms of efficacy and was not significantly more expensive overall; but carries anaesthetic risk. There may be a clinically significant difference in outcome depending on management; however, more evidence is required to investigate this.

Comparison of PEAK PlasmaBlade™ to conventional diathermy in abdominal-based free-flap breast reconstruction surgery-A single-centre double-blinded randomised controlled trial

BACKGROUND

Electrosurgery makes dissection with simultaneous haemostasis possible. The produced heat can cause injury to the surrounding tissue. The PEAK PlasmaBlade™(PPB) is a new electrosurgery device which may overcome this by having the ability to operate on a lower temperature, therefore reducing collateral thermal damage.

METHOD

A single-centre, double-blinded, randomised controlled trial (RCT) was conducted which included 108 abdominal-based free-flap breast reconstruction patients who had their flap raise performed using either the PPB (n = 56) or the conventional diathermy (n = 52). Data were collected during their in-patient stay and out-patient appointments. The primary outcome value was the number of days the abdominal drains were required.

RESULTS

Baseline characteristics were similar between the groups, except a significantly lower flap weight in the PPB group. The median number of days the drains were required did not differ significantly (p = 0.48; 6.0 days for the diathermy and 5.0 days for the PPB). The total drain output (p = 0.68), the inflammatory cytokine in the drain fluid (p>0.054) and complications (p>0.24) did not differ significantly between the two groups. At the 2-week follow-up appointment, there was a trend towards less abdominal seromas on abdominal ultrasound (p = 0.09) in the PPB group which were significantly smaller (p = 0.04).

CONCLUSION

The use of the PPB did not result in a significant reduction of drain requirement, total drain output or inflammatory cytokines but did reduce the size of seroma collections at the 2-week follow-up appointment. Therefore, the use of the PPB device could reduce early seroma formation after drain removal.

Retrospective Evaluation of the Effectiveness of a Synthetic Glue and a Fibrin-Based Sealant for the Prevention of Seroma Following Axillary Dissection in Breast Cancer Patients

Introduction: Seroma formation represents one of the most frequent postoperative complications of axillary dissection in breast cancer (BC) patients. We aimed to retrospectively explore the effectiveness of the intraoperative use of a synthetic cyanoacrylate glue (specifically Glubran®2) vs. the intraoperative use of a fibrin sealant (specifically Tisseel) in reducing seroma formation compared to the use of nonsealant in BC patients who underwent breast surgery and axillary dissection. Materials and Methods: We conducted a retrospective, monocentric observational study on BC patients who underwent axillary dissection associated with breast surgery. The axillary dissection was completed with the application of a closed suction drain and was preceded by the application of either Glubran®2 glue or Tisseel sealant or nonsealant. We analyzed the quantity of serum drained in the first 3 postoperative days, length of hospitalization, days of permanence of axillary drain, seroma development, and presence of postoperative infection signs. Results: Forty-one BC patients were considered. Based on the device used during the surgical treatment, the patients were divided into three groups: group A (17 patients), to whom suction axillary drain was applied; group B (7 patients), to whom Tisseel and axillary suction drain were applied; and group C (17 patients), to whom Glubran®2 and axillary suction drain were applied. Among the three groups, we did not find significant differences in terms of amount of serum drained in the first 3 postoperative days, length of hospitalization, and incidence of seroma. Group C maintained the axillary drain in a significantly lower number of days compared to the other two groups (p = 0.02); it also had a lower incidence of postoperative infections (6%) compared to group A (23%) and group B (57%) (p = 0.02). Conclusions: We did not find any evidence that the use of surgical glues may reduce the formation of seroma following axillary dissection in BC patients. Nevertheless, the use of cyanoacrylate glue in association with closed suction axillary drain seems to contribute to the reduction in days of axillary drain permanence and of postoperative infections, which are known factors delaying the schedule of any adjuvant oncological therapies.

Incidence of Complications in Delayed Abdominal-Based Flap Breast Reconstruction Using a Drainless Recipient Site: A Case Series

BACKGROUND

Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site.

METHODS

A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications.

RESULTS

Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5).

CONCLUSIONS

In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.

Ultrasonic dissection versus electrocautery for immediate prosthetic breast reconstruction

Background

Ultrasonic dissection devices cause less thermal damage to the surrounding tissue than monopolar electrosurgical devices. We compared the effects of using an ultrasonic dissection device or an electrocautery device during prosthetic breast reconstruction on seroma development and short-term postoperative complications.

Methods

We retrospectively reviewed the medical records of patients who underwent implant-based reconstruction following mastectomy between March 2017 and September 2018. Mastectomy was performed by general surgeons and reconstruction by plastic surgeons. From March 2017 to January 2018, a monopolar electrosurgical device was used, and an ultrasonic dissection device was used thereafter. The other surgical methods were the same in both groups.

Results

The incidence of seroma was lower in the ultrasonic dissection device group than in the electrocautery group (11 [17.2%] vs. 18 [31.0%]; P=0.090). The duration of surgery, total drainage volume, duration of drainage, overall complication rate, surgical site infection rate, and flap necrosis rate were comparable between the groups. Multivariate analysis revealed that the risk of seroma development was significantly lower in the ultrasonic dissection device group than in the electrocautery group (odds ratio for electrocautery, 3.252; 95% confidence interval, 1.242–8.516; P=0.016).

Conclusions

The findings of this study suggest that the incidence of seroma can be reduced slightly by using an ultrasonic dissection device for prosthesis-based breast reconstruction. However, further randomized controlled studies are required to verify our results and to assess the cost-effectiveness of this technique.

Topical moistening of mastectomy wounds with diluted tranexamic acid to reduce bleeding: randomized clinical trial

BACKGROUND

Topical administration of tranexamic acid (TXA) may be an alternative to intravenous administration to reduce bleeding with a lower risk of systemic adverse events. The aim of this study was to investigate whether moistening a surgical wound with TXA before closure, leaving a thin film of drug only, would reduce postoperative bleeding.

METHODS

This was a two-centre, stratified, parallel-group, placebo-controlled, double-blind RCT. Patients undergoing mastectomy with or without axillary lymph node clearance were randomized 1 : 1 to moistening of wound surface before closure with either 25 mg/ml TXA or 0·9 per cent sodium chloride (placebo). The primary endpoint was postoperative bleeding as measured by drain production in the first 24 h. Secondary endpoints were early haematoma, total drain production, postoperative complications and late aspirations of seroma within 3 months.

RESULTS

Between 1 January 2016 and 31 August 2018, 208 patients were randomized. Two patients were converted to a different surgical procedure at surgery, and four did not receive the intervention owing to technical error. Thus, 202 patients were included in the study (101 in the TXA and 101 in the placebo group). TXA reduced mean drain production at 24 h (110 versus 144 ml; mean difference 34 (95 per cent c.i. 8 to 60) ml, P = 0·011). One patient in the TXA group had early haematoma compared with seven in the placebo group (odds ratio (OR) 0·13 (95 per cent c.i. 0·02 to 1·07); P = 0·057). There was no significant difference in postoperative complications between TXA and placebo (13 versus 10; OR 1·11 (0·45 to 2·73), P = 0·824) or need for late seroma aspirations (79 versus 67 per cent; OR 1·83 (0·91 to 3·68), P = 0·089).

CONCLUSION

Moistening the wound with TXA 25 mg/ml before closure reduces postoperative bleeding within the first 24 h in patients undergoing mastectomy. Registration number: NCT02627560 (https://clinicaltrials.gov).

Bacterial colonization of seromas after breast cancer surgery with and without local steroid prophylaxis

Background

Seroma formation is a frequent postoperative sequela after mastectomy for primary breast cancer. We investigated the role of bacterial colonization of seroma fluid with three different culture methods and the effect of intracavitary steroids.

Methods

The study group consisted of 212 patients scheduled for mastectomy from a previously performed double-blind randomized placebo-controlled intervention trial. The patients were allocated to a single dose of 80 mg of steroids (methylprednisolone) or saline, and the effect on seroma formation was investigated. From each aspiration, an equal volume of seroma fluid (10 mL) was distributed into one sterile transport tube (conventional method), one aerobic blood culture bottle and one anaerobic blood culture bottle.

Results

There was significant variation in the number of bacterial species detected in seroma samples among the three culture methods, ranging from 18 species with the conventional culture tubes to 40 species with aerobic blood culture bottles. Patients receiving prophylactic steroids had significantly more frequent colonization than those in the saline group. Nevertheless, the clinical surgical site infection rate of 7.0% was equal between the two groups.

Conclusions

In general, data analysis of the entire set of case material did not succeed in demonstrating a relationship between a specific bacterial species or a combination of species and seroma formation. However, in the few patients with growth of a pathogenic species, both the duration of seroma formation and volume of seroma fluid were more pronounced.

Trial registration: Ethics Committee of Copenhagen (H-4-2009-137), (EudraCT number 2009-016650-40), the Danish Data Protection Agency (code J. no. F.750.75-2), and the Danish Health and Medicines Authority (sponsor protocol code number 23837). Start date November 2010.

The use of ultrasonic scalpel lowers the risk of post-mastectomy seroma formation in obese women

Introduction: Seroma formation (SF) is the most common postoperative complication after mastectomy and axillary surgery. The aim of this study was to assess its incidence and risk factors following a modified radical mastectomy in breast cancer patients.

Materials and methods: 271 patients who underwent a modified radical mastectomy (250 with traditional electrocautery and 21 with an ultrasonic scalpel) were studied. The SF rate was calculated and its association with patient-related factors, surgical features and postoperative variables was assessed and statistically analyzed with P<0.05 as a significance threshold.

Results: SF was observed in 18% of patients. Patient's age, operating time and number of removed axillary lymph nodes did not significantly differ between SF and non-SF patients. Patients BMI, total drainage amount, number of days with drain were higher and postoperative hospital stay was significantly longer in SF patients (P<0.001 each). The dissection instrument was also an important risk factor: SF developed in 20% of patients operated with electrocautery and in none with an ultrasonic scalpel (P<0.05). The association between surgical instrument and the number of removed lymph nodes, patient's age and BMI was not significant. Dissection with an ultrasonic scalpel resulted in a statistically significant lower total drainage amount. However, it was also related to a significantly longer operating time (P<0.001 each).

Conclusions: Risk of SF after a modified radical mastectomy is significantly higher in patients with obesity. Despite longer operating time, using an ultrasonic scalpel is a valuable option in those cases because it lowers the total drainage amount and seems to be an important protective factor against SF.

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study

Background

The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction.

Methods

Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined.

Results

Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs. 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation.

Conclusions

This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

Examination of the Effects of Celecoxib on Postmastectomy Seroma and Wound Healing

Objectives:

To examine the effect of celecoxib on wound healing and development of seroma after mastectomy.

Seroma is an accumulation of serous fluid in dead space emerging after breast cancer surgery. The pathophysiology of seroma has not been clearly elucidated. Development of seroma leads to prolongation of hospital stay, increase in costs, ischemia of the flaps, infections due to fluid accumulation, and delayed adjuvant treatment.

Seroma is still a current problem, and the most common treatment method for this problem is drainage and repeated aspirations for 5–7 days after surgery.

Methods:

The effect of celecoxib whose anti-inflammatory, antiangiogenic, and antioxidant effectiveness has been demonstrated in a mastectomy model applied on female Wistar rats has been investigated in the present study. A total of 20 rats including 10 rats in the control and 10 in the celecoxib group were studied.

Intraperitoneal 0.25 cc/250 g (20 mg/kg/day) celecoxib was administered to the celecoxib group for 5 days after mastectomy, and the same volume of physiological saline solution was given to the control group for 5 days. Rats were followed up for 10 days after surgery. During this process, vitality of the rats, movements of the extremities, wound healing conditions, wound infections, flap necrosis, and occurrence of seroma were recorded. At the end of this period, seromas were aspirated, tissue samples were retrieved, and the rats were sacrificed. Fibrin, hemorrhage, edema, vascularization, congestion, polymorphonuclear leukocytes, and increase in fibrotic tissue fibroblasts, lymphocytes, and macrophages were evaluated in tissue samples.

In seroma fluids, interleukin-1 beta (IL-1β), an acute phase reactant, and vascular endothelial growth factor, a vital parameter of vascular proliferation and angiogenesis, were examined.

Results:

At the end of the experiments, the seroma volume decreased significantly in the celecoxib group (p=0.804; 0.001), the IL-1β level decreased significantly as detected in the biochemical examination (p=0.014), and in the histopathological examination, an increase in congestion in the celecoxib group was determined.

Conclusion:

In conclusion, celecoxib markedly decreased interleukin and the volume of seroma after mastectomy; suppressed the level of an acute phase reactant, IL-1β; and demonstrated this effect through its anti-inflammatory activity. We believe that the effects of celecoxib should be investigated using different dose applications and larger number of subjects.

The Use of TissuGlu® Surgical Adhesive for Mastectomy With or Without Lymphonodectomy

BACKGROUND/AIM

Using drains after breast surgery is a preventive, but invasive measure to reduce seroma formation. A polyurethane-based tissue adhesive (TissuGlu®) might facilitate drainage-free wound healing after mastectomy in a non-invasive manner.

PATIENTS AND METHODS

Retrospectively, data from 84 patients (42 receiving TissuGlu®, 42 receiving a drainage) who underwent mastectomy, were collected (90 days postoperative follow-up). Study endpoints were defined as the number of fluid-related postoperative clinical interventions, cumulative volume of postoperative wound fluid, duration of hospitalization and postoperative complications.

RESULTS

In the entirety of postoperative interventions, no significant difference could be demonstrated (p=0.298). The drainage arm showed significantly less seroma aspirations (p=0.024) and complications (p=0.012). A significantly reduced length of hospitalization (p<0.001) and less cumulative wound secretion volume (p<0.001) appeared in the TissuGlu® group.

CONCLUSION

The polyurethane-based tissue adhesive is a less invasive alternative to drain use in mastectomy.

Case Report: Breast Seroma Mimicking Breast Implants

Introduction Breast seroma may be caused by a variety of factors including lymphatic disruption, continuous inflammation and foreign bodies such as breast implants. In cases of breast implants associated seroma the diagnosis of Anaplastic Large Cell Lymphoma (ALCL) should be investigated. Presentation of Case A 45-year-old Caucasian woman was referred with bilateral swelling of the breasts causing tension and pain. MRI showed accumulations compatible with bilateral silicone implants. Ultrasound-guided aspiration showed no malignancy or silicone. The patient had a history of both soy- and silicone implants. Three years prior her breast implants was removed due to capsule formation. To treat the pain and rule out potential malignancy we performed capsulectomy of only the right breast, on the wish of the patient. We found brown fluid, no breast implants and histology of fluid and tissue showed no malignancy.

DISCUSSION

Breast seroma usually develops weeks after surgery such as mastectomy or axillary lymph node dissection. This patient developed a seroma through months and years after her last surgery. In cases of late seroma malignancy should be ruled out. Diagnostic statements should not solely be based on radiology, but in conjunction with clinical findings.

CONCLUSION

We performed capsulectomy on a patient with breast seroma mimicking breast implants. We excluded the diagnosis of breast implant-associated ALCL. Radiology has limitations and should be considered in conjunction with the patient's statement and the clinical findings.

Breast reconstruction with anatomical implants: A review of indications and techniques based on current literature

One important modality of breast cancer therapy is surgical treatment, which has become increasingly less mutilating over the last century. Breast reconstruction has become an integrated part of breast cancer treatment due to long-term psychosexual health factors and its importance for breast cancer survivors. Both autogenous tissue-based and implant-based reconstruction provides satisfactory reconstructive options due to better surgeon awareness of "the ideal breast size", although each has its own advantages and disadvantages. An overview of the current options in breast reconstruction is presented in this article.

Comparison of electrocautery and plasmablade on ischemia and seroma formation after modified radical mastectomy for locally advanced breast cancer

The aim of this study was to compare postoperative drainage volumes and IMA levels in patients who underwent modified radical mastectomy (MRM) with using PlasmaBlade (PB) or electrocautery (EC). A total of 36 patients who underwent MRM with PB or EC in our clinic between August 2012 to February 2013 were enrolled. Number of removed and positive lymph nodes, duration of drainage and total drainage volume was recorded. Seroma formation after drain removal and number of aspirations were also recorded. Serum ischemia modified albümine (IMA) levels were analysed before surgery, 1 hour and 24 hour after surgery. In total, 36 patients were treated with MRM in the study period. Of the 36 patients, 16 underwent MRM with PB, and 20 underwent MRM with EC. The patients demographics were similar in both groups. The mean drainage volume and seroma formation were significantly higher in the PB group when compared with EC group (P<0.05). Number of aspirations due to the seroma were also high in PB group. The total aspiration volume of seroma was not different in both groups. IMA levels 24 hours after surgery in the PB group was significantly higher than EC group. There was no statistical significance between the groups for IMA levels at 1st hour. PB is a monopolar energy device and is associated with increased levels of ischemia. This situation resulted with an increased volume of total axillary drainage and elevated risk of seroma formation.

Analysis of factors influencing drain amount, time to drain removal, and seroma formation in patients undergoing immediate expander-implant breast reconstruction

BACKGROUND

Placement of a closed suction drain is a common cause of patient complaints, such as postoperative pain or discomfort following immediate expander-implant breast reconstruction. This study aims to identify factors that affect drainage volume, time to drain removal, and seroma formation.

METHODS

A retrospective chart review of prospectively collected data was conducted on patients who underwent immediate expander-implant breast reconstructions following nipple-sparing or skin-sparing mastectomy without skin excision (nipple areolar complex excision only) between February 2010 and April 2015. Daily drainage volume was measured until the drain was removed. Eight independent variables, including acellular dermal matrix (ADM) usage and inflation ratio (the rate of initial inflation volume to mastectomy weight) were analysed by univariable and multivariable analyses.

RESULTS

A total of 162 breasts in 148 patients were included in this study. The inflation ratio did not influence the drain amount or days to drain removal. Although the use of ADM was significantly associated with increased drainage during the first 5 postoperative days (p = 0.015), it was not significant when adjusted for time. Old age, larger expander size, and larger drain amount on the first postoperative day were predictors for longer days to drain removal (p < 0.001). Old age had a trend toward higher risk of seroma formation that approached statistical significance (p = 0.057).

CONCLUSIONS

The use of ADM and initial inflation ratio do not influence days to drain removal or seroma formation. A longer period of drain placement is expected when a larger expander is used or in elderly patients.

Seroma in Prosthetic Breast Reconstruction

BACKGROUND

Seroma, as a complication of prosthetic breast reconstruction, results in patient distress, increased office visits, undesirable aesthetic outcomes, and--importantly--may escalate to infection and frank prosthesis loss. Herein, the authors review the pathophysiology and risk factors and attempt to collate published practices for avoidance and management of seroma.

METHODS

A systematic literature review was performed using MEDLINE, Web of Science, Embase, and Cochrane Library for studies published between 2000 and January of 2015. Random-effects meta-analysis was used to estimate the overall pooled incidence of seroma and to examine the effect of drain number and acellular dermal matrix use.

RESULTS

Seventy-two relevant primary articles and three systematic reviews were identified. Fifty-one citations met inclusion criteria, including two randomized controlled trials. The overall pooled incidence was 5.4 percent (95 percent CI, 4.1 to 6.7 percent). Obesity, acellular dermal matrix, and preoperative irradiation were cited risk factors. Pooled relative risk for acellular dermal matrix was 1.83 (95 percent CI, 1.28 to 2.62). Drain practices were collated from 34 articles.

CONCLUSIONS

Seromas following prosthetic breast reconstruction are complicated by the hypovascular, proinflammatory milieu of the mastectomy skin flap, the geometrically complex dead space, and the presence of a foreign body with potential contamination and biofilm. There is reasonable evidence to suggest that these factors contribute to a progression of seroma to infection and prosthesis loss. These findings have motivated this summary article on current practice guidelines and strategies to prevent and treat seromas.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Prospective randomized controlled study to assess the value of a hemostatic and sealing agent for preventing seroma after axillary lymphadenectomy

BACKGROUND AND OBJECTIVES

Postoperative seroma after axillary lymphadenectomy leads to an increased use of resources and an impaired quality of life of patients. This randomized clinical trial was designed to assess the value of a hemostatic and sealing agent for decreasing seroma occurrence after axillary lymphadenectomy.

METHODS

A prospective, randomized, blind study was conducted on 91 axillary lymphadenectomies distributed into a control group (n = 47) and a test group in which a collagen sponge coated with human coagulation factors was used (n = 44). Primary end-points were number of days before removal of axillary drainage, axillary drainage output, and occurrence of seroma, wound infection, haematoma, or wound dehiscence, within 8 weeks of surgery. Bivariate and multivariate analyses on seroma occurrence were performed.

RESULTS

Seroma occurred in 29 patients (31.86%). A significant direct relationship (P = 0.002) was only noted between use of the hemostatic and sealing agent and nonoccurrence of seroma. In the multivariate study, the only variable found to be significantly related to seroma occurrence was use of the above agent (P = 0.046; odds ratio: 3.365 [95%CI: 1.024-11.060]).

CONCLUSIONS

Use of a collagen sponge coated with human coagulation factors following axillary lymphadenectomy was associated to a lower incidence of postoperative seroma. J. Surg. Oncol. 2016;114:423-427. © 2016 Wiley Periodicals, Inc.

Effects of Quilting Suture Interval on Donor Site Seromas After Breast Reconstruction With Latissimus Dorsi Muscle Flap: A Randomized Trial

BACKGROUND

Although breast reconstruction using a deep inferior artery perforator flap has been increasing, using a latissimus dorsi (LD) muscle flap is still the favored method for Asian female patients with breast cancer. However, because the incidence of donor site seromas has been relatively high, a quilting method on the donor cavity or insertion of drainage tube has been used to reduce the incidence and/or severity of postoperative seroma. We evaluated the effects of different intervals of quilting sutures on the postoperative drainage volume and components of seroma fluid.

PATIENTS AND METHODS

A total of 36 patients with breast cancer underwent partial or total mastectomy with LD flap reconstruction. They were randomized into 3 groups according to the interval of quilting sutures: nonquilting (n = 10), 6-cm quilting (n = 14), and 3-cm quilting (n = 12). The clinicopathologic factors and time to drain removal, drainage volume, frequency of aspiration, and serous fluid components were investigated.

RESULTS

No statistically significant differences were found in the clinicopathologic factors among the 3 groups. The time to drain removal was significantly shorter in the 6-cm quilting and 3-cm quilting groups than in the nonquilting group (P = .039 and P = .041, respectively). The total volume of drainage from the donor site was also decreased in the quilting groups (6-cm group, P = .046; 3-cm group, P = .021). The seroma components were not different among the 3 groups.

CONCLUSION

Performing quilting sutures on LD flap donor sites is an effective method to reduce the volume of postoperative seroma. The present findings showed that a 6-cm suture interval is appropriate.

Talc seromadesis in patients with chronic seroma formation after breast surgery

Background

Seroma formation, after breast surgery is a commonly seen complication with an incidence ranging from 10 to 85 %. In general, though seroma usually disappears within several weeks, some patients are troubled with chronic seroma. Seroma predisposes to infection leading to wound related complications and may also delay adjuvant chemoradiation, leading to less effective breast cancer treatment.

Case description

A 52-years-old Dutch woman presenting with a pT3N1M0 infiltrating lobular breast carcinoma received neo-adjuvant chemotherapy, following modified radical mastectomy with sentinel node procedure. She suffered from chronic seroma formation, delaying adjuvant radiation therapy. We successfully performed talc seromadesis to eliminate seroma formation. During six-month follow-up, no seroma was detected.

Discussion and evaluation

Talc seromadesis after breast surgery is a rarely described in literature. In order to develop this technique further research aimed to evaluate its effectiveness on safety and possible later breast reconstruction must be carried out.

Conclusion

Talc seromadesis may be a safe, cost effective and minimally invasive solution to treat chronic seroma after breast surgery.

Factors that Affect Drain Indwelling Time after Breast Cancer Surgery

OBJECTIVE

The most common procedure to prevent seroma formation, a common complication after breast and axillary surgery, is to use prophylactic surgical drains. Ongoing discussions continue regarding the ideal time for removing drains after surgical procedures. In this study, we aimed to investigate factors that affect drain indwelling time (DIT).

MATERIALS AND METHODS

From 2014 to 2015, a total of 91 consecutive patients with breast cancer were included in the study. The demographic characteristics of the patients, treatment methods, histopathologic features of the tumor, size of removed breast tissue (BS), tumor size (TS), number of totally removed lymph nodes (TLN), and metastatic lymph nodes (MLN), whether they had neoadjuvant chemotherapy, and the DIT were retrospectively recorded from the hospital database.

RESULTS

The mean age of the patients was 48.9 years, and the mean DIT was 4.8 days. The mean size of breast removed was 17.3 cm and tumor size was 4.7 cm, and the mean number of metastatic lymph nodes was 3.3, and mean total number of lymph nodes was 14.1. Patients who had neoadjuvant chemotherahpy had longer DIT. There was a positive correlation between the BS, TS, TLN, MLN, length of hospital stay, and DIT. Linear regresion analysis revealed that the BS, TLN, and history of neoadjuvant chemotherahpy were independent risk factors for DIT.

CONCLUSION

DIT primarily depends on BS, TLN, and history of neoadjuvant chemotherahpy. A policy for the management of removing drains to prevent seroma formation should thus be individualized.

A Prospective, Randomized, Multicenter Trial Assessing a Novel Lysine-Derived Urethane Adhesive in a Large Flap Surgical Procedure without Drains

OBJECTIVE

To evaluate the safety and effectiveness of a lysine-derived urethane adhesive as a noninvasive alternative to closed suction drains in a commonly performed large flap surgical procedure.

METHODS

One hundred thirty subjects undergoing abdominoplasty at five centers were prospectively randomized to standard flap closure with surgical drains (Control group) or a lysine-derived urethane adhesive (Treatment group) without drains. The primary outcome measured was the number of post-operative procedures, including drain removals (as the event marking the use of a surgical drain) and needle aspirations. Secondary endpoints included total wound drainage, cumulative days of treatment, and days to drain removal. A patient questionnaire evaluating quality of life measures was also administered.

RESULTS

Subjects in the Treatment group required significantly fewer post-operative procedures compared to the Control group (1.8 ± 3.8 vs. 2.4 ± 1.2 procedures; p < 0.0001) and fewer cumulative days of treatment (1.6 ± 0.4 vs. 7.3 ± 3.3; p < 0.0001). A procedure to address fluid accumulation was required for only 27.3 % of the subjects in the Treatment group versus 100 % of Control group, which by study design required the use of drains. The mean duration of use of indwelling surgical drains for the Control group was 6.9 ± 3.3 days. All fluid collections treated with percutaneous aspiration were resolved and there were no unanticipated adverse events.

CONCLUSION

The results of the study support that the use of a lysine-derived urethane adhesive is a safe and effective alternative to drains in patients undergoing a common large flap surgical procedure.

Randomized clinical trial of prevention of seroma formation after mastectomy by local methylprednisolone injection

Background

Seroma formation, the most prevalent postoperative complication after mastectomy, is an inflammatory process that is potentially preventable via local steroid administration. This study investigated the effect of local steroid administration on seroma formation.

Methods

This was a double-blind randomized placebo-controlled intervention study of a single dose of 80 mg methylprednisolone versus saline on seroma formation after mastectomy. Patients were further classified according to the surgical axillary procedure: mastectomy with sentinel lymph node biopsy (M + SLNB) or mastectomy with level I–II axillary lymph node dissection (M + ALND). Treatments were administered into the wound cavity via the drain orifice following removal of the drain on the first day after surgery. The primary endpoint was seroma formation; secondary endpoints included the frequency of side-effects and complications.

Results

A total of 212 women scheduled for mastectomy for primary breast cancer were included. After M + SLNB, 32 (46 per cent) of 69 women developed a seroma in the methylprednisolone group, compared with 52 (78 per cent) of 67 in the saline group (P &lt; 0·001). The mean cumulative seroma volume in the intention-to-treat population for the first 10 and 30 days was significantly lower in the methylprednisolone group (24 ml versus 127 ml in the saline group, and 177 versus 328 ml respectively) (P &lt; 0·001). After M + ALND, similar proportions of patients developed a seroma in the methylprednisolone (35 of 37, 95 per cent) and saline (34 of 36, 94 per cent) groups, and methylprednisolone administration had no significant effect on seroma formation. No differences in infection rate were observed.

Conclusion

Methylprednisolone administered into the wound cavity on the first day after M + SLNB exerted a highly significant preventive effect against seroma formation during the next 30 days. This effect was not seen in the M + ALND group. Future studies may clarify whether higher or repeated methylprednisolone doses increase the efficacy.

Evaluation of the Quilting Technique for Reduction of Postmastectomy Seroma: A Randomized Controlled Study

Background. Postmastectomy seroma causes patients' discomfort, delays starting the adjuvant therapy, and may increase the possibility of surgical site infection. Objective. To evaluate quilting of the mastectomy flaps with obliteration of the axillary space in reducing postmastectomy seroma. Methods. A randomized controlled study was carried out among 120 females who were candidates for mastectomy and axillary clearance. The intervention group (N = 60) with quilting and the control group without quilting. All patients were followed up routinely for immediate and late complications. Results. There were no significant differences between the two groups as regards the demographic characteristics, postoperative pathological finding, and the immediate postoperative complications. The incidence of seroma was significantly lower in the intervention group compared with the control group (20% versus 78.3%, P < 0.001). Additionally, the intervention group had a shorter duration till seroma resolution (9 days versus 11 days, P < 0.001) and a smaller volume of drainage (710 mL versus 1160 mL, P < 0.001) compared with the control group. Conclusion. The use of mastectomy with quilting of flaps and obliteration of the axillary space is an efficient method to significantly reduce the postoperative seroma in addition to significantly reducing the duration and volume of wound drainage. Therefore we recommend quilting of flaps as a routine step at the end of any mastectomy.