Analysis of selected factors influencing seroma formation in breast cancer patients undergoing mastectomy

Seroma incidence and risk factors in women undergoing mastectomies as surgical breast cancer treatment

INTRODUCTION

Seroma is the most common early complication following surgical breast cancer treatment. Its development is associated with pain, scar complications, adjuvant therapy delays, the need for outpatient visits, and increased care costs.

OBJECTIVE

Assess seroma incidence and risk factors in women undergoing mastectomies.

METHOD

This study comprises a prospective cohort encompassing women aged 18 or over undergoing mastectomies as a breast cancer treatment. Patients underwent physiotherapy on the 1st, 7th, and 30th postoperative days for kinetic-functional, skin, and wound healing assessments and were attended to by nurses for surgical wound care, draining liquid on the 7th, 14th, and 21st postoperative days. Seroma was defined as the presence of local fluctuations requiring puncture, regardless of the punctured volume.

RESULTS

A total of 249 women were evaluated, with a mean age of 57.5 (SD = 11.8). A total of 77.1% were classified as overweight or obese, 60.2% were hypertensive, 21.3% were diabetic, 66.7% underwent neoadjuvant chemotherapy and 62.7% underwent axillary lymphadenectomies. Seroma incidence was 71.1%, requiring, on average, two aspiration punctures until condition resolution. Overweight or obese women and those who underwent axillary lymphadenectomies exhibited 1.92- and 2.06-fold higher risk for seroma development (OR = 1.92; 95% CI 1.02-3.61; p = 0.042; and OR = 2.06; 95% CI 1.17-3.63; p = 0.012), respectively.

CONCLUSION

Seroma incidence was very high. Being overweight or obese and undergoing axillary lymphadenectomy comprise independent seroma development risk factors. This study is part of a randomized clinical trial evaluating the effectiveness of applying compressive taping to prevent post-mastectomy seroma, which was approved by the Brazilian National Cancer Institute, Research Ethics Committee (2,774,824), and it is registered in the ClinicalTrials.gov (NCT04471142, on July 15, 2020).

Subcutaneous fat thickness predicts postoperative seroma following laparoscopic total extra-peritoneal hernioplasty

PURPOSE

Seroma formation is the most common cause of morbidity associated with laparoscopic inguinal hernia repair. This study aimed to examine the relationship between the thickness of subcutaneous fat (TSF) and the risk of postoperative seroma.

METHODS

We reviewed data from a prospective cohort of 229 male patients who underwent laparoscopic total extra-peritoneal (TEP) hernioplasty for indirect inguinal hernia between August 2018 and July 2021. The TSF was assessed using preoperative ultrasound images. The risk factors for postoperative seroma were determined using univariate and multivariate logistic regression models.

RESULTS

Postoperative seromas occurred in 26 patients (11.4%). The factors associated with postoperative seroma included longer hernia duration, larger hernia defects, extension into the scrotum, and greater TSF (P < 0.05). In multivariate analysis, a greater TSF was independently associated with a greater risk of postoperative seroma (per 1 mm: odd ratio [OR] 1.105, 95% confidence interval [CI] 1.048-1.165, P < 0.001; TSF ≥ 26.0 mm: OR 7.033, 95% CI 2.485-19.901, P < 0.001). Similar results were obtained in the subgroup analysis. The area under the curve of TSF for predicting seroma formation was 0.703 (95% CI 0.601-0.806).

CONCLUSION

Ultrasound-derived TSF may be a promising prognostic factor for postoperative seroma in patients undergoing laparoscopic TEP repair. Further validation is required and then this parameter can be used to improve decision-making process.

Similarity of Seroma Rate at the Medial Thigh following Free Flap Harvesting or Medial Thigh Lift: A Systematic Review and Meta-analysis

Despite the growing use of autologous breast reconstruction with medial thigh-based free flaps, such as transverse upper gracilis (TMG) or profunda artery perforator (PAP) flaps, these procedures are infrequently performed on patients with obesity. This systematic review and meta-analysis aimed to compare the frequency of seroma occurrence, a common complication after medial thigh flap surgery. Comparison was performed between TMG and PAP flaps, as well as medial thigh lifts (MTL), a procedure with a similar operative technique but which is typically offered to patients with a higher body mass index (BMI). Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we analyzed EMBASE, PUBMED, and MEDLINE data (English/German). The primary outcomes assessed were occurrence of seroma, as well as hematoma and wound dehiscence. Subgroup analyses explored age, BMI, and various surgical factors. This meta-analysis incorporated 28 studies, totaling 1096 patients. MTL patients had significantly higher BMIs, whereas seroma rates were similar among TMG, PAP, and MTL patients. The incidence of hematoma and wound dehiscence was also similar across the groups. In the metaregression analysis, factors such as age and BMI showed no significant correlation with seroma occurrence in all groups. This systematic review and meta-analysis identified comparable rates of seroma formation after TMG flap, PAP flap, and MTL procedures. Considering that this phenomenon occurred despite the elevated BMI of the MTL group, we propose that patients with higher BMI need not be excluded as candidates for autologous medial thigh-based breast reconstruction. Hence, these procedures should not be limited to small- to medium-sized breasts. Large-scale prospective studies are imperative to validate these conclusions and reveal the underlying factors contributing to seroma formation.

Prospective Study to Evaluate Efficacy of Single Versus Double Drains in Breast Cancer Patients Undergoing Surgery

Seroma formation is a common sequel following modified radical mastectomy (MRM), which hinders healing, may prolong hospital stay, and cause a delay in adjuvant treatment. Closed suction drains have been used to prevent formation of seroma; however, the use of a single drain in the axilla along with draining the mastectomy flaps and axilla separately remains a topic of debate. This prospective randomized dual-arm study was conducted in the Department of Endocrine Surgery. All female patients with carcinoma breast diagnosed on core tissue biopsy, undergoing modified radical mastectomy, upfront or post neoadjuvant systemic therapy were included. Patients were randomized into two groups. In the first group, a single drain was placed in the axilla whereas in the second group, a drain each was placed below the mastectomy flaps and the axilla. Patients' particulars and the weight of the mass excised along with the operative details were documented. The volume of the drain was recorded daily. The flap drain was removed on postoperative day 5 and the axillary drain was removed when the drain volume was less than 30 mL/24 h for 2 consecutive days. The period of drain placement, volume of drainage, volume of seroma (if formed), and other complications (if any) were recorded. Patients in the single drain group had a significantly earlier drain removal time as compared to those with double drains (p = 0.01). The number of patients in whom seroma formation had occurred was more in the double drain group, but the difference was not significant. The average volume of aspirated seroma fluid was insignificantly more in the single drain group. The only other complication noticed was flap necrosis-in 5% patients of the double drain group. Total volume of drainage (p < 0.0001) and type of drain (p = 0.0208) were associated with higher rates of seroma formation, whereas BMI (p = 0.0516), weight of excised breast mass (p = 0.407), and age (p = 0.6379) were not associated with the rate of seroma formation. Outcomes in terms of drain volume or seroma formation were statistically indifferent between the two groups. Still, use of only a single axillary drain should be promoted, keeping in mind the earlier drain removal period, better patient compliance, and reduced hospital stay.

Harmonic Scalpel Versus Monopolar Electrotome in Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty: A Retrospective Study in 122 Patients

BACKGROUND

The transaxillary approach of breast augmentation is the most popular method in Asia, but longer period of recovery was observed in spite of the assistance of endoscope.

OBJECTIVES

Introducing the ultrasonic dissection devices might be a solution to minimizing tisue damage thus relieving pain and shortening the period of recovery.

METHOD

Between March 2020 and September 2022, we retrospectively reviewed the cases of 122 patients underwent endoscopic augmentation mammoplasty via the transaxillary approach using either the monopolar electrotome (ME) alone or assisted with Harmonic Scalpel (HS) in defining the retropectoral pocket and severing the pectoralis major muscle.

RESULT

The total drainage volume was significantly lower in the HS group than ME group (74.33 ± 48.81 vs. 180.30 ± 125.10 mL; p < 0.0001). VAS score of the first 24 hour after surgery of the ME group was significantly higher than that of the HS group (6.10 ± 1.27 vs. 2.88 ± 1.29, p < 0.0001). Operation time in HS group was reduced compared to ME group (113.1 ± 14.46 mins vs. 131.3 ± 35.51 mins, p < 0.001). The duration of drainage placement (1.08 ± 0.27 vs. 2.72 ± 1.18 days) and hospital stay after surgery (3.08 ± 0.42 vs. 5.64 ± 2.78 days; p < 0.0001) were largely reduced in HS group.

CONCLUSION

The assistance of Harmonic Scalpel significantly reduced total postoperative drainage, relieved pain and shortened operation time, length of drainage placement and hospital stay compared to using monopolar electrotome alone in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty.

LEVEL OF EVIDENCE IV

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 .

Analysis of risk factors affecting the postoperative drainage after a laparoscopic partial nephrectomy: a retrospective study

Purpose

Laparoscopic partial nephrectomy (LPN) remains the most commonly used measure for treating localized renal cell cancer (RCC) with an increasing incidence of RCC ever since the 1990s. This study aimed to identify risk factors that affect the postoperative time of drainage and total drainage volume after LPN.

Method

The clinical data of 612 RCC patients who received LPN from January 2012 to December 2022 in our hospital, including the postoperative drainage time and total drainage volume, were retrospectively analyzed. Univariable and multivariable linear regression and correlation analyses were used to identify the correlations between 21 factors, which include gender, age, history of alcohol consumption, family history of RCC, body weight, body mass index (BMI), and operation time, postoperative drainage time, and total drainage volume.

Results

The mean time of drainage was 3.52 ± 0.71 days (range: 2 to 8 days), with an average total drainage volume of 259.83 ± 72.64 mL (range: 50 to 620 mL). Both univariable and multivariable linear regression analyses revealed several statistically significant associations. Gender (p = 0.04), age (p = 0.008), smoking history (p < 0.001), diabetes (p = 0.032), operation time (p = 0.014), and BMI (p = 0.023) were identified as significant factors associated with the time of drainage. On the other hand, age (p = 0.008), smoking history (p < 0.001), diabetes (p = 0.006), and BMI (p = 0.016) emerged as independent risk factors influencing the total drainage volume.

Conclusion

The duration of postoperative drainage was found to be associated with gender, age, smoking history, diabetes, operation time, and BMI. In contrast, the total drainage volume was primarily influenced by age, smoking history, diabetes, and high BMI following LPN. For patients with these conditions, meticulous attention to hemostasis and bleeding control is crucial during the perioperative period.

The Effects of Tranexamic Acid in Breast Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Tranexamic acid (TXA) is used in trauma and surgical settings. Its role in reducing postoperative blood loss in breast surgery remains unclear. The primary objective of this study was to determine the effect of TXA on postoperative blood loss in breast surgery.

METHODS

Searches of the PubMed, Ovid MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases were performed from inception to April 3, 2020. Inclusion criteria were any retrospective reviews, prospective cohort studies, and randomized controlled trials that administered TXA (topical or intravenously) in the context of breast surgery. Quality of studies were evaluated using the risk of bias in randomized trials tool and the risk of bias in nonrandomized studies of interventions tool. Data were pooled, and a meta-analysis was performed.

RESULTS

In total, seven studies were included, representing 1226 patients (TXA, 632 patients; control, 622 patients). TXA was administered as follows: topically (20 mL of 25 mg/mL TXA intraoperatively; n =258 patients), intravenously (1 to 3 g perioperatively; n = 743 patients), or both (1 to 3 g daily up to 5 days postoperatively; n = 253 patients). TXA administration reduced hematoma formation in breast surgery (risk ratio, 0.48; 95% CI, 0.32 to 0.73), with no effect on drain output (mean difference, -84.12 mL; 95% CI, -206.53 to 38.29 mL), seroma formation (risk ratio, 0.92; 95% CI, 0.60 to 1.40), or infection rates (risk ratio, 1.01; 95% CI, 0.46 to 2.21). No adverse effects were reported.

CONCLUSION

The use of TXA in breast surgery is a safe and effective modality with low-level evidence that it reduces hematoma rates without affecting seroma rates, postoperative drain output, or infection rates.

Effect of Clavipectoral Fascia Suturing on Postmastectomy Seroma Formation

<b><br>Introduction:</b> Post-mastectomy seroma formation is a challenging sequela which has a negative impact on patient recovery and quality of life.</br> <b><br>Aim:</b> We aim to publicize our technique of clavipectoral fascia re-closure and to assess its efficacy in reducing the incidence of seroma formation.</br> <b><br>Methods:</b> This is a prospective randomized controlled trial, conducted in South Cancer institute, Assiut University, Egypt. It included 84 breast cancer patients who were randomly divided into two groups: a control group (n = 44) and a fascia suture group (n = 40). The patients were followed up until drain removal and then to 3 months after surgery.</br> <b><br>Results:</b> The fascia suture group showed significantly shorter duration of drain removal with a significant reduction in the total amount of drained fluid and the amount of drained fluid 1 week postoperatively. One patient in the fascia suture group developed Grade 2-3 seroma vs. 7 in the control group (P < 0.05).</br> <b><br>Conclusions:</b> Clavipectoral fascia suture technique is a simple and effective method for reducing seroma formation after mastectomy in breast cancer patients and is advisable in patients at a high risk for seroma formation.</br>.

Clinical and cost outcomes of a polyethylene glycol (PEG)-coated patch versus drainage after axillary lymph node dissection in breast cancer: results from a multicentre randomized clinical trial

BACKGROUND

The aim of this study was to compare the clinical outcomes between breast cancer patients who underwent axillary lymph node dissection with postoperative management using a polyethylene glycol-coated patch versus axillary drainage. The direct costs associated with both postoperative management strategies were also evaluated.

METHODS

This was a multicentre RCT in women with breast cancer who underwent axillary lymph node dissection (ClinicalTrials.gov identifier: NCT04487561). Patients were randomly assigned (1 : 1) to receive either drainage or a polyethylene glycol-coated patch as postoperative management. The primary endpoints were the need for an emergency department visit for any event related to the surgery and the rate of seroma development.

RESULTS

A total of 227 patients were included , 115 in the patch group (50.7 per cent) and 112 (29.4 per cent ) in the drainage group. The incidence of emergency department visits was significantly greater for patients with drainage versus a polyethylene glycol-coated patch (incidence rate difference 26.1 per cent, 95 per cent c.i. 14.5 to 37.7 per cent; P < 0.001). Conversely, the seroma rate was significantly higher in the polyethylene glycol-coated patch group (incidence rate difference 22.8 per cent, 95 per cent c.i. 6.7 to 38.9 per cent; P < 0.0055). Compared with drainage, using a polyethylene glycol-coated patch resulted in cost savings of €100.41 per patient. An incremental cost-effectiveness ratio analysis found that drainage was associated with an incremental cost-effectiveness ratio of €7594.4 for no need for hospital admission and €491.7 for no need for an emergency department visit.

CONCLUSION

Compared with patients who received drainage after axillary lymph node dissection, the use of a polyethylene glycol-coated patch resulted in a higher rate of seroma, but a lower number of postoperative outpatient or emergency department visits and thus a reduction in overall costs.

Comparison of the effect of the harmonic scalpel and monopolar cautery in transaxillary endoscopic dual-plane breast augmentation

BACKGROUND

Transaxillary endoscopic dual-plane breast augmentation is becoming increasingly mature. The intraoperative separation of the implant into the space is often performed using monopolar cautery. The use of the harmonic scalpel has proved more beneficial in several surgeries. However, no study has ever addressed the effects of harmonic scalpel usage compared to monopolar cautery in transaxillary endoscopic dual-plane breast augmentation.

METHODS

In this randomized controlled study, we enrolled patients (n = 78) who underwent breast augmentation in our hospital from January to October 2022. Participants were randomized with an intentional unequal allocation ratio (2:1 in the harmonic scalpel group: monopolar cautery group). Outcome measures included: total postoperative drainage volume, postoperative drainage volume for the first 24 h, number of postoperative drainage days, daily pain scored through the visual analog scale, operative time, and reoperation rate.

RESULTS

A total of 51 patients in the harmonic scalpel group and 24 patients in the monopolar cautery group were analyzed. Overall, in comparison to the monopolar cautery group, the harmonic scalpel group showed improved total postoperative drainage volume, postoperative drainage volume for the first 24 h, number of postoperative drainage days, and postoperative pain scores. No differences were found regarding operative time and reoperation rate.

CONCLUSION

Compared with monopolar cautery, harmonic scalpel usage in transaxillary endoscopic breast augmentation has evident advantages regarding postoperative drainage and patients' pain scores, making it an instrument worth of recommendation.

Effect of Mastectomy Flap Fixation on Post-operative Fluid Drainage and Seroma Formation in Breast Cancer Patients A Double-blinded Randomised Control Trial

&lt;b&gt; Introduction:&lt;/b&gt; Post-operative seroma formation is one of the most common complications following modified radical mastectomy (MRM). Quilting is a technique where the mastectomy flaps are sutured to the underlying chest wall muscles with sutures, obliterating the dead space. The authors hypothesised that post-mastectomy dead space obliteration by intermittent mastectomy flap fixation leads to decreased drain output and seroma formation. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Material and methods: &lt;/b&gt; A double-blinded randomised control trial with two arms was conducted from November 2019 to March 2021 in our institute located in India. Patients with non metastatic breast carcinoma planned for MRM were randomly categorised into two groups of 35 patients each. In the test group, each flap was fixed to the underlying muscle using four intermittent 3-0 polyglactin sutures, which was followed by skin closure, and only skin closure was done in the control group. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; The test and control groups did not differ significantly with respect to demographic and tumour characteristics. The average drain output of the test group (155.43 ml) was significantly less than of the control group (206.29 ml). The overall incidence of seroma formation is lower in the test group (5.7%) when compared to the control group (28.6%). The duration of hospital stay in the test group (4.63 days) was significantly shorter when compared to the control group (6.66 days). There was no significant increase in the overall operating time or complications like surgical site infection or skin dimpling due to flap fixation. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusions:&lt;/b&gt; Fixation of MRM flaps is associated with better post-operative outcomes related to drain output and seroma formation without a significant increase in other morbidities or usage of resources.

Analysis of factors influencing postoperative drainage time in breast cancer

BACKGROUND

To investigate the related factors affecting the postoperative indwelling time of drainage tubes (hereinafter referred to as drainage time) in breast cancer (BC) and evaluate the effect of Pseudomonas aeruginosa-mannose-sensitive hemagglutinin (PA-MSHA) preparation on reducing postoperative drainage time.

METHODS

The clinical data of 165 BC patients in our hospital, including the postoperative drainage time and occurrence of seroma and related complications (such as fever, incision infection, and flap necrosis) after extubation, were retrospectively analyzed. Univariate, multivariate, and stratified analyses were used to determine the correlations between 15 factors including age, body weight, body mass index (BMI), and PA-MSHA preparation, and the postoperative total drainage volume and drainage time.

RESULTS

Age, BMI, and PA-MSHA preparation were independent factors affecting the postoperative drainage volume and drainage time of BC patients. Age and BMI were positively correlated with postoperative drainage volume and drainage time (P≤0.004, P≤0.037). PA-MSHA preparation significantly reduced the postoperative total drainage volume and drainage time (P<0.001), decreased the incidence of seroma after extubation (P=0.024), and did not increase complications (P>0.05).

CONCLUSIONS

Obese and elderly patients were at a significantly high risk of a high drainage volume and long drainage time. Local treatment with PA-MSHA preparation had the advantages of reducing postoperative drainage volume, reducing drainage time, preventing seroma, and not increasing complications, and was a safe and effective treatment. For BC patients aged over 60 years and with a BMI ≥25, the intraoperative local spraying of wounds with PA-MSHA preparation to reduce postoperative drainage times is a valuable option.

Experience with modified radical mastectomy in a low-income country: a multi-center prospective observational study

BACKGROUND

Modified radical mastectomy is the procedure of choice in centers with little to no radiotherapy services. Studying the in-hospital outcome and complications associated with the procedure is important in low-income countries.

METHODS

This is a multi-center prospective observational study involving all patients operated with modified radical mastectomy with curative intent.

RESULTS

A total of 87 patients were studied with 10.3% of which were male and 54% were between the age of 30-49 years. Clinical stage IIB and IIIA were reported in 33 (37.9%) and 25 (28.7%) respectively and 62.1% had clinically positive lymph nodes at presentation. All of the studied patients underwent curative surgery, with an average lymph node dissection of 10.2 ± 0.83. Seroma rate was 17.2% and was significantly associated with diabetes (AOR: 6.2 (CI 1.5-8.7)) and neoadjuvant chemotherapy (AOR: 8.9 (CI 1.2-14.2)). Surgical site infection occurred in 14.9% and was significantly associated with Retroviral infections (AOR: 4.2 (CI 2.1-5.8)) and neoadjuvant chemotherapy (AOR: 1.8 (CI 1.3-3.9)). No in-hospital mortality occurred during the course of the study.

CONCLUSION

Seroma rate was lower than published studies while surgical site infections rate was higher. Neoadjuvant chemotherapy was associated with increase in seroma and surgical site infection rates. Additionally, diabetes increased the rate of seroma. Surgical site infections were higher in patients with retroviral infections.

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.

Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer

Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.

Conventional suture with prolonged timing of drainage is as good as quilting suture in preventing seroma formation at pectoral area after mastectomy

Background

The aim of this study was to compare conventional suture with prolonged timing of drainage with quilting suture on the formation of seroma at pectoral area after mastectomy (ME) with sentinel lymph node biopsy (SLN) or axillary lymph node dissection (ALND) for breast cancer.

Methods

Three hundred and eighty-eight consecutive breast cancer patients were retrospectively analyzed and categorized into three groups. Patients in group 1 were with quilting suture, group 2 with conventional suture and 13–15 days drainage in situ, and group 3 with conventional suture and 20–22 days drainage. The primary outcome was the incidence of grades 2 and 3 seroma at anterior pectoral area within 1 month postoperatively. Cox regression was used for analysis.

Results

The incidence of grades 2 and 3 seroma was comparable among groups (9.5% vs. 7.9% vs. 5.3%, p = 0.437), as well as late grades 2 and 3 seroma among groups (4.3% vs. 2.9% vs. 1.5%, p = 0.412). Old age, high body mass index, and hypertension were independent risk factors for grades 2 and 3 seroma.

Conclusions

Prolonged timing of drainage to 13–15 days in conventional suture was long enough to decrease the incidence of grades 2 and 3 seroma as lower as that in quilting suture group at pectoral area within 1 month after mastectomy.

Development and validation of a nomogram to predict drainage duration in patients with breast cancer treated with modified radical mastectomy

Appropriate drainage duration is vital for the postoperative rehabilitation of patients with breast cancer (BC) undergoing modified radical mastectomy (MRM). To provide better and individualized postoperative management for these patients, this study explored independent predictors of postoperative drainage duration in patients with BC. This was a single-center retrospective cohort study. Patients diagnosed with BC and treated with MRM from May 2016 to April 2020 were randomly divided into training (n = 729) and validation (n = 243) cohorts. Univariate and multivariate Cox analyses revealed that the body mass index, serum albumin level, hypertension, number of total dissected axillary lymph nodes, and ratio of positive axillary lymph nodes were independent predictors of postoperative drainage duration in the training cohort. Based on independent predictors, a nomogram was constructed to predict the median postoperative drainage duration and the probability of retaining the suction drain during this period. This nomogram had good concordance and discrimination both in the training and validation cohorts and could effectively predict the probability of retaining the suction drain during drainage, thus assisting clinicians in predicting postoperative drainage duration and providing individualized postoperative management for patients with BC.

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.

Quilting suture versus conventional closure in prevention of seroma after total mastectomy and axillary dissection in breast cancer patients

BACKGROUND

Total mastectomy and axillary dissection is a common procedure for breast cancer patients in our institution. Seroma is common. This study aimed to compare the quilting suture and conventional closure in prevention of seroma after total mastectomy and axillary dissection.

METHODS

This randomized comparative study was carried out from January 2018 to June 2019 in Yangon General Hospital. One hundred and forty patients (70 conventional and 70 quilting) were included. For quilting group, customized strategically placed interrupted alternate sutures were placed 2-3 cm apart with 3/0 vicryl sutures between skin flap and pectoral muscle.

RESULTS

Age, body mass index and tumour diameter were comparable between the groups. The mean duration of operation was 111.44 ± 7.045 min in conventional and 124.5 ± 6.39 min in quilting (P = 0.0001). The mean drain output for conventional group was not significantly different from quilting group. In quilting, some area developed dimpling which resolved within a week. A total of 21 (30%) patients in the conventional group and 10 patients (14.3%) in the quilting group developed seroma (P = 0.041). The mean frequency and amount of seroma aspiration were significantly lower in the quilting group. Shoulder movement limitation and analgesia use showed no significant difference.

CONCLUSION

Although total amount of drain output, duration of drain, hospital stay and post-operative complications were not different, the incidence of seroma was significantly lower in quilting group. Seroma is treated with more ease in the quilting group as the frequency and amount of aspiration were lower and less frequent follow-up visits were required. Quilting can reduce the seroma incidence in total mastectomy and axillary dissection for breast cancer patients.

Quilting suture is better than conventional suture with drain in preventing seroma formation at pectoral area after mastectomy

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.

Drainage Collection After Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty Using Cold or Electrosurgical Separation of Interpectoral Space

BACKGROUND

Endoscopic transaxillary augmentation mammaplasty breast augmentation offers several advantages over other augmentation methods. Nonetheless, this procedure is fraught with some problems, including greater surgical trauma due to the longer separation area. We hypothesized that cold separation of the interpectoral space could reduce surgical injury in comparison to the electrosurgical method. This study aimed to compare the outcomes of endoscopic-assisted transaxillary augmentation mammaplasty using cold separation versus electrosurgical separation of the interpectoral space.

METHODS

In this prospective clinical trial, cold and electrosurgical separation of the interpectoral space were achieved using a separation shovel and monopolar electrotome, respectively. A total of 20 patients who visited our department in Beijing, China, for primary breast augmentation surgeries from October 1, 2017, and May 31, 2018, were included. The primary outcome was total postoperative drainage volume. The secondary outcomes were operative time, daily drainage volume, daily pain as assessed using the visual analogue scale (VAS), and reoperation rate. Quantitative data were compared using independent-samples t test. Chi-square test was used to compare 2 classified indexes.

RESULTS

The total drainage volume was significantly lower in the cold separation group than in the electrosurgical separation group (170.45 ± 75.40 mL vs 281.05 ± 148.43 mL; P = .005). The VAS score on the first postoperative day was significantly lower in the cold separation group than in the electrosurgical separation group (6.45 ± 1.93 vs 7.55 ± 1.43; P = .048). Two (20%) reoperations owing to postoperative pain or implant stiffness were performed in the electrosurgical separation group.

CONCLUSIONS

Cold separation is more conducive to reducing drainage, relieving postoperative pain, and causing less damage than the electrosurgical method in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty.

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.

Impact of the surgical modality for axillary lymph node dissection on postoperative drainage and seroma formation after total mastectomy

Background

The most common complications after total mastectomy with axillary lymph node treatment are prolonged drainage and seroma formation. The aim of this study was to find factors correlated with prolonged fluid discharge (prolonged drainage or seroma formation after 20th operative day or later), including surgical techniques or devices and clinical factors.

Patients and methods

A total of 202 conclusive primary breast cancer patients underwent total mastectomy with axillary lymph node treatment between January 7, 2014 and June 20, 2018 at our hospital. The factors that correlated with the total fluid discharge volume and prolonged fluid discharge were examined statistically. The surgical modalities for total mastectomy with axillary treatment were classified into the following three groups:, Group A; skin flap formation by EC and axillary lymph node dissection by EC with ligation of the arteries and veins, Group B; skin flap formation by EC and axillary lymph node dissection by ultrasonic dissector (UD) without ligation of the vessels. Group D; skin flap formation by electrocautery (EC) and axillary lymph node dissection by picking up using forceps and ligation (PL).

Results

The total fluid discharge volume and prolonged fluid discharge after total mastectomy with sentinel node retrieval (33 patients) were significantly lower than those after total mastectomy with axillary lymph node dissection (169 patients). In patients treated without drainage, a high rate of seroma formation and prolonged fluid discharge were observed, and 1 patient developed seroma infection.In the total mastectomy with axillary lymph node dissection group, logistic regression analysis revealed that body mass index, 1-week drainage volume, and surgical modality were independently correlated with prolonged fluid discharge.

Conclusions

The surgical procedure for axillary lymph node dissection should be considered to avoid prolonged fluid discharge, and the lymph vessels should be ligated in axillary lymph node dissection. An ultrasonic dissector was not effective in reducing the total fluid discharge volume. An optimal axillary lymph node dissection technique should be developed. For the patients without drainage, careful postoperative treatment should be given to avoid infectious seroma formation, even for patients who underwent total mastectomy with sentinel lymph node retrieval.

Effect of topical microporous polysaccharide hemospheres on the duration and amount of fluid drainage following mastectomy: a prospective randomized clinical trial

Background

Seroma formation is the most common complication after mastectomy and places patients at risk of associated morbidities. Microporous polysaccharide hemospheres (MPH) consists of hydrophilic, plant based, polysaccharide particles and is currently used as an absorbable hemostatic agent. An animal model evaluating MPH and seroma formation after mastectomy with axillary lymph node dissection showed a significant decrease in seroma volume. Study aim was to evaluate topical MPH on the risk of post-mastectomy seroma formation as measured by total drain output and total drain days.

Methods

Prospective randomized single-blinded clinical trial of patients undergoing mastectomy for the treatment of breast cancer. MPH was applied to the surgical site in the study group and no application in the control group.

Results

Fifty patients were enrolled; eight were excluded due to missing data. Forty-two patients were evaluated, control (n = 21) vs. MPH (n = 21). No difference was identified between the two groups regarding demographics, tumor stage, total drain days, total drain output, number of clinic visits, or complication rates. On a subset analysis, body mass index (BMI) greater than 30 was identified as an independent risk factor for high drain output. Post hoc analyses of MPH controlling for BMI also revealed no statistical difference.

Conclusions

Unlike the data presented in an animal model, no difference was demonstrated in the duration and quantity of serosanguinous drainage related to the use of MPH in patients undergoing mastectomy for the treatment of breast cancer. BMI greater than 30 was identified as an independent risk factor for high drain output and this risk was not affected by MPH use. NCT03647930, retrospectively registered 08/2018.

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.

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.

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.

A Head-to-head Comparison between SurgiMend and Epiflex in 127 Breast Reconstructions

Background:

The use of acellular dermal matrices (ADM) has become a widely used option in breast reconstruction. A great deal of literature is available, totaling over 2400 ADM reconstructions. Nonetheless, head-to-head comparisons between SurgiMend and Epiflex are not yet reported. In fact, this is the first clinical data report on the use of Epiflex. This work will, therefore, compare postoperative complication rates and costs for these ADMs.

Methods:

This analysis is a retrospective review of a single surgeon’s 6-year experience with both SurgiMend—an acellular bovine dermal collagen matrix for soft-tissue reconstruction and Epiflex—a decellularized human skin tissue from 2008 to 2013.

Results:

One hundred patients had a total of 127 implant-based reconstructions using SurgiMend (64 cases; 50.4%) or Epiflex (63 cases; 49.6%). Gross complication rates were 11.1% for SurgiMend and 40.6% for Epiflex including hematoma, postoperative skin irritation, infection, necrosis, and revision surgery. The most common complication was postoperative red breast syndrome. Severe complications requiring revision surgery were significantly increased in patients treated with Epiflex (12.5%) compared with SurgiMend (4.8%).

Conclusions:

This retrospective analysis favors the use of SurgiMend over Epiflex because of significantly lower gross complication rates. Severe complication rates are comparable with those reported in literature for both products. Although results promote the use of SurgiMend, the single surgeon retrospective nature of this work limits its clinical impact.

Daily serum collection after acellular dermal matrix-assisted breast reconstruction

Background

The acellular dermal matrix (ADM)-assisted breast reconstruction technique is widely known, but discouraging results due to early postoperative complications have been reported. As the literature identifies seroma as the most common issue after breast surgery without identifying its pathogenesis, we aimed to report the trend of postoperative daily serum collection after ADM-assisted breast reconstruction and compare it with data in the literature in order to discover more about this little-known topic.

Methods

A retrospective study on 28 consecutive patients who received ADM-assisted breast reconstruction between February 2013 and February 2014 was performed. In order to reduce the number of variables that could affect serum production, only one brand of ADM was used and all tissues were handled gently and precisely. The daily drainage volume was recorded per patient during the first four days of hospitalization. Likewise, postoperative complications were noted during routine follow-up.

Results

In total, five (17.9%) bilateral and 23 (82.1%) unilateral ADM-assisted breast reconstructions (33 implants) were performed. The mean age, body mass index, and length of hospital stay were 53.6 years, 21.3 kg/m², and 4.5 days, respectively. One major complication led to implant loss (3.0%), and nine minor complications were successfully treated with ambulatory surgery (27.3%). Serum collection linearly decreased after 24 hours postoperatively.

Conclusions

Daily drainage decreased following the theoretical decline of acute inflammation. In concordance with the literature, daily serum production may not be related to the use of ADM.

Flap adhesion and effect on postoperative complication rates using Tissuglu® in mastectomy patients

Introduction

Post-mastectomy seroma and related complications are common problems in modern oncological surgery. Occurrence rates of up to 59 % have been reported in literature. High-risk patients, that is, those who have undergone previous surgeries, present with a high body mass index, have had radiation or chemotherapy, present a particular challenge. Noninvasive measures such as fibrin-based sealants have thus far not been able to effectively reduce complications associated with fluid accumulation. A recent study using a lysine-derived urethane adhesive named TissuGlu^® however, showed promising results in patients after abdominoplasty.

Methods

32 consecutively recruited patients received a mastectomy using a gold standard mastectomy technique as well as TissuGlu^® flap fixation. A control group of 173 patients, having received a gold standard mastectomy-only, was analyzed retrospectively, totaling 205 patients. Primary endpoints were post-discharge seroma formation and revision surgery/re-hospitalization. Secondary endpoints were initial seroma volume, postoperative pain, hematoma formation and day of drain removal.

Results

No significant difference in seroma formation was demonstrated. The revision surgery/re-hospitalization rate was reduced from 6.9 to 0 %, though this did not reach significance. Significant improvement could be shown in the TissuGlu^® group regarding time to drain removal (17 % decrease), and hematoma formation (14 % decrease). No difference was shown in postoperative pain.

Conclusion

Although patient numbers are still small, advantages in revision surgery/re-hospitalization rate, hematoma formation as well as time to drain removal was shown for the TissuGlu^® group.

Clinical question/level of evidence

Therapeutic, IV.

Breast cancer surgery without drains: no influence on seroma formation

It is not clear whether drains are necessary after breast cancer surgery. The purpose of this study was to compare seroma formation in patients that had postoperative drainage for 24 h with patients that had no drain after breast cancer surgery. In this retrospective cohort study 96 patients with a primary breast cancer were included. Between January 2009 and April 2011 44 patients had breast cancer surgery followed by postoperative drainage. Between May 2011 and February 2013 52 patients underwent breast cancer surgery without drainage. The operative procedures that were included were: axillary lymph node dissection, modified radical mastectomy or simple mastectomy±sentinel lymph node biopsy. There was no difference between both groups regarding frequency of seroma (84.6% versus 90.9%; p=0.290) and amount of seroma (540 ml versus 590 ml; p=0.446). Postoperative hospital stay was shorter in patients without drainage (2 versus 2.5 days; p=0.003). There was no difference between both groups in other secondary outcome measures. Modified radical mastectomy was an independent predictor of the amount of postoperative seroma (HR 0.039 [0.007-0.235]; p<0.001). These results suggest that there is no difference in seroma after breast cancer surgery between patients that had postoperative drainage and patients that had no postoperative drainage.