Breast Seromas: Symptoms, Causes, Treatment, Prevention: what is it?
The Department of Plastic and Reconstructive Surgery is located at Southmead Hospital.
Modification radical mastectomy is one of the most common causes of Seroma formation.The best management for seroma is prevention by surgical techniques.Repeated aspiration, compression, seroma-desis, and/or sclerotherapy could be used to manage re-enactments.Recurrent cases are reserved for surgical intervention.The case of a 43-year-old woman with chronic recurrent chest wall and axillary seroma is hereby presented.It was associated with pain in the axillary and shoulder regions.This was eventually managed by surgical excision of the encapsulated seroma, which was found to receive feeding lymphatic vessels and to entangle a nerve in the scar tissue.A muscle-sparing latissimus dorsi flap was used to reconstruct the defect.The patient had a good recovery.She had a significant improvement in her quality of life 10 months after the procedure.The progression of the condition, its treatment methods, and interesting findings are presented.We reviewed literature for the management of similar cases.There is a treatment dilemma for patients with chronic encapsulated seroma.When managing cases which are resistant to conservative efforts, surgical resection of such seromas should be considered.When the overlying skin is under tension, has poor quality and is at risk of delayed wound healing, it is a good idea to import vascularised tissue.
muscle sparing latissimus dorsi flap, bicep sparing axillary seroma, and thoracodoral artery perforator flap are included in the case report.
Patients who have undergone modified radical mastectomy are more likely to have Seroma formation compared to breast conserving surgery.Some studies show that the incidence of post-mastectomy seroma is more than 50%.The post-mastectomy aetiology is mostly speculative but accepted to be multifactorial.The literature has reported correlations with patient age, Obesity, hypertension, and a tentative association to breast size.
Collections which persist months post-mastectomy can pose a challenge to the patient and clinician.In addition, repeated aspiration can lead to wound breakdown.We present a case study where conservative measures have failed and surgery was offered to address the problem of an encapsulated seroma and the subsequent dead space.The encapsulated seroma was found to be stuck to the chest wall muscles, and with a couple of lymphatic vessels, feeding directly into the capsule.There are findings that explain why chronic seromas are resistant to conservative management.It is possible to import vascularised tissue to ensure tension free closure and reduce deep scar.It shows that surgical treatment should be considered in similar cases.The patient did not have a repeat of the seroma at 10 months down the line.The following case is presented in accordance with the guidelines.
After having had bilateral breast reduction, a 36-year-old lady was diagnosed with left breast cancer.She was fit and well despite having had an acoustic neuroma and being on a drug for depression.She stopped smoking when she was 30 years old.Her body mass index was 33.
A left-sided simple mastectomy and axillary lymph node clearance was performed in 2012She had a risk-reducing simple mastectomy on the right side and a revision of the left mastectomy scar one year later.She continued to develop recurrent seroma of the chest wall.She had a stiff left shoulder and axillary pain.
She was first referred to the plastic surgery unit.She had developed symptoms of altered sensation and pain along her left arm.Changes to the skin and tissue in the chest wall were correlated with the treatment.Active physical therapy was recommended for conservative therapy.The active range of movement in her shoulder was marginally improved with intensive therapy, but it was not good enough for her to go on with her life.
She was referred to the plastic surgery clinic again in August.Over the course of 6 years, the patient has had four to six weekly visits to the doctor.The patient had to go to the breast care centre for all these years because of this.The skin was thin and had scars.The shoulder girdle has a moderate degree of muscular atrophy.On the left side, there was a clinically palpable loculated seroma.She was associated with subjective pain along the arm and down the forearm, as well as positive Tinel's sign over the left axilla.At this point, she was a nonsmoker.The senior author offered her an excision of the scar and a flap of tissue from the chest wall.The patient declined the lengthy discussion about breast reconstruction options.She was clear that she was happy with the flat chest if the recurrent seroma is addressed.
The procedure was performed under general anaesthesia with the patient placed in a left position.Prophylactic antibiotics and one gram of tranexamic acid were given.The encapsulated seroma was attached to the mastectomy scar.The part of the muscle that was stuck to was the pectoralis major muscle.It went into the axilla between the major and minor muscles.In the event that more surgery is needed, several visible feeding lymphatic vessels were carefully ligated with a 5-o prolene suture.The intercosto-brachial nerve was entangled in the scar tissue and neurolysis of it was performed.The capsule and fluid were sent off to be analyzed.The capsule was negative for ALCL and showed a pseudocystic wall with no obvious lining.A mild inflammatory infiltrate was present.The samples indicated the same cells.Warm saline and haemostasis followed the washout.
The dead space was closed with a muscle-sparing latissimus dorsi-type II flap.There are five.A 5 cm cuff of muscle is included around the perforators, based on the descending branch of the thoracodorsal artery.The nerve supply and the rest of the network were preserved.The chest wall had the elliptical skin paddle of the flap in it.A drain was placed in the chest wall of the donor site.The skin was closed with Monocryl.The donor site of the back was re-approximated with barbed 2-o polydioxanone.The skin was closed with layers of Monocryl and glue.She was discharged from the hospital on the third day after the removal of the drain.She had an easy recovery.There were no signs of collections two months after surgery.The same findings were noted 10 months after the surgery.The patient reported improvement in their paraesthesia.The shoulder girdle musculature has been noted as a consequence of chronic functional impairment.Her shoulder abduction range was improved and there was complete resolution of her shoulder pain.The patient was relieved that she didn't have to go back to the breast care centre.
There is a high disease burden for patients with chronic seroma.Over the years, several methods have been tested and include sclerotherapy with agents such as talc, tetracycline and hypertonic saline.Some remain resistant to conservative therapy despite the fact that this may be effective in treating most cases.
Blood and lymphatic vessels are more likely to be damaged compared to breast conserving therapies, which is why axillary dissection is a strong risk factor for seroma formation.The axillary clearance is likely to have contributed to the inflammation and fibrosis of the patient.
Targeted therapy is challenging because of the unclear pathophysiology of seroma formation.The catalyst for the ongoing process has been suggested by several authors as a contributing factor with inflammatory and fibrinolytic reactions.The initial phase of healing has been suggested by the composition of the fluid.The driving force behind angiogenesis and the inflammatory process is linked to raised VEGF and decreased endostatin.The heightened intensity of this process leads to seroma formation.In our case, we were able to identify several feeding lymphatic vessels which may explain the refractory nature of the seroma and the gradual evolution of a pseudocapsule that complicates further management.
The perfect environment for the formation of a dead space which fills with seroma fluid is provided by the extensive dissection of the chest wall and axillary fossa.The capsule should be removed with the excision of the dead space.
In a few case reports, surgical intervention for chronic recurrent seroma has been described.In cases where the volume of dead space is significant and the overlying skin envelope is thin, deficient and damaged by radiotherapy treatment, vasoids, such as TDAP orMS-LD flap, should be considered.The flap is illustrated in van Bastelaar et al.It is a sound option that has the potential for problems.In our experience and in this case, a muscle-sparing technique is chosen, whenever feasible, due to its advantage of minimising shoulder weakness and dysfunction, as well as significantly reducing the incidence of post-operative seroma and wound healing complications.A small cuff of LD muscle is included with the perforator when we can't identify a medium to large one.
The case report is helpful for reference when surgeons face similar cases.We were not able to follow the patient up for more than 10 months because she didn't want to go to the hospital anymore.She only had aspiration of seroma and compression therapy before we performed this procedure.
In chronic seroma, surgical intervention should be considered.In cases where the volume of dead space is significant, the overlying skin is thin or affected by radiotherapy changes, and/or direct closure would be under tension, vascised tissue is recommended.With very low donor site morbidity, reconstructing the defect with aMS-LD is an effective solution.
Both authors have completed the ICMJE uniform disclosure form.There are no conflicts of interest for the authors.
The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part are appropriately investigated and resolved.The study was done in accordance with the Declaration of Helsinki.The patient gave written informed consent for the publication of the Case Report.The written consent can be reviewed by the Editor-in-Chief of this journal.