Quilting after mastectomy significantly reduces seroma formation

GENERAL SURGERY Quilting after mastectomy significantly reduces seroma formation G S Mannu,1,2 MSc MRCSE; K Qurihi,1 FRCS; F Carey,1 MBBS BSc; M A Ahmad,1 FRCS; M Hussien,1 MS MD FRCS 1 2 Breast Surgery Unit, Norfolk and Norwich University Hospital, Norfolk, UK General Surgery, Oxford University Hospital, Oxford, UK Corresponding author: G S Mannu () Introduction. Seroma formation is one of the most frequently encountered complications following mastectomy. It may cause significant morbidity, including delayed wound healing, infection and frequent clinic attendance for seroma aspiration. Objective. To evaluate the effect of surgical quilting after mastectomy in the prevention of postoperative seroma and to investigate which factors influence seroma formation. Methods. This was a single-centre prospective cohort study over a 1-year period. All patients who had a mastectomy operation during this period were included in this study. Group 1 patients (quilting) had mastectomy flaps sutured to pectoral muscle using interrupted absorbable sutures. Seroma requiring aspiration, number of aspirations and volume aspirated were recorded postoperatively. Results. During the study period, 168 patients were recruited, with 54 patients in group 1 (quilting) and 114 patients in group 2 (nonquilting). The proportion of patients who developed seroma requiring aspiration was 69% (n=79) in the non-quilting group and 29% (n=15) in the quilting group (p<0.001). Additionally, the total volume of seroma drained was 427 mL (standard error (SE)=69) in the nonquilting group and 63 mL (SE=21) in the quilting group (p=0.0008). The total number of seroma aspirations was 152 in the non-quilting group compared with 23 in the quilting group (p=0.0001). Seroma was more common in smokers (p=0.003) and was not decreased by the presence of drains. Conclusion. Quilting of the mastectomy flaps significantly reduces seroma formation. Both total volume of seroma aspirated and number of aspirations are significantly reduced using this technique. We would therefore recommend quilting of mastectomy flaps to reduce the incidence of postoperative seromas and morbidity. S Afr J Surg 2015;53(2):50-54. DOI:10.7196/sajsnew.7864 Breast cancer remains one of the leading causes of cancer deaths among women.[1] Simple mastectomy is a common surgical procedure that is used in the management of breast cancer. Seroma is one of the most frequently encountered complications following mastectomy and is a serous fluid that accumulates in the space between the skin flap and underlying tissues. It may cause significant morbidity, including delayed wound healing, and can result in frequent outpatient attendance for seroma aspiration. Repeat aspirations may in turn increase the risk of wound infection and impact on adjuvant treatment, thus compounding patient anxiety during an already difficult time. The incidence of seroma formation after mastectomy has been reported in the literature to vary from 15 to 81%.[2-5] A number of techniques have been employed in an attempt to reduce or prevent seroma formation among mastectomy patients using both mechanical and chemical approaches. However, there is significant heterogeneity in their benefits and there is a paucity of uniform evidence for their use. Quilting is a simple surgical procedure that eliminates the anatomical dead space remaining after mastectomy (Fig. 1). It involves placing interrupted absorbable sutures between the mastectomy flap and pectoral muscle prior to wound closure. It has been described in several studies assessing the technique at donor sites of autologous breast reconstruction. [6-9] However, it has not yet been prospectively 50 SAJS VOL. 53 NO. 2 JULY 2015 investigated in a large patient population in the context of addressing seroma formation following mastectomy. The objective of this prospective study is to evaluate the effect of surgical quilting after mastectomy in the prevention of postoperative seroma and to investigate which factors influence seroma formation. Methods This is a single-centre, prospective cohort study carried out from January 2012 to January 2013. Participants and setting Norfolk and Norwich University Hospital is a tertiary referral centre and our unit operates on 600 new breast cancer patients per year, including 200 from the UK national breast cancer screening programme. All patients who had a mastectomy with or without axillary surgery during this period were included in this study. Patients who had a skin-sparing mastectomy with immediate breast reconstruction were excluded. Data were collected on the day of surgery and at an outpatient follow-up clinic 2 weeks postoperatively. Intervention All patients received a single dose of cefuroxime 750 mg intravenously at the time of induction of anaesthesia. Surgery was carried out by four consultant breast surgeons. All patients in the cohort underwent simple mastectomy with preservation of pectoralis major mus cl e and t he p e c tor a l is f as c i a . Mastectomy flaps were dissected using electro-diathermy and the lymph node procedure (whether sentinel node biopsy or axillary clearance) was performed as planned. Only one surgeon performed t h e qu i lt i ng pro c e du re rout i n e l y, using a uniform technique in all simple mastectomies, while the remaining three did not. In the quilting group (group 1), after completion of the mastectomy and axillary procedure, multiple interrupted sutures were inserted in rows 5 cm apart between the mastectomy flaps and the underlying muscles using absorbable sutures (2-0 vicryl) prior to approximation of the wound edges using continuous 3-0 subcuticular monocryl sutures (Fig. 1). No patients in the quilting group had a drain inserted. In the non-quilting control group (group 2), simple mastectomy was performed by three independent surgeons without quilting, and the skin edges were approximated with continuous 3-0 subcuticular monocryl. The use of drains was left to the discretion of the operating surgeon, but in order to investigate the effect of drains on seroma formation in this group, all surgeons were required to record their use of drains. Although the breast and axillary surgeries were conducted by different surgeons between the two arms of the study, it was by a standardised approach across the department determined by the unit’s policy which has been previously published.[10,11] Information collected and outcomes Data were collected on the day of surgery and on the subsequent followup appointments prospectively. The data collected included patient’s age, body mass index (BMI), side of procedure, smoking status, nature of axillary surgery, use of drains, antiplatelet or anticoagulant medication and use of neo-adjuvant therapy. The primary dichotomous outcome measure was seroma formation requiring aspiration. Secondary outcomes were the number of aspirations performed and the volume of seroma drained (in millilitres) in each (...truncated)