Seroma

A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. This fluid is composed of blood plasma that has seeped out of ruptured small blood vessels and inflammatory fluid produced by the injured and dying cells.

Seromas are different from hematomas, which contain red blood cells, and different from abscesses, which contain pus and result from an infection. Serous fluid is also different from lymph.

Early or improper removal of sutures can sometimes lead to formation of seroma or discharge of serous fluid from operative areas. Seromas can also sometimes be caused by injury, such as when the initial swelling from a blow or fall does not fully subside. The remaining serous fluid causes a seroma that the body usually absorbs gradually over time (often taking many days or weeks); however, a knot of calcified tissue sometimes remains.

Seromas are particularly common after breast surgery[1] (for example after mastectomy[2]), abdominal surgeries, and reconstructive surgery. They are a treatment target in partial-breast radiation therapy,[3] The larger the surgical intervention, the more likely it is that seromas appear. Larger seromas take longer to resolve than small seromas, and are more likely to undergo secondary infection.

Seromas may persist for several months[4] or even years, with the tissue surrounding the seroma hardening over time.

On CT scans, seromas have a radiodensity of 0–20 Hounsfield units (HU), generally in the lower part of this range, consistent with clear fluid.[5]

Treatment

Seromas may be difficult to manage at times. Research suggests that the procedure of quilting (inserting interrupted deep stitches in the wound) after mastectomy significantly reduces seroma formation.[6] The removal of seromas by fine-needle aspiration is controversial:[7] it is recommended by some for the reason that seromas can be a culture medium for bacteria,[8] whereas others advise it only for collection of excessive amounts of fluid, because even an aspiration carried out under aseptic conditions carries a certain risk of infection.[9] Depending on the volume and duration of leakage, control of a leak may take up to a few weeks to resolve with aspiration of serums and the application of pressure dressings. Manual lymphatic drainage (MLD) conducted by a trained professional can also assist in managing and treating seromas.

If a serum or leak does not resolve (e.g., after a soft tissue biopsy), it may be necessary to take the patient back to the operating room in order to place some form of closed-suction drain into the wound. This usually is not necessary and conservative management prevails.[10]

In case of lumpectomy, the formation of a seroma at the lumpectomy site has been cited in medical literature as being beneficial, with claims that it can contribute to preserve the contour of the breast.[1][11][12]

In some cases a seroma may need to be drained prior to a course of radiotherapy adjuvant to surgery.

Prevention

The main measures to prevent seroma formation are surgical and non-surgical.

1. Surgical: Gentle surgical technique with careful and meticulous control of bleeding. Controversy exists in abdominoplasty surgery(tummy tuck) as to whether the use of electrosurgical dissection either contributes to serum formation or prevents it.

Drains are traditionally used but their use has been challenged by various authors who believe quilting sutures alone may be sufficient to reach results as good as or better than when using drains. Seromas accumulate in what is known as "dead space" where a potential place for the fluid exists. Efforts are directed at reducing or eliminating dead space.[13] Quilting sutures reduce the risk of the skin-fat layer separating from the deeper muscle layer and having the separation fill up with fluid, by physically holding those layers together. Drains suck the two layers together so that the body's natural glue (Fibrin) and wound healing have a chance for a permanent bond between the layers.

Liposuction contributes to seroma formation. When liposuction is done in conjunction with creating a "flap", and potential space is confluent with the liposuctoined area, there is a greater risk of seroma. Effective use of preventive measures will minimize the risk.

2. Non-surgical: Prevention of movement between the layers allows the tentative initial bond of Fibrin to be reinforced by wound healing with a thin, strong, layer of scar. Avoiding certain positions for certain surgeries may have an effect. (In abdominoplasty, sitting upright with the knees bent and hips flexed will cause pressure across the lower abdomen and a tendency to seroma formation. The patient is best to stand or at least be semi-recumbent).

External pressure may help in immobilization but also is thought to reduce the tendency of the fluid to leak out of vessels by increasing the back-pressure on those fluid sources.

Following masculinising chest reconstruction (double mastectomy) in trans men or breast augmentation, surgeons often recommend binding the chest for several weeks to minimize the risk of seromas.

See also

References
  1. Michael S. Sabel (23 April 2009). Essentials of Breast Surgery: A Volume in the Surgical Foundations Series. Elsevier Health Sciences. p. 177. ISBN 978-0-323-07464-3.
  2. Moshe Schein; Paul N Rogers; Ari Leppäniemi; Danny Rosin (1 October 2013). Schein's Common Sense Prevention and Management of Surgical Complications: For surgeons, residents, lawyers, and even those who never have any complications. tfm Publishing Limited. pp. 397–. ISBN 978-1-903378-98-4.
  3. Wong, Elaine K.; Truong, Pauline T.; Kader, Hosam A.; Nichol, Alan M.; Salter, Lee; Petersen, Ross; Wai, Elaine S.; Weir, Lorna; Olivotto, Ivo A. (1 October 2006), "Consistency in seroma contouring for partial breast radiotherapy: Impact of guidelines", Int J Radiat Oncol Biol Phys, 66 (2): 372–6, doi:10.1016/j.ijrobp.2006.05.066, PMID 16965989
  4. Dick Rainsbury; Dick Rainsbury & Virginia Straker (2008). Breast Reconstruction. Class Publishing Ltd. p. 142. ISBN 978-1-85959-197-0.
  5. Page 258 in: Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (2015). The SAGES Manual of Groin Pain. Springer. ISBN 9783319215877.CS1 maint: multiple names: authors list (link)
  6. Mannu, Gurdeep Singh; Qurihi, Khalid; Carey, Frank; Ahmad, Mohammad Ady; Hussien, Maged (25 September 2015). "Quilting after mastectomy significantly reduces seroma formation" (PDF). South African Journal of Surgery. 53 (2): 50. doi:10.7196/SAJSNEW.7864.
  7. Michael Depalma; Michael J Depalma, MD MD (2011). Ispine: Evidence-Based Interventional Spine Care. Demos Medical Publishing. p. 245. ISBN 978-1-935281-93-1.
  8. Department of Pathology University of Massachusetts Medical School (Emeritus) Guido Majno Professor; Department of Pathology University of Massachusetts Medical School (Emerita) Isabelle Joris Associate Professor (12 August 2004). Cells, Tissues, and Disease : Principles of General Pathology: Principles of General Pathology. Oxford University Press. p. 435. ISBN 978-0-19-974892-1.
  9. P. Prithvi Raj; Serdar Erdine (31 May 2012). Pain-Relieving Procedures: The Illustrated Guide. John Wiley & Sons. p. 397. ISBN 978-1-118-30045-9.
  10. Schwartz's principles of surgery: self assessment and board review, 8th edition, chapter 11, patient safety, errors, and complications in surgery
  11. A. Thomas Stavros (2004). Breast Ultrasound. Lippincott Williams & Wilkins. p. 393. ISBN 978-0-397-51624-7.
  12. M. A. Hayat (5 November 2008). Methods of Cancer Diagnosis, Therapy and Prognosis: Breast Carcinoma. Springer Science & Business Media. p. 562. ISBN 978-1-4020-8369-3.
  13. sforza, marcos; et al. (July 2015). "Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective?". Aesthetic Surgery Journal. 35 (5): 574–80. doi:10.1093/asj/sju103. PMID 25953479. Retrieved December 26, 2017.
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