How to prevent complications after MRM?

Prevention of Complications After Modified Radical Mastectomy

Regular monitoring, early intervention, and proper wound care are essential to prevent complications after modified radical mastectomy (MRM), including seroma formation, wound infections, and flap necrosis.

Common Complications After MRM

Recent evidence shows that MRM is associated with significant postoperative complications:

• Seroma formation: Occurs in approximately 23% of patients, typically around postoperative day 8-9 1
• Wound infections: Observed in about 11% of patients, usually around postoperative day 5 1
• Flap necrosis: Less common but serious complication
• Hematoma: Can occur in the immediate postoperative period

Preoperative Measures

1. Risk factor assessment:

   • Age >60 years (associated with increased seroma risk) 2
   • Obesity (associated with increased infection risk) 2
   • Smoking status (associated with epidermolysis) 2
   • Comorbidities

2. Preoperative optimization:

   • Smoking cessation at least 4 weeks before surgery
   • Glycemic control in diabetic patients
   • Nutritional assessment and optimization

Intraoperative Techniques

1. Surgical technique optimization:

   • Consider using harmonic scalpel which may reduce blood loss (mean 57.5 ml vs. conventional techniques) 3
   • Meticulous hemostasis during surgery
   • Careful handling of tissue flaps

2. Wound closure considerations:

   • Application of fibrin glue under flaps and in axilla can significantly reduce lymphatic drainage and seroma formation (9% vs. 34.78% in control groups) 4
   • Proper placement of closed suction drains

Postoperative Management

1. Drain management:

   • Monitor drainage volume daily
   • Remove drains when output is less than 30-50 ml/24 hours 2
   • Be aware that drainage volume >30 ml in 24 hours before drain removal is associated with seroma formation 2

2. Wound care:

   • Regular inspection of surgical site
   • Early detection and treatment of complications
   • Proper dressing changes using sterile technique

3. Patient education:

   • Arm exercises to prevent shoulder stiffness
   • Signs of infection to watch for (redness, warmth, pain, discharge)
   • When to seek medical attention

4. Follow-up schedule:

   • First follow-up within 1 week of discharge
   • Regular follow-ups for at least 6 weeks to monitor for complications

Special Considerations

1. Perioperative antibiotics:

   • Consider prophylactic antibiotics, especially in high-risk patients

2. Physical therapy:

   • Early mobilization to prevent shoulder stiffness
   • Gradual introduction of arm exercises

3. Compression garments:

   • May help reduce seroma formation in selected patients

Management of Specific Complications

1. Seroma:

   • Aspiration under aseptic conditions if symptomatic
   • Consider repeated aspirations if recurrent
   • Compression dressings may help

2. Wound infection:

   • Culture-directed antibiotics
   • Wound care and possible debridement if severe

3. Flap necrosis:

   • Conservative management for minor necrosis
   • Surgical debridement for extensive necrosis

Risk Stratification

Patients can be stratified into risk categories to guide preventive measures:

• High risk: Age >60, obese, smokers, extensive axillary dissection

  • More intensive monitoring
  • Consider additional preventive measures (fibrin glue, compression)

• Standard risk: Younger, non-obese, non-smokers

  • Standard postoperative care and monitoring

By implementing these evidence-based strategies, the incidence and severity of complications after MRM can be significantly reduced, leading to improved patient outcomes and quality of life.