ABCR  Vol.2 No.1 , January 2013
Axillary “Exclusion”—A Successful Technique for Reducing Seroma Formation after Mastectomy and Axillary Dissection
Introduction: A seroma is the commonest complication of breast cancer surgery, and although its consequences most often cause no more than discomfort and anxiety, more important sequelae include flap necrosis and wound breakdown. Infection developing within seroma increases morbidity and often results in the need for re-admission, re-imaging, drainage and antibiotic usage. Numerous methods to reduce post-mastectomy seroma formation have been tried with no consistent success. Methods: 24 consecutive patients undergoing mastectomy and axillary clearance were recruited before and after a departmental change in practice. At the point of skin closure, patients either underwent “axillary exclusion” or not. Total drain outputs were recorded by community district nursing staff for all patients. At the first post-operative visit, the presence and severity of seroma was recorded. Results: 24 patients were included (study group 14, control group 10). Age, size of tumour, and number of positive lymph nodes and laterality were comparable between groups. Mean drain output for the entire group was 471 ml (3 - 1030 ml) over 5.21 days. The control group had a drain output of 763.5 ml (95%CI 674.2 - 852.8) while the study group had a mean drainage of 262.2 ml (95%CI 161.9 - 362.5), a reduction of over 65%, p < 0.001. 15 (62.5%) out of 24 patients developed seroma. 42.9% of the study group and 90% of the control group developed seroma, p < 0.01. Conclusion: Seromas are a common complication following mastectomy and axillary clearance. Our technique of axillary exclusion has resulted in significantly reduced drainage volumes and fewer seromas.

Cite this paper
Chand, N., Aertssen, A. and Royle, G. (2013) Axillary “Exclusion”—A Successful Technique for Reducing Seroma Formation after Mastectomy and Axillary Dissection. Advances in Breast Cancer Research, 2, 1-6. doi: 10.4236/abcr.2013.21001.
[1]   D. R. Aitken and J. P. Minton. “Complications Associated with Mastectomy,” Surgical Clinics of North America, Vol. 63, No. 6, 1983, pp. 1331-1352.

[2]   K. Tadych and W. L. Donegan. “Postmastectomy Seromas and Wound Drainage,” The Journal of Surgery, Gynecology and Obstetrics, Vol. 165, No. 6, 1987, pp. 483-487.

[3]   W. S. Halsted. “Developments in the Skin Grafting Operations for Cancer of the Breast,” Journal of the American Medical Association, Vol. 60, No. 6, 1913, pp. 416-451. doi:10.1001/jama.1913.04340060008004

[4]   E. C. Coveney, P. J. O’Dwyer, J. G. Geraghty and N. J. O’Higgins, “Effect of Closing Dead Space on Seroma Formation after Mastectomy—A Prospective Randomised Clinical Trial,” European Journal of Surgical Oncology, Vol. 19, No. 2, 1993, pp. 143-146.

[5]   E. A. Gonzales, E. C. Saltzstein, C. S. Riedner and B. K. Nelson, “Seroma Formation Following Breast Cancer Surgery,” Breast Journal, Vol. 9, No. 5, 2003, pp. 385-388. doi:10.1046/j.1524-4741.2003.09504.x

[6]   V. Benjasirichai, A. Piyapant, C. Pokawattana and J. Dowreang, “Reducing Postoperative Seroma by Closing of Axillary Space,” Journal of the Medical Association of Thailand, Vol. 90, No. 11, 2007, pp. 2321-2325.

[7]   K. Kuroi, K. Shimozuma, T. Taguchi, H. Imai, H. Yamashiro, S. Ohsumi and S. Saito, “Pathophysiology of Seroma in Breast Cancer,” Breast Cancer, Vol. 12, No. 4, 2005, pp. 288-293. doi:10.2325/jbcs.12.288

[8]   C. J. Pogson, A. Adwani and S. R. Ebbs, “Seroma Following Breast Cancer Surgery,” European Journal of Surgical Oncology, Vol. 29, No. 9, 2003, pp. 711-717. doi:10.1016/S0748-7983(03)00096-9

[9]   W. E. Burak, P. S. Goodman, D. C. Young and W. B. Farrar, “Seroma Formation Following Axillary Dissection for Breast Cancer: Risk Factors and Lack Of Influence of Bovine Thrombin,” Journal of Surgical Oncology, Vol. 64, No. 1, 1997, pp. 27-31. doi:10.1002/(SICI)1096-9098(199701)64:1<27::AID-JSO6>3.0.CO;2-R

[10]   A. Agrawal, A. A. Ayantunde and K. L. Cheung, “Concepts of Seroma Formation and Prevention in Breast Cancer Surgery,” ANZ Journal of Surgery, Vol. 76, No. 12, 2006, pp. 1088-1095. doi:10.1111/j.1445-2197.2006.03949.x

[11]   K. Kuroi, K. Shimozuma, T. Taguchi, H. Imai, H. Yamashiro, S. Ohsumi and S. Saito, “Effect of Mechanical Closure of Dead Space on Seroma Formation after Breast Surgery,” Breast Cancer, Vol. 13, No. 3, 2006, pp. 260-265. doi:10.2325/jbcs.13.260

[12]   J. Bonnema, D. A. Ligtenstein, T. Wiggers and A. N. van Geel, “The Composition of Serous Fluid after Axillary Dissection,” European Journal of Surgery, Vol. 165, No. 1, 1999, pp. 9-13. doi:10.1080/110241599750007441

[13]   J. A. McCaul, A. Aslaam, R. J. Spooner, I. Louden, T. Cavanagh and A. D. Purushotham, “Aetiology of Seroma Formation in Patients Undergoing Surgery for Breast Cancer,” Breast, Vol. 9, No. 3, 2000, pp. 144-148. doi:10.1054/brst.1999.0126

[14]   K. Jain, R. Sowdi, A. D. Anderson and J. MacFie, “Randomized Clinical Trial Investigating the Use of Drains and Fibrin Sealant Following Surgery for Breast Cancer,” British Journal of Surgery, Vol. 91, No. 1, 2004, pp. 54-60. doi:10.1002/bjs.4435

[15]   W. T. Y. Loo and L. W. C. Chow, “Factors Predicting Seroma Formation after Mastectomy for Chinese Breast Cancer Patients,” Indian Journal of Cancer, Vol. 44. No. 3, 2007, pp. 99-103. doi:10.4103/0019-509X.38940

[16]   E. Hashemi, A. Kaviana, M. Najafi, M. Ebrahimi, H. Hooshmand and A. Montazeri, “Seroma Formation after Surgery for Breast Cancer,” World Journal of Surgical Oncology, Vol. 2, 2004, p. 44. doi:10.1186/1477-7819-2-44

[17]   H. R. Unalp and M. A. Onal, “Analysis of Risk Factors Affecting the Development of Seromas Following Breast Cancer Surgeries: Seromas Following Breast Cancer Surgeries,” The Breast Journal, Vol. 13, No. 6, 2007, pp. 588-592. doi:10.1111/j.1524-4741.2007.00509.x

[18]   F. Lumachi, A. A. Brandes, P. Burelli, S. M. M. Basso, M. Lacobone and M. Ermani, “Seroma Prevention Following Axillary Dissection in Patients with Breast Cancer by Using Ultrasound Scissors: A Prospective Clinical Study,” European Journal of Surgical Oncology, Vol. 30, No. 5, 2004, pp. 526-530. doi:10.1016/j.ejso.2004.03.003

[19]   C. D. Knight Jr., F. D. Griffen and C. D. Knight Sr., “Prevention of Seromas in Mastectomy Wounds. The Effect of Shoulder Immobilization,” Archives of Surgery, Vol. 130, No. 1, 1995, pp. 99-101. doi:10.1001/archsurg.1995.01430010101021

[20]   W. E. Stebhens, “Postmastectomy Serous Drainage and Seroma: Probably Pathogenesis and Prevention,” ANZ Journal of Surgery, Vol. 73, No. 11, 2003, pp. 877-880. doi:10.1046/j.1445-2197.2003.02832.x

[21]   N. C. Estes and J. L. Glover, “Use of Vacutainer Suction as a Convenient Method of Resolving Postmastectomy Seromas,” Surgery, Gynecology & Obstetrics, Vol. 155, No. 4, 1982, pp. 561-562.

[22]   D. Oertli, U. Laffer, F. Haberthuer, U. Kreuter and F. Harder, “Perioperative and Postoperative Tranexamic Acid Reduces the Local Wound Complication Rate after Surgery for Breast Cancer,” British Journal of Surgery, Vol. 81, No. 6, 1994, pp. 856-859. doi:10.1002/bjs.1800810621

[23]   K. A. Porter, S. O’Connor, E. Rimm and M. Lopez, “Electrocautery as a Factor in Seroma Formation Following Mastectomy,” American Journal of Surgery, Vol. 176, No. 1, 1998, pp. 8-11. doi:10.1016/S0002-9610(98)00093-2

[24]   J. M. Garnier, A. Hamy, J. M. Classe, O. Laborde, P. Sagot, P. Lopes, G. Boog, J. C. Drianno and Y. Guillard, “A New Approach to the Axilla: Functional Axillary Lymphadenectomy and Padding,” Journal of Gynaecology, Obstetrics and Reproductive Biology, Vol. 22, No. 3, 1993, pp. 237-242.

[25]   J. M. Classe, P. F. Dupre, T. Fran?ois, S. Robard, J. L. Theard and F. Dravet, “Axillary Padding as an Alternative to Closed Suction Drain for Ambulatory Axillary Lymphadenectomy: A Prospective Cohort of 207 Patients with Early Breast Cancer,” Archives of Surgery, Vol. 137, No. 2, 2002, pp. 169-172. doi:10.1001/archsurg.137.2.169

[26]   A. Berger, C. Tempfer, B. Hartmann, P. Kornprat, A. Ross- mann, G. Neuwirth, A Tulusan and E. Kubista, “Sealing of Postoperative Axillary Leakage after Axillary Lymphadenectomy Using a Fibrin Glue Coated Collagen Patch: A Prospective Randomised Study,” Breast Cancer Research and Treatment, Vol. 67, No. 1, 2001, pp. 9-14. doi:10.1023/A:1010671209279

[27]   T. R. Chilson, F. D. Chan, R. R. Lonser, T. M. Wu and D. R. Aitken, “Seroma Prevention after Modified Radical Mastectomy,” American Surgeon, Vol. 58, No. 12, 1992, pp. 750-754.

[28]   A. D. Purushotham, E. McLatchie, D. Young, W. D. George, S. Stallard, J. Doughty, D. C. Brown, C. Farish, A. Walker, K. Millar and G. Murray, “Randomized Clinical Trial of No Wound Drains and Early Discharge in the Treatment of Women with Breast Cancer,” British Journal of Surgery, Vol. 89, No. 3, 2002, pp. 286-292. doi:10.1046/j.0007-1323.2001.02031.x

[29]   D. J. Browse, D. Goble and P. A. Jones. “Axillary Node Clearance: Who Wants to Immobilize the Shoulder?” European Journal of Surgical Oncology, Vol. 22, No. 6, 1996, pp. 569-570. doi:10.1016/S0748-7983(96)92164-2

[30]   C. Y. Chen, A. L. Hoe and C. Y. Wong, “The Effect of a Pressure Garment on Post-Surgical Drainage and Seroma Formation in Breast Cancer Patients,” Singapore Medical Journal, Vol. 39, No. 9, 1998, pp. 412-415.

[31]   J. Zavotsky, R. C. Jones, M. B. Brennan and A. E. Giuliano, “Evaluation of Axillary Lymphadenectomy without Axillary Drainage for Patients Undergoing Breast-Conserving Therapy,” Annals of Surgical Oncology, Vol. 5, No. 3, 1998, pp. 227-231. doi:10.1007/BF02303777

[32]   D. C. Rice, S. M. Morris, M. G. Sarr, M. B. Farnell, J. A. van Heerden, C. S. Grant, C, M. Rowland, D. M. Ilstrup and J. H. Donohue, “Intraoperative Topical Tetracycline Sclerotherapy Following Mastectomy: A Prospective, Randomized Trial,” Journal of Surgical Oncology, Vol. 73, No. 4, 2000, pp. 224-227. doi:10.1002/(SICI)1096-9098(200004)73:4<224::AID-JSO7>3.0.CO;2-0

[33]   R. Gupta, K. Pate, S. Varshney, J. Goddard and G. T. Royle, “A Comparison of 5-Day and 8-Day Drainage Following Mastectomy and Axillary Clearance,” European Journal of Surgical Oncology, Vol. 27, No. 1, 2001, pp. 26-30. doi:10.1053/ejso.2000.1054

[34]   J. Barwell, L. Campbell, R. M. Watkins and C. Teasdale, “How Long Should Suction Drains Stay in after Breast Surgery with Axillary Dissection?” Annals of the Royal College of Surgeons of England, Vol. 79, No. 6, 1997, pp. 435-437.

[35]   R. Anand, R. Skinner, G. Dennison and J. A. Pain, “A Prospective Randomised Trial of Two Treatments for Wound Seroma after Breast Surgery,” European Journal of Surgical Oncology, Vol. 28, No. 6, 2002, pp. 620-622. doi:10.1053/ejso.2002.1298

[36]   P. J. O’Dwyer, “Axillary Dissection in Primary Breast Cancer,” British Medical Journal, Vol. 302, No. 6773, 1991, pp. 360-361. doi:10.1136/bmj.302.6773.360

[37]   T. R. Chilson, F. D. Chan, R. R. Lonser, T. M. Wu and D. R. Aitken, “Seroma Prevention after Modified Radical Mastectomy,” American Surgeon, Vol. 58, No. 12, 1992, pp. 750-754.

[38]   W. H. Lindsey, T. M. Masterson, W. D. Spotnitz, M. C. Wilhelm and R. F. Morgan, “Seroma Prevention Using Fibrin Glue in a Rat Mastectomy Model,” Archives of Surgery, Vol. 125, No. 3, 1990, pp. 305-307. doi:10.1001/archsurg.1990.01410150027005

[39]   M. Moore, W. E. Burak Jr., E. Nelson, T. Kearney, R. Simmons, L. Mayers and W. D. Spotnitz, “Fibrin Sealant Reduces the Duration and Amount of Fluid Drainage after Axillary Dissection: A Randomized Prospective Clinical Trial,” Journal of the American College of Surgeons, Vol. 192, No. 5, 2001, pp. 591-599. doi:10.1016/S1072-7515(01)00827-4