Quilting prevents seroma formation following breast cancer surgery: closing the dead space by quilting prevents seroma following axillary lymph node dissection and mastectomy

Cyanoacrylate glue in breast surgery: the GLUBREAST Trial

Introduction

In 2018, the National Cancer Institute of Naples has launched the GLUBREAST Trial to verify the efficacy of cyanoacrylate sealing glue to prevent or reduce seroma after axillary dissection in breast surgery. The glue is a synthetic sealant (N-Butyl-2-CyanoAcrylate+Metacryloxisulfolane) biocompatible, CE approved for internal human uses and surgical procedures. The assumed mechanism of action in breast surgery is that the glue would create a seal coating in the operative field to occlude lymphatic leaks and limit seroma formation.

Materials and methods

The trial included 180 patients scheduled for breast-conserving surgery or for radical modified mastectomy without reconstruction. Out of 180 patients, 91 were randomized to receive suction drain and sealant glue after axillary dissection (Experimental Arm), whereas 89 patients (Control Arm) received suction drain without glue.

Statistics

A multivariable mixed effect model on presence of liquid drained and volume drained was calculated. Stratified models by visits were performed.

Results

The trial ended in June 2022. Older age was associated with a higher volume of seroma drained per day (β 0.30; 95% CI: 0.00-0.60). A 5-U increase in body mass index was associated with higher daily drained seroma volume in patients who underwent breast-conserving surgery (β 5.0; 95% CI: 0.62-9.4), but not in patients who underwent mastectomy (β 2.5; 95% CI: -3.6-8.6). We did not find statistically significant differences in presence of liquid drained and volume drained among the study groups. An advantage for the Experimental Arm was observed from third and fourth to fifth outpatient visits without reaching a statistical significance (p=0.069 and p=0.072, respectively); so far, 5% of patients in the Experimental Group had clinical benefit from the glue.

Conclusions

The vast majority of data in the literature come from case series, and surgeons need a higher level of evidence to drive surgical decision-making and choose proper devices to increase patient quality of life. The GLUBREAST randomized trial tested the efficacy of cyanoacrylate sealing glue to prevent postoperative seroma in breast surgery. Although only a small number of patients benefited from sealant application, we regret to say this trial has some limitation, i.e., the prolonged presence of suction drain. Further research is warranted to better clarify the benefit of cyanoacrylate glue in breast surgery.

Effectiveness of TachoSil as Sealant in Lymphatic Leakage of Breast Cancer With Axillary Dissection

Objectives: This study is aimed at evaluating the effectiveness of TachoSil in controlling lymphatic leakage in breast cancer patients undergoing axillary dissection. By examining its ability to reduce postsurgical lymphatic drainage, the study will assess its impact on complications like seroma formation, recovery time, and overall patient outcomes, including quality of life and reduced healthcare costs. Methods: Breast cancer patients treated in the Department of Surgical Oncology at King Abdulaziz Medical City were enrolled to receive either TachoSil or undergo drain placement after axillary dissection. Repeated measures multivariate analysis of variance (MANOVA) was used to observe the difference in lymphatic drainage volume over time considering other covariates, such as age, sex, family history, neoadjuvant chemotherapy (NAC), and stage. Results: The TachoSil group showed significantly lower lymphatic drainage volumes at 24 h (106.5 ± 11.3) than the control group (141.7 ± 13.0) (p < 0.001). There were no significant differences in lymphatic drainage volume at 3 days (p = 0.176) and 7 days (p = 0.091). However, at 10 days, the TachoSil group exhibited significantly lower lymphatic drainage volume (19.9 ± 6.1) than the control group (44.5 ± 9.2) (p < 0.001). Repeated measures MANOVA showed a statistically significant difference in lymphatic drainage over time, with a moderate effect (p < 0.001). Conclusion: The findings suggest that TachoSil sealant effectively reduces early postoperative lymphatic drainage volume and maintains lower drainage rates up to 10 days following axillary dissection in breast cancer patients. The use of TachoSil sealant may have potential benefits in reducing the incidence of complications associated with lymphatic drainage and improving patient outcomes.

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.

A quilting sutures technique for flap closure in patients undergoing modified radical mastectomy for the prevention of seroma: A single-center, randomized controlled trial

Seroma formation is a common adverse event following modified radical mastectomy, and it leads to delayed wound healing and increased post-operative pain and increases overall morbidity of patients. The quilting sutures as a newer technique for the skin flap closure is done to reduce incidence of seroma formation. Although it has controversy in the literature for the satisfactory outcome, the study has aimed to compare the Quilting suture technique with the conventional closure method to evaluate the efficacy of the quilting technique. The primary objective of the study was to access and compare the frequency of seroma formation following the quilting suture technique with standard flap closure in MRM. The secondary objectives were to compare drain output, post-operative complications, and the requirement of additional procedures for management of related complications. The 72 female participants in this randomized control trial had modified radical mastectomy after being diagnosed with breast cancer. The quilting suture technique was applied in the 36 patients and conventional technique applied in 36 patients for skin flap closure. The frequency of seroma formation and other complications were reported. Between the two groups, there was no statistically significant difference in the frequency of seroma production (P = 0.233). Total drainage volume (P = 0.213), drainage duration (P = 0.652), and post-operative complications (P = 0.641) did not substantially differ between the two groups. The study concludes that the quilting sutures technique does not decrease the incidence of seroma formation, total drain output, and total duration of drainage. There is no significant difference in complications and requirement of additional procedures compared to the standard technique.

Seroma formation after mastectomy: A systematic review and network meta-analysis of different flap fixation techniques

Flap fixation is the most promising solution to prevent seroma formation after mastectomy. In this systematic review with network meta-analysis (NMA), three different techniques were compared. The NMA included 25 articles, comprising 3423 patients, and revealed that sutures are superior to tissue glue in preventing clinically significant seroma. In addition, running sutures seemed to be superior to interrupted sutures. An RCT comparing these suture techniques seems necessary, given the quality and nature of existing literature.

Drain-free mastectomy and flap fixation: The interim analysis of a randomized controlled noninferiority trial

INTRODUCTION

Flap fixation after mastectomy has proven to be one of the most promising solutions to reduce seroma formation. Drain placement remains standard practice in many clinics, even though this may be redundant after flap fixation.

METHODS

This is a prospective randomized controlled trial comparing mastectomy and wound closure using flap fixation with or without drain placement. The primary outcome measure was clinically significant seroma (CSS) incidence. The aim of this interim analysis was to assess the assumptions for the sample size calculation and to provide preliminary results.

RESULTS

Between July 2020 and January 2023, 112 patients were included. CSS incidence was 9.1% in the drain group and 21% in the no-drain group. In total, 10 patients were lost to follow-up. These numbers are similar to the ones used for the sample size calculation. In the drain group, three patients required interventions for wound complications compared to nine in the no-drain group (odds ratio: 3.612 [95% confidence interval: 0.898-14.537]).

CONCLUSION

The sample size calculation seems to be correct and no protocol amendments are necessary. Current preliminary results show no significant differences in CSS incidence. Complete results should be awaited to draw a well-powered conclusion regarding drain policy after mastectomy.

Risk factors for severe complications and salvage management in direct-to-implant immediate breast reconstruction: A retrospective study

Controversies regarding the risk factors affecting direct-to-implant (DTI) immediate breast reconstruction still exist. This study aimed to evaluate the risk factors for severe complications in DTI breast reconstruction and explore potential salvage management strategies. We conducted a retrospective review of 238 patients (240 breasts) who underwent DTI immediate breast reconstruction between 2011 and 2020. Multivariate logistic regression analyses were used to identify the risk factors predicting severe complications. Seventeen (7.08%) reconstructed breasts experienced severe complications, of which only 5 were successfully salvaged through surgical revision, while the others failed and resulted in implant removal. Multivariate analyses demonstrated that mesh use [odds ratio (OR) = 4.054, 95% confidence interval: 1.376-11.945, P = .011] and post-mastectomy radiotherapy (odds ratio = 4.383, 95% confidence interval 1.142-16.819, P = .031) were independent predictors of severe complications. Mesh use and post-mastectomy radiotherapy for breast reconstruction increase the risk of severe complications. Despite positive surgical treatment, the successful salvage rate was poor.

Prevention of Seroma Formation and Its Sequelae After Axillary Lymph Node Dissection: An Up-to-Date Systematic Review and Guideline for Surgeons

INTRODUCTION

Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND.

METHODS

A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method.

RESULTS

A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen.

CONCLUSIONS

To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.

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>.

Economic evaluation of flap fixation techniques after mastectomy: Results of a double-blind randomized controlled trial (SAM-trial)

BACKGROUND

An economic evaluation was performed alongside an RCT investigating flap fixation in reducing seroma formation after mastectomy. The evaluation focused on the first year following mastectomy and assessed cost-effectiveness from a health care and societal perspective.

METHODS

The economic evaluation was conducted between 2014 and 2018 in four Dutch breast clinics. Patients with an indication for mastectomy or modified radical mastectomy were randomly assigned to: conventional closure (CON), flap fixation with sutures (FFS) or flap fixation with tissue glue (FFG). Health care costs, patient and family costs and costs due to productivity losses were assessed. Outcomes were expressed in incremental cost-effectiveness ratios (ICERs): the incremental cost per quality-adjusted life year (QALY). Bootstrapping techniques, sensitivity and secondary analyses were employed to address uncertainty.

RESULTS

The FFS-group yielded most QALYs (0.810; 95%-CI 0.755-0.856), but also incurred the highest mean costs at twelve months (€10.416; 95%-CI 8.231-12.930). CON was the next best alternative with 0.794 QALYs (95%-CI 0.733-0.841) and mean annual costs of €10.051 (95%-CI 8.255-12.044). FFG incurred fewer QALYs and higher costs, when compared to the CON group. The ICER of FFS compared to CON was €22.813/QALY. Applying a willingness to pay threshold in the Netherlands of €20.000/QALY, the probability that FFS was cost-effective was 42%, compared to 37% and 21% for CON and FFG, respectively.

CONCLUSION

The cost-effectiveness of FFS following mastectomy, versus CON and FFG, is uncertain from a societal perspective. Yet, from a health care and hospital perspective FFS is likely to be the most cost-effective intervention.

The QUILT study: quilting sutures in patients undergoing breast cancer surgery: a stepped wedge cluster randomized trial study

BACKGROUND

Seroma is the most common complication following breast cancer surgery, with reported incidence up to 90%. Seroma causes patient discomfort, is associated with surgical site infections (SSI), often requires treatment and increases healthcare consumption. The quilting suture technique, in which the skin flaps are sutured to the pectoralis muscle, leads to a significant reduction of seroma with a decrease in the number of aspirations and surgical site infections. However, implementation is lagging due to unknown side effects, increase in operation time and cost effectiveness. Main objective of this study is to assess the impact of large scale implementation of the quilting suture technique in patients undergoing mastectomy and/or axillary lymph node dissection (ALND).

METHODS

The QUILT study is a stepped wedge design study performed among nine teaching hospitals in the Netherlands. The study consists of nine steps, with each step one hospital will implement the quilting suture technique. Allocation of the order of implementation will be randomization-based. Primary outcome is 'textbook outcome', i.e.no wound complications, no re-admission, re-operation or unscheduled visit to the outpatient clinic and no increased use of postoperative analgesics. A total of 113 patients is required based on a sample size calculation. Secondary outcomes are shoulder function, cosmetic outcome, satisfaction with thoracic wall and health care consumption. Follow-up lasts for 6 months.

DISCUSSION

This will be one of the first multicentre prospective studies in which quilting without postoperative wound drain is compared with conventional wound closure. We hypothesize that quilting is a simple technique to increase textbook outcome, enhance patient comfort and reduce health care consumption.

Risk factors for seroma formation after axillary lymph node dissection with special focus on the impact of early shoulder exercise

BACKGROUND

Shoulder and arm dysfunction such as reduced range of motion (ROM) and seroma formation, are common complications following axillary lymph node dissection (ALND). There are conflicting results on the effect of early postoperative exercise on the risk of seroma. This study aims to present incidence of symptomatic seroma formation in a large, population-based cohort, and assesses whether early shoulder mobilization, and other common patient and treatment-related factors are predictors of seroma.

METHODS

This observational cohort study at the Surgical clinic at Lund University Hospital in Sweden, included 217 consecutive patients who underwent ALND due to breast cancer, cutaneous malignant melanoma (CMM), or carcinoma of unknown primary. A shoulder exercise program was introduced on the first postoperative day and data were collected at routine follow-up 4-6 weeks postsurgery. Main outcome was the strength of the associations between postsurgery exercise and seroma incidence based on logistic regression analyses, supported by data on seroma volume and number of aspirations.

RESULTS

Two hundred patients completed the study. The overall seroma incidence was 67.5% and the odds of seroma were lower for patients practicing ROM exercise two times/day versus 0-1 time/day (OR 0.42, 95% CI 0.18-0.96, p = .038). ROM exercise greater than two times/day did not increase the volume, neither did the arm cycling exercise. ALND combined with mastectomy and CMM surgery were associated with larger seroma volumes (1116 ± 1068ml, p = .006) and (1318 ± 920 ml, p < .001), respectively, compared to the breast conserving surgery (537 ± 478ml) while neoadjuvant chemotherapy showed no influence. The effect of age, patients ≥60 years compared to younger, or BMI ≥ 30.0 were weaker (p = .08).

CONCLUSIONS

Extensive surgical treatments for breast cancer and malignant melanoma produces more seroma, and higher age and obesity may also influence the risk. ROM exercises twice daily predict a lower incidence of seroma following ALND, and more frequent shoulder exercise do not increase the volumes.

A Comparative Study Between Mastectomy Flap Quilting Sutures with Axillary Drain Versus Conventional Sutures with Axillary and Pectoral Drain in Reducing Post-Modified Radical Mastectomy Seroma Formation

The aim of this study was to compare quilting suture with axillary drain versus conventional sutures with axillary and pectoral drain on the formation of seroma after modified radical mastectomy with axillary lymph node dissection. The study was undertaken among 90 female patients with breast cancer who were candidates for modified radical mastectomy with axillary clearance. The intervention group (N = 43) with quilting and axillary drain placement and the control group (N = 33) without quilting with axillary and pectoral drain placement. All the patients were followed up for complications pertaining to this procedure. There were no significant differences between the two groups with regard to demographic characteristics, comorbidities, pre-operative chemotherapy, post-operative pathological findings, lymph node involvement or clinical staging. The incidence of seroma formation on follow-up was significantly lower in the intervention group than that in the control group (23% versus 58%; p < 0.05) whereas there was no significant difference with respect to flap necrosis, superficial skin necrosis and wound gaping between the two groups. Furthermore, it took a shorter duration for seroma to resolve in the intervention group (4 days versus 9 days; p < 0.001) with a smaller duration of hospital stay (4 days versus 9 days; p < 0.001). The use of quilting sutures for flap fixation in order to obliterate dead space post-modified radical mastectomy with placement of axillary drain significantly reduced seroma formation along with shorter duration of wound drainage and a smaller hospital stay with only slightly increased operative time. Therefore, we recommend quilting of flap as a routine step after mastectomy.

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.

Using Drain-Free Flap Fixation Techniques Versus Traditional Wound Closure With Drain Placement to Prevent Seroma Formation and Its Complications in Breast Cancer Patients Undergoing Mastectomy: A Systematic Review and Meta-analysis

During the past decade, there has been some controversy related to using flap fixation techniques instead of conventional wound closure methods and drain placement during mastectomy procedures. The purpose of our study was to address this controversy using a systematic review and meta-analysis of current published literature. Nineteen studies met our inclusion criteria. Our sample population consisted of 2,956 participants divided into two groups. The study group (SG) consisted of 1,418 individuals and the control group (CG) consisted of 1,538 participants. We found there was a significant reduction in the incidence of seroma formation (odds ratio [OR] = 0.35; 95% confidence interval, CI [0.3, 0.42]; p < .000) and surgical site infection (OR = 0.65; 95% CI [0.48, 0.88]; p = .006) in the SG compared with the CG. The length of hospital stay was also significantly reduced in the SG (0.59 days; 95% CI [0.73, 0.46]; χ 2 [6, N = 502] = 52.88; p < .000) compared with the CG. The results of our study show that using a flap fixation technique after mastectomy can decrease the patient's risk for seroma formation and surgical site infection while reducing their length of hospital stay. Further studies with longer follow-up periods are warranted to evaluate long-term complications associated with using a flap fixation technique compared with using conventional wound closure techniques and drain placement.

Technical aspects of flap fixation after mastectomy for breast cancer: Guidelines for improving seroma-related outcome

OBJECTIVES

Previous studies have identified the added value of flap fixation in reducing seroma formation and its sequelae after mastectomy. The seroma reduction after mastectomy (SAM)-trial proved that sutures were superior to tissue glue. In this article, we will elaborate on the results of the SAM-trial to provide a clear surgical guideline.

METHODS

All patients in the suture flap fixation cohort from the SAM-trial were analyzed if details regarding flap fixation were available. The most optimal number of sutures was determined using a receiving operator characteristics curve. The incidence of seroma formation between patients receiving the most optimal number of sutures and patients receiving fewer sutures was compared.

RESULTS

The most optimal number of sutures proved to be 15. Patients with ≥15 sutures had a lower incidence of seroma formation at every time frame during follow-up. There was a significant difference at 6 weeks (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.09-8.56), 3 months (OR: 4.62, 95% CI: 1.34-12.92), and 1 year postoperatively (OR: 20.48, 95% CI: 2.18-192.22). Ten days and 6 months postoperatively did not differ significantly.

CONCLUSIONS

Flap fixation in general, but also the surgical technique influences the incidence of seroma formation after mastectomy. Results suggest a minimum of 15 sutures, spaced approximately 3.7 cm apart.

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction

BACKGROUND

Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction.

METHODS

A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered.

RESULTS

Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps.

CONCLUSIONS

Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

The Quest for Outpatient Mastectomy in COVID-19 Era: Barriers and Facilitators

Background

The rate of inpatient mastectomies remains high despite multiple studies reporting favourably on outpatient mastectomies. Outpatient mastectomies do not compromise quality of patient care and are more efficient than inpatient care. The objective of this study was to evaluate the feasibility of outpatient mastectomy.

Materials and Methods

Implementation of an outpatient mastectomy program was evaluated in a retrospective study. All patients who underwent mastectomy between January 2019 and September 2021 were included.

Results

213 patients were enrolled in the study: 62.4% (n = 133) outpatient mastectomies versus 37.6% (n = 80) inpatient mastectomies. A steady rise in outpatient mastectomies was observed over time. The second quarter of 2020, coinciding with the first COVID-19 wave, showed a peak in outpatient mastectomies. The only significant barrier to outpatient mastectomy proved to be bilateral mastectomy. Unplanned return to care was observed in 27.8% of the outpatient versus 36.3% of the inpatient mastectomies (P=0.198); the reason for unplanned return of care was similar in both groups.

Conclusions

Outpatient mastectomy is shown to be feasible and safe with a steady increase during the study period. A barrier to outpatient mastectomy was bilateral mastectomy. Incidence of unplanned return to care or complications did not differ significantly between the outpatient and inpatient cohorts.

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

<b> Introduction:</b> 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. </br></br> <b> Material and methods: </b> 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. </br></br> <b>Results:</b> 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. </br></br> <b>Conclusions:</b> 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.

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.

Quilting following mastectomy reduces seroma, associated complications and health care consumption without impairing patient comfort

Background

An important complication following mastectomy is seroma formation. Quilting, in which skin flaps are sutured to the underlying muscle, is reported to reduce seroma incidence, but might induce pain and impair shoulder function. Main objective is to compare quilting with conventional wound closure, regarding seroma incidence, health care consumption, and patient discomfort.

Methods

In a combined prospective and retrospective study, 254 patients undergoing mastectomy and/or axillary lymph node dissection (ALND) were included. Patients received quilting sutures or conventional closure. Primary outcome was clinical significant seroma (CSS). In prospectively included patients shoulder function and analgesic use was observed.

Results

CSS incidence was 12.9% in the quilted versus 62.3% in the nonquilted cohort (p < 0.001). Surgical site infections were reported significantly less in the quilted cohort. Duration of hospital stay was shorter and outpatient clinic visits were less in the quilted cohort. Surgical procedure required 10 additional minutes for quilting. No significant differences were observed in postoperative shoulder function and analgesic use.

Conclusion

Quilting following mastectomy reduces CSS incidence. Quilting requires 10 additional minutes during surgery. It facilitates day treatment and results in less additional outpatient clinic visits culminating in reduced health care consumption. Shoulder function and pain are not affected by quilting.

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.

Flap fixation in preventing seroma formation after mastectomy: an updated meta-analysis

Seroma formation following mastectomy is one of the most experienced complications, with a very variable incidence ranging from 3 to 90%. In recent years, many publications have been realized to define an effective technique to prevent its formation and several approaches have been proposed. Given the potential of flap fixation in reducing seroma formation, we performed a meta-analysis of the literature to investigate the role of this approach as definitive gold standard in mastectomy surgery. Inclusion criteria regarded all studies reporting on breast cancer patients undergoing mastectomy with or without axillary lymph node dissection; studies that compared mastectomy with flap fixation to mastectomy without flap fixation were selected. Papers were eligible for inclusion if outcome was described in terms of seroma formation. As secondary outcome, also surgical site infection (SSI) was evaluated. The included studies were 12, involving 1887 female patients: 221/986 (22.41%) patients experienced seroma formation after flap fixation and 393/901 (43.61%) patients had this complication not receiving flap fixation, with a significant statistical difference between the two groups (OR = 0.267, p = 0.001, 95% CI 0.153, 0.464). About, SSI 59/686 (8.6%) in flap fixation group and 67/686 (9.7%) in patients without flap fixation, with no statistical differences between groups (OR = 0.59, p = 0.056, 95% CI 0.344, 1.013).The heterogeneity between included studies does not allow us to reach definitive conclusions but only to suggest the strong evaluation of this approach after mastectomy in seroma preventing and SSI reduction.

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.

Negative pressure wound therapy does not decrease postoperative wound complications in patients undergoing mastectomy and flap fixation

Patients and breast cancer surgeons are frequently confronted with wound complications after mastectomy. Negative pressure wound therapy (NPWT) is a promising technique for preventing wound complications after skin closure in elective surgery. However, a clinical study evaluating postoperative complications following the use of NPWT, focusing solely on closed incisions in patients undergoing mastectomy, has yet to be performed. Between June 2019 and February 2020, 50 consecutive patients underwent mastectomy with NPWT during the first seven postoperative days. This group was compared to a cohort of patients taking part in a randomized controlled trial between June 2014 and July 2018. Primary outcome was the rate of postoperative wound complications, i.e. surgical site infections, wound necrosis or wound dehiscence during the first three postoperative months. Secondary outcomes were the number of patients requiring unplanned visits to the hospital and developing clinically significant seroma (CSS). In total, 161 patients were analyzed, of whom 111 patients in the control group (CON) and 50 patients in the NPWT group (NPWT). Twenty-eight percent of the patients in the NPWT group developed postoperative wound complications, compared to 18.9% in the control group (OR = 1.67 (95% CI 0.77–3.63), p = 0.199). The number of patients requiring unplanned visits or developing CSS was not statistically significant between the groups. This study suggests that Avelle negative pressure wound therapy in mastectomy wounds does not lead to fewer postoperative wound complications. Additionally, it does not lead to fewer patients requiring unplanned visits or fewer patients developing clinically significant seromas.

Trial registration: ClinicalTrials.gov number, NCT03942575. Date of registration: 08/05/2019.

Does chemotherapy or radiotherapy affect the postoperative complication in breast cancer patients who underwent immediate breast reconstruction with tissue expander?

BACKGROUND

Immediate breast reconstruction with tissue expander in breast cancer patients who were expected to receive adjuvant therapy, such as chemotherapy or radiotherapy, has been a topic of debate. Postoperative complications from tissue expander procedures can delay the timing of adjuvant treatment and subsequently increase the probability of recurrence. The purpose of this study was to identify the impact of chemotherapy and radiotherapy on postoperative complications in patients who underwent immediate reconstruction (IR) using tissue expander.

METHODS

We conducted a retrospective study of 1081 breast cancer patients who underwent mastectomy and IR using tissue expander insertion between 2012 and 2017 in Samsung Medical Center. The patients were divided into two groups based on complications (complication group vs. no complication group). Complication group was regarded to have surgical removal or conservative treatment based on clinical findings such as infection, capsular contracture, seroma, hematoma, rupture, malposition, tissue viability, or cosmetic problem. The complication group had 59 patients (5.5%) and the no complication group had 1022 patients (94.5%).

RESULTS

In univariate analysis, adjuvant radiotherapy and adjuvant chemotherapy were significantly associated with postoperative complications. In multivariate analysis, however, only higher pathologic N stage was significantly associated with postoperative complications (p < 0.001). Chemotherapy (p = 0.775) or radiotherapy (p = 0.825) were not risk factors for postoperative complications.

CONCLUSIONS

IR with tissue expander after mastectomy may be a treatment option even when the patients are expected to receive adjuvant chemotherapy or radiotherapy. These results will aid patients who are concerned about the complications of IR caused by chemotherapy or radiotherapy determine whether or not to have IR.

TRIAL REGISTRATION

Patients were selected and registered retrospectively, and medical records were evaluated.

Fascia Suture Technique Is a Simple Approach to Reduce Postmastectomy Seroma Formation

Purpose

Seroma formation is a common complication in breast cancer patients undergoing mastectomy, and it negatively affects patient recovery after surgery. The present study aimed to evaluate a simple method using fascia suture technique to fix the flap and reduce the incidence of seroma.

Methods

A single-center, prospective, randomized controlled trial was carried out among 160 patients who had undergone mastectomy from May 2018 to September 2019. All patients were randomly divided into the fascia suture group (n = 80) or control group (n = 80) and were followed up for at least 3 months for the assessment of immediate and late complications after surgery.

Results

No significant differences were observed between the 2 groups with regard to the basic characteristics. Duration of surgery in the fascia suture group was longer by about 6 minutes compared with that in the control group (114.93 ± 13.67 minutes vs. 108.81 ± 15.20 minutes, p = 0.008). The fascia suture group had a shorter duration of drain placement (10.99 ± 3.26 days vs. 13.85 ± 5.37 days, p < 0.001), a smaller volume of the total drainage (460.95 ± 242.92 mL vs. 574.83 ± 285.23 mL, p = 0.007), and the first 3-day drainage (224.96 ± 101.01 mL vs. 272.3 ± 115.47 mL, p = 0.006), compared with the control group. The incidence of seroma formation (G2 or G3) was significantly lower in the fascia suture group compared with the control group (28.8% vs. 12.5%, p = 0.033). Besides, there was no statistical difference between the 2 groups in the assessment of other complications, including postoperative pain, hematoma, surgical site infections, flap necrosis, and skin dimpling (all p > 0.050).

Conclusion

The fascia suture technique is a simple and effective method for reducing seroma formation and should be used to prevent seroma formation after mastectomy.

Trial Registration

Chinese Clinical Trials Registry Identifier: ChiCTR1800015913.

Reducing Seroma Formation and Its Sequelae After Mastectomy by Closure of the Dead Space: A Multi-center, Double-Blind Randomized Controlled Trial (SAM-Trial)

BACKGROUND

Seroma is a common complication after mastectomy, with an incidence of 3% to 85%. Seroma is associated with pain, delayed wound healing, and additional outpatient clinic visits, leading potentially to repeated seroma aspiration or even surgical interventions. This study aimed to assess the effect of flap fixation using sutures or tissue glue in preventing seroma formation and its sequelae.

METHODS

Between June 2014 and July 2018, 339 patients with an indication for mastectomy or modified radical mastectomy were enrolled in this randomized controlled trial in the Netherlands. Patients were randomly allocated to one of the three following arms: conventional wound closure (CON, n = 115), flap fixation using sutures (FFS, n = 111) or flap fixation using tissue glue (FFG, n = 113). The primary outcome was the need for seroma aspiration. The secondary outcomes were additional outpatient department visits, surgical-site infection, shoulder function and mobility, cosmesis, skin-dimpling, and postoperative pain scores.

RESULTS

Flap fixation after mastectomy leads to fewer seroma aspirations than conventional wound closure (CON 17.5% vs FFS 7.3% vs FFG 10.8%; p = 0.057), with a significant difference between flap fixation with sutures and conventional wound closure (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16-0.89; p = 0.025). Flap fixation has no significant negative effect on surgical-site infections, shoulder function and mobility, cosmesis, skin-dimpling, or postoperative pain.

CONCLUSION

Flap fixation using sutures leads to a significant reduction in aspirations of post-mastectomy seromas. The authors strongly advise surgeons to use sutures for flap fixation in patients undergoing mastectomy. (ClinicalTrials.gov no. NCT03305757).

PREREGISTRATION

The trial was registered after enrollment of the first participant. However, no specific explanation exists for this except that through the years more importance has been given to central trial registration. Our research team can ensure that after enrollment of the first participant, no changes were made to the trial, analysis plan, and/or study design.

A systematic review of seroma formation following drain-free mastectomy

BACKGROUND

Seroma is a common complication after mastectomy. The aim of this review is to elucidate whether closed suction drainage can safely be omitted in patients undergoing mastectomy when assessing seroma formation and its complications. The second aim is to assess the influence of flap fixation on seroma related complications, as there is existing evidence showing that combining mastectomy with flap fixation may make the use of drainage systems obsolete.

SEARCH & SELECTION

A review of the literature was performed and articles that compared mastectomy with drainage and mastectomy without drainage were selected. Due to the small number of eligible studies, no selection based on whether flap fixation was performed was possible. If outcome was described in terms of seroma formation or seroma related complications, papers were eligible for inclusion. Studies older than 20 years, animal studies, studies not written in English and studies with male patients were excluded.

RESULTS

A total of eight articles were eligible for inclusion. Four prospective studies and four retrospective studies were included. In four studies, flap fixation was performed. Frequency of seroma formation as well as seroma that required intervention was reported. The included studies demonstrated that omitting closed suction drainage does not lead to a higher incidence of seroma formation in patients undergoing mastectomy.

CONCLUSION

Despite substantial heterogeneity, there is evidence that drainage can safely be omitted without exacerbating seroma formation and its complications. A well-powered, randomized controlled trial evaluating the effect of drainage omission on seroma formation, with or without flap fixation, is needed.

Propeller Flaps in the Posterior Trunk

The reconstruction of complex posterior trunk defects remains challenging. But now with an increased knowledge of angiosomes and the practice of perforator flaps, the posterior trunk offers a new plethora of options for reconstruction. Propeller flaps based on such perforator(s) offer an elegant solution for managing defects while achieving primary donor-site closure without significant morbidity. We will discuss the relevant anatomy and design principles for propeller flaps based on a review of the literature and our experience. Steps beginning with preoperative planning, perforator selection, and intraoperative surgical technique will be discussed, together with pearls on both avoiding and managing complications.

The relationship between post-surgery infection and breast cancer recurrence

Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.

A single-center, randomized, non-inferiority study evaluating seroma formation after mastectomy combined with flap fixation with or without suction drainage: protocol for the Seroma reduction and drAin fRee mAstectomy (SARA) trial

BACKGROUND

Seroma formation is a common complication after breast cancer surgery and can lead to delayed wound healing, infection, patient discomfort and repeated visits to the outpatient clinic. Mastectomy combined with flap fixation is becoming standard practice and is currently combined with closed-suction drainage. There is evidence showing that closed-suction drainage may be insufficient in preventing seroma formation. There is reasonable doubt whether there is still place for closed-suction drainage after mastectomy when flap fixation is performed. We hypothesize that mastectomy combined with flap fixation and closed suction drainage does not cause a significant lower incidence of seroma aspirations, when compared to mastectomy and flap fixation alone. Furthermore, we expect that patients without drainage will experience significantly less discomfort and comparable rates of surgical site infections.

METHODS

This is a randomized controlled trial in female breast cancer patients undergoing mastectomy and flap fixation using sutures with or without sentinel lymph node biopsy (SLNB). Patients will be eligible for inclusion if they are older than 18 years, have an indication for mastectomy with or without sentinel procedure. Exclusion criteria are modified radical mastectomy, direct breast reconstruction, previous history of radiation therapy of the unilateral breast, breast conserving therapy and inability to give informed consent. A total of 250 patients will be randomly allocated to one of two groups: mastectomy combined with flap fixation and closed-suction drainage or mastectomy combined with flap fixation without drainage. Follow-up will be conducted up to six months postoperatively. The primary outcome is the proportion of patients undergoing one or more seroma aspirations. Secondary outcome measures consist of the number of invasive interventions, surgical site infection, quality of life measured using the SF-12 Health Survey, cosmesis, pain and number of additional outpatient department visits.

DISCUSSION

To our knowledge, no randomized controlled trial has been conducted comparing flap fixation with and without closed-suction drainage with seroma aspiration as the primary outcome. This study could result in finding evidence that supports performing mastectomy without closed-suction drainage.

TRIAL REGISTRATION

This trial was approved by the medical ethical committee of Zuyderland Medical Center METC-Z on 20 March 2019 (METCZ20190023). The SARA Trial was registered at ClinicalTrials.gov as per July 2019, Identifier: NCT04035590 .

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.

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.

Effect of subcutaneous closure technique on incisional complications and postoperative pain in cats undergoing midline celiotomy: A randomized, blinded, controlled trial

OBJECTIVE

To compare the effect of three methods of subcutaneous tissue closure on postoperative incisional complications and pain in cats.

STUDY DESIGN

Single-center, randomized, blinded, controlled trial conducted in a veterinary teaching hospital.

ANIMALS

Two hundred ninety-seven cats undergoing midline celiotomy for ovariohysterectomy (n = 280) or other abdominal procedure (n = 17).

METHODS

Cats (n = 297) were assigned to one of three subcutaneous closure methods: simple continuous apposition with tacking to the rectus fascia (n = 108, quilting [Q] group); simple continuous apposition (SC; n = 94); no subcutaneous closure (NC; n = 95). Primary outcomes were incidence of seroma formation, postoperative pain, and surgical site infection or dehiscence. Active follow-up was obtained at 10 and 30 days postoperatively.

RESULTS

Baseline characteristics did not differ between groups. Seroma was less common in the Q group (13.0%) than in the NC (27.3%) and SC (25.9%) groups (P = .03). Compared with the other two groups, the relative risk of seroma formation in the Q group was 0.49 (95% CI = 0.28-0.86, P = .01). Median mechanical pain thresholds were higher (indicating greater comfort) in cats with subcutaneous sutures (Q and SC = 1.23 [interquartile range (IQR), 0.2-2.6 N], NC = 0.83 [IQR, 0-1.87 N], P = .04) on the day after surgery.

CONCLUSION

Closing subcutaneous tissues with a quilting closure pattern reduced seroma formation in cats undergoing celiotomy.

CLINICAL SIGNIFICANCE

Placing a quilting suture pattern in the subcutaneous tissues after celiotomy is a simple low-cost measure that reduces seromas in cats. Abstaining from subcutaneous closure cannot be recommended because of increased seroma formation and pain.

Increasing the incidence of drain-free day-case mastectomies with the use of a fibrin tissue sealant; data from a single surgical center in the United Kingdom

Day-case mastectomy surgery provides benefits to both patients and hospitals. Key barriers are the use of a drain and the risk of postoperative seroma formation. We introduced the use of a tissue sealant (Artiss) into the surgical site (post-mastectomy without immediate reconstruction and postaxillary clearance) and evaluated its effect on our practice, particularly day-case rates. A prospective audit of 177 patients who underwent a simple mastectomy with or without axillary surgery, or axillary node clearance with or without breast-conserving surgery was conducted at a single surgical center in the UK between November 2015 and November 2016. Artiss was used in all operations and, where appropriate, the drain was omitted to facilitate day-case surgery. The clinical outcomes were compared between patients undergoing different operations and duration of hospital stay. There was no statistically significant difference between day-case patients and inpatients in seroma aspiration rates (24.5% and 21.7%, respectively; P = 0.381) or other complications (22.4% and 16.1%, respectively; P = 0.106). The day-case mastectomy rate increased from 3.9% in the first quarter to 45.5% in the final quarter, which was a significant increase reaching well beyond the national target. The use of Artiss enabled us to increase the drain-free day-case surgery rates over a 1-year period, exceeding the 30% target recommended by the British Association of Day Surgery. We did not observe any increase in patient morbidity, and the change was cost-effective. We have now implemented the routine use of Artiss in women undergoing simple mastectomy with or without axillary surgery and stand-alone axillary node clearances as part of enhanced recovery clinical pathways.

Analysis of TNF-α and interleukin-6 in seroma of patients undergoing mastectomy with or without flap fixation: is there a predictive value for seroma formation and its sequelae?

BACKGROUND

Seroma formation is a common complication after mastectomy. Flap fixation has the potential to prevent seroma formation, but identifying patients that are at risk of developing seroma, remains challenging. The aim of this study was to assess the association between pro-inflammatory cytokines in seroma fluid one day after surgery and seroma formation and it sequelae.

METHODS

Patients undergoing mastectomy were randomized into one of three groups: no flap fixation, flap fixation using sutures or flap fixation using tissue glue. Seroma samples from 40 consecutive patients undergoing mastectomy were collected on the first postoperative day for analysis of interleukin-6 and tumor necrosis factor-α. Seroma formation and its sequelae were assessed in the outpatient clinic ten days, six weeks and three months after surgery.

RESULTS

TNF-α concentrations were not detectable in the seroma samples of any of the 40 patients. BMI (p = 0.001) and weight of the resected surgical specimen (p = 0.003) were associated with higher IL-6 levels in seroma on the first postoperative day after mastectomy. A higher seroma concentration of IL-6 was associated with significantly fewer patients with clinical seroma formation three months after surgery (p = 0.027).

CONCLUSION

IL-6 is associated with clinical seroma formation three months after surgery. There is however no evident association between IL-6 and complications related to seroma formation. Higher IL-6 levels are predictive of less long-term seroma formation. Application of flap fixation does not seem to influence the level of IL-6.

A multi-center, double blind randomized controlled trial evaluating flap fixation after mastectomy using sutures or tissue glue versus conventional closure: protocol for the Seroma reduction After Mastectomy (SAM) trial

Background

Seroma formation is a common complication after mastectomy and is associated with delayed wound healing, infection, skin flap necrosis, patient discomfort and repeated visits to the out patient clinic to deal with seroma and its sequelae. Closing the dead space after mastectomy seems to be key in reducing seroma and its complications. Various methods have been described to reduce the dead space after mastectomy: closed suction drainage, quilting of the skin flaps and application of adhesive tissue glues. The aim of this trial is to compare seroma formation and its sequelae in the various methods of flap fixation.

Methods

This is a multicenter, double-blind, randomized controlled trial in female breast cancer patients undergoing mastectomy, with or without axillary clearance. Exclusion criteria consist of breast conserving therapy, direct breast reconstruction and incapacity to comprehend implications and extent of study and unable to sign for informed consent. A total of 336 patients will be randomized. Patients will be randomly allocated to one of three treatment arms consisting of flap fixation using ARTISS tissue glue with a low suction drain, flap fixation using sutures and a low suction drain or conventional wound closure (without flap fixation) and low suction drainage. Follow up will be conducted up to twelve months post surgery. The primary outcome is the number of seroma aspirations and secondary outcomes consist of number of out patient clinic visits, surgical skin infection rate, shoulder function, cosmesis, health-related quality of life and costs and cost-effectiveness (cost/QALY).

Discussion

This is the first study of its kind to evaluate the effect of flap fixation and its sequelae (ie seroma aspirations, number of out patient clinic visits, infection, shoulder function, patient assessed cosmesis, quality of life and cost-effectiveness) in a double blind randomized controlled trial.

Trial registration

This trial was approved by the hospitals’ joint medical ethical committee (14-T-21, 2 June 2014). The SAM Trial is registered in ClinicalTrials.gov since October 2017, Identifier: NCT03305757.

Reconstructive breast surgery with partially absorbable bi-component Seragyn® BR soft mesh: an outcome analysis

OBJECTIVE

Synthetic meshes and acellular dermal matrices are increasingly used in implant-based breast reconstruction. The objective of this study was to determine the incidence and severity of complications following the implantation of the partially absorbable bi-component soft mesh SERAGYN® BR and assess risk factors for adverse operative outcomes.

METHODS

A retrospective clinical study was performed: The SERAGYN® BR soft mesh was utilized in 148 operations (skin-sparing mastectomy, nipple-sparing mastectomy, breast-conserving surgery, and secondary reconstruction after mastectomy) in four different institutions in Germany from June 2012 to February 2014. We analyzed whether the results were affected by tumor morphology (e.g., grading), patient characteristics and comorbidities, previous surgery or therapies, and use of alloplastic materials.

RESULTS

The SERAGYN® BR soft mesh was successfully implanted in 131 of 148 operations. The rate of reconstructive failure was 11.5%. The most common complication was seroma (25.7%), followed by hematoma and skin infection (each 14.2%). Wound-healing issues were detected in 13.5% cases, secondary wound infections in 10.8%. 83.8% of operations had no severe complications. Independent predictors for reconstructive failure were wound-healing issues, nipple- or skin necrosis, wound- or skin infections, a high volume of excised tissue, hematomas, seromas, and sentinel lymph node excisions. A higher body mass index was correlated with a higher rate of infection.

CONCLUSION

SERAGYN® BR mesh can be used successfully in breast reconstructive surgery. Rates of major complications or reconstructive failure are comparable to the use of other synthetic or biological meshes.

Surgical removal of fibrous axillary seroma pocket and closing of dead space using a lattisimus dorsi flap

Seroma formation after axillary dissection is a common problem in breast cancer surgery. We report the case of a 68-year-old female with breast cancer who underwent a wide local excision and axillary clearance due to stage III breast cancer. Patient received post-operative whole breast irradiation therapy and developed a painful, infected seroma one month after surgery. This was treated with antibiotic therapy after which the infection subsided. One year after surgery patient presented with a painful persisting seroma in the left axilla. We decided to surgically treat the seroma by removing the fibrous seroma capsula and closing of the dead space with a latissimus dorsi flap. Six weeks after surgery, patient was pain and seroma free and was happy with the surgical result. Latissimus dorsi flap harvesting is an ideal way to treat persisting fibrous encapsulated seroma pockets after axillary clearance in the treatment of breast cancer.

Can Gentamicin-collagen Sponges Prevent Seroma Formation Following Mastectomy?

BACKGROUND

The aim of this study was to investigate whether gentamicin-collagen (GC) sponges can lower the incidence of seroma and surgical site infections following breast cancer surgery.

PATIENTS AND METHODS

A retrospective cohort study was performed. Two consecutive cohorts of patients who underwent a mastectomy with or without an axillary lymph node dissection were compared. The first cohort was treated conventionally (n = 38), the second cohort received GC sponges (n = 39). Endpoints were the incidence of clinical significant seroma (CSS) and surgical site infections (SSI), the mean number of aspirations, and the mean aspirated volume.

RESULTS

GC sponges lowered the CSS incidence from 73.7% to 38.5% (P = .002). The mean number of aspirations and the mean aspirated volume were not affected. SSI incidence was 15.8% in the conventional cohort compared with 7.7% in the GC cohort (P = .23).

CONCLUSION

Application of GC sponges significantly lowered the incidence of CSS. The incidence of SSI was halved, although this was not significant.

A systematic review of flap fixation techniques in reducing seroma formation and its sequelae after mastectomy

BACKGROUND

Seroma formation is a common complication after mastectomy. This review aims to elucidate which surgical techniques are most effective in reducing the dead space and therefore seroma formation in patients undergoing mastectomy.

METHODS

A literature search was performed to identify clinical studies comparing any form of flap fixation to conventional closure technique in patients undergoing mastectomy with or without axillary clearance. Studies were eligible for inclusion if outcome was described in terms of seroma formation and/or complications of seroma formation. Studies on animal research or breast reconstruction with tissue expanders or flap harvesting (latissimus dorsi) were excluded.

RESULTS

A total of nine articles were eligible for inclusion. Five were retrospective studies and four were prospective. Retrospective and prospective studies have demonstrated the higher incidence of seroma formation in patients not undergoing mechanical flap fixation. The incidence of seroma-related complications in these studies vary. Four out of the nine studies demonstrate that patients undergoing flap fixation, need significantly fewer seroma aspirations. There are very few studies on the use of tissue glues preventing seroma formation.

CONCLUSION

The scientific body of evidence favoring flap fixation after mastectomy is convincing. Mechanical flap fixation seems to reduce seroma formation and seroma aspiration after mastectomy. There are, however, no well-powered randomized controlled trials evaluating all aspects of seroma formation and its sequelae. Further research should elucidate whether flap fixation using sutures or tissue glue is superior.