Can I Continue Normal Activity After a Seroma Draining

Abstract

Abdominoplasty is one of the more common procedures after which seroma may occur. Reported incidences range from 5% to 50%. For more than 5 years, we have used the quilting suture technique in 130 patients without the occurrence of seroma after abdominoplasty. The technique has also been used to treat pseudobursas and tissue avulsion and after mastectomy to prevent seromas.

Plastic surgeons experienced in the treatment of soft tissue injuries know that seromas are common. Recent studies on the pathophysiology of seroma formation and various methods of treatment have been published. ¹–⁷ Reported incidences of seroma formation after abdominoplasty range from 5% to 50%. The different theories and techniques available testify to the absence of an ideal solution.

Abdominoplasty is one of the more common procedures after which a seroma may occur, frequently in the hypogastric region, and less often in the epigastrium. Seromas are first detected during the second postoperative week after abdominoplasty or trunk skin undermining, or in the limb region, where dead space is created. Traditionally, common treatment encompasses aspiration of the seroma with a syringe and a 14- to 18-gauge needle, performed once or twice a week, and a local compressive bandage. The method of compression depends on the region treated. In abdominoplasty an elastic belt with a tailored piece of foam over the seroma site is used. The seroma tends to resolve after five or six aspirations. In the axillary region, compression is difficult because of discomfort and pain, as well as difficulty in keeping the dressing in place.

Often by the time patients consult with us, the seroma is fibrotic and presents as a pseudobursa that protrudes and is indurated. Noninvasive and invasive procedures have been used to improve this situation. Local heat and massage performed by the patient at home a minimum of three times a day may be tried. This may take up to 6 weeks for improvement. The patient should apply a hot water bag or an electric heating pad for 10 minutes and then use an electric vibrator with any type of cream on the skin for 10 to 15 minutes.

The invasive method involves first anesthetizing the patient. A 3-mm cannula crisscrosses the area to create tunnels and release the fibrous tissue. The skin becomes loose to the touch as the protrusion disappears. The skin still remains firmer compared with normal skin. Heat and local massage with an electric vibrator are used after surgery. The patient should be seen by the doctor every 2 weeks during the first 2 months and bimonthly afterward as necessary.

One patient required two successive tunneling sessions to be performed 6 months apart. The patient was a 47-year-old woman who underwent abdominal liposuction elsewhere. A hematoma the size of an orange developed in the epigastrium. This area became fibrotic and hard, with overlying "peau d'orange" skin. Steroid injections administered by the patient's physician did not solve the problem. We performed two tunneling procedures, followed by local massage applied by the patient twice a day for several weeks. We also taught her to apply a metal disc the size of the bulge and fixed with adhesive skin tape for additional local compression. Although the situation improved, the skin remained firm and was lighter in color than the surrounding skin.

Prevention of Seromas

We have been using the quilting suture technique to prevent seromas for more than 5 years. During an abdominoplasty, 3-0 Vicryl^® sutures are placed along the undermined skin flap inner surface. The sutures bite the muscular fascia below and the superficial fascia of the skin flap above. The distance between the stitches is no more than 5 cm. In abdominoplasty, these sutures are placed after the rectus abdominis muscle is plicated, the excess skin flap is resected, and the umbilicus sutures have been placed but not tightened. The quilting sutures begin at the epigastric level and continue down to the wound edge at the pubic-inguinal line. Generally placing 30 to 40 sutures adds 30 minutes to the operation. It is important to continually check the skin flap, stretched to its final position after each line of stitches. "Dimples" on the exposed external surface of the skin require that the sutures be repositioned, where these dimples are pronounced (Figure 1). These sutures prevent shearing at the interface between the surgical planes. This is believed to prevent seromas. This same technique can be applied in a situation where movement between two tissue planes is likely to cause seroma formation.

Figure 1

A, An intraoperative view of an abdominoplasty with the skin flap retracted shows the extent of the dead space before the rectus abdominis muscles are plicated. B and C, Schematic and close-up transoperative aspect of the quilting suture. 3-0 Vicryl^® isolated stitches placed at 4 to 5 cm intervals bite the rectus abdominis muscle fascia and the cutaneous flap's superficialis fascia. These stitches are placed from the xiphoid down to the skin incision. The distribution of the stitches creates an image similar to that created by liposuction tunnels. Suction drains are usually removed during the second postoperative day. In the last 10 cases no suction drains have been used, and there have been no seromas.

Patients are instructed to rest at home during the first week of the postoperative period in a supine position with the trunk slightly elevated, alternating with a standing position or semiupright on a sofa. They should avoid long hours of sitting straight, because this position folds the flap, thereby compromising the adhesion between the two surfaces. We have successfully used this technique in 130 patients.

One of the authors (R.B.) first successfully used this technique approximately 12 years ago in a patient with lower limb traumatic avulsion. In that instance the patient was seen with a huge seroma that was being aspirated twice a week for 4 months and continued to recur, in spite of the compressive dressing applied after each aspiration. Irritant liquids were used three times without substantial improvement. The patient' serum protein and hemoglobin levels were getting lower and lower. Finally a previous 30-cm lateral thigh scar was entered. A pseudobursa was identified, and numerous 3-0 Vicryl^® sutures approximated its walls. A semicompressive bandage was used for 10 days. There was no recurrence of the seroma.

Axillary dissection combined with mastectomy leaves a significant dead space. Typically a suction drain remains until the drainage drops to a few milliliters per day or the drain becomes obstructed. If a seroma develops after the drain is removed, repeated aspiration is required. Fibrosis that may be symptomatic and require months of physiotherapy to improve may occur. The dissected segments of the pectoralis major, pectoralis minor, the serratus, and the latissimus dorsi are sutured to one another, as well as to the inner aspect of the skin flap, reducing to one quarter the primary dead space. A suction drain is still used but is removed after a maximum of 5 postoperative days. No seromas have been detected.

When we started using the quilting suture technique for abdominoplasties 5 years ago, we still used drains, but we noticed that the drainage was half of what it had been before this technique was used. In our last 10 cases of mini and traditional abdominoplasty, we omitted drains, and no seromas have developed. In the axilla, drains are still used but are left in no more than 4 to 5 days.

Treatment of Seroma

In situations where more traditional treatments of seroma have been unsuccessful, this technique is very useful. We have treated patients in whom treatment with local irritants (antibiotics, talcum powder, alcohol, iodine solution, steroids, etc) or revision surgery with pseudobursa resection or local suction have been attempted. In these situations we have opened the bursa and applied the quilting suture without resecting pseudomembrane (Figure 2). Skin closure and local compression are performed as previously described. No drainage is used. Compressive bandages remain for 10 days. There has been no recurrence of seromas in secondary surgeries managed in this manner.

Figure 2

A, Close-up view of an extensive abdominal bursa treated twice for recurrent seroma after traditional abdominoplasty in an obese male patient during the first 4 postoperative months. In the two previous operations the pseudomembrane was resected surgically. During aspiration of the seroma, steroids were injected in the cavity without success. The bursa surface seroma shows a granulation tissue aspect that was not resected in this stage. B, Close-up view demonstrates the quilting sutures being applied to all the extension of the bursa surface, following the surgical principles described. No drains were used and no seroma recurrence was observed.

Conclusion

We believe that seromas occur as a consequence of the shearing forces between the nonadherent skin flap and underlying muscle. We have found the use of closely applied quilting sutures in abdominoplasty, recurrent pseudobursas, tissue avulsion, and mastectomy are effective in preventing seroma.

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© 1998 American Society for Aesthetic Plastic Surgery

© 1998 American Society for Aesthetic Plastic Surgery

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Source: https://academic.oup.com/asj/article/18/6/439/277295

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