What are the management options for a seroma?

Management Options for Seromas

Ultrasound-guided aspiration is the primary intervention for symptomatic seromas, providing effective drainage while reducing the risk of infection and improving patient comfort. 1

Definition and Etiology

• A seroma is a collection of serous fluid that typically develops within the first week following surgery, commonly after breast procedures, mastectomy, and axillary surgery 2, 3
• The exact cause is multifactorial, with surgical factors including technique, extent of dissection, and surgical devices used for dissection playing important roles 3

Risk Factors

• Higher body mass index (BMI) and larger breast size significantly increase the risk of seroma formation 4, 3
• Use of acellular dermal matrices in reconstruction cases increases seroma incidence 5, 6
• Additional risk factors include lymph node surgery, delayed reconstruction, prepectoral reconstruction, and smoking 4, 6
• Use of synthetic mesh for breast reconstruction also increases seroma risk 6

Management Algorithm

For Asymptomatic Seromas:

• Observation with regular monitoring via follow-up ultrasound examinations to assess for changes in size or characteristics 1
• Monitor for signs of infection including fever, increasing pain, or erythema over the collection site 1
• Avoid unnecessary interventions that could introduce infection risk 1

For Symptomatic Seromas:

1. Ultrasound-guided aspiration - First-line treatment for symptomatic seromas 1, 3

   • Reduces risk of infection compared to blind aspiration 1
   • For breast reconstruction cases, aspiration via the expander port site is effective 4
   • May require serial aspirations for complete resolution 3

2. Drainage considerations:

   • Prolonged drain placement beyond 3 weeks should be avoided to prevent infection 4
   • Early drain removal (within 7 days) is generally safe and doesn't significantly increase seroma formation 7
   • Use of single or multiple drains, early or late removal, and drains with or without suction do not significantly affect seroma incidence 3

3. Surgical techniques to prevent recurrence:

   • Obliteration of dead space using flap fixation techniques (quilting sutures) significantly reduces seroma formation and drainage duration 7, 8
   • For persistent seromas in breast reconstruction cases, pocket irrigation with Rifampin solution may help decrease lymphorrhea 6

4. Negative pressure wound therapy (NPWT):

   • Application of NPWT on closed surgical incisions has shown reduced surgical site infection rates in multiple studies 5
   • NPWT may be considered for high-risk patients, though evidence specifically for seroma prevention is less robust 5

Special Considerations

• Patients with implants or prosthetic materials require more aggressive management to prevent infection that could lead to implant loss 1, 4
• For persistent seromas after breast reconstruction, serial aspiration via expander port site while continuing expansion provides a safe method to manage seromas and avoid expander loss 4
• Early shoulder movement post-operatively may increase seroma formation, while delayed physiotherapy decreases it 3

Complications and Pitfalls

• Prolonged seromas increase infection risk and may delay adjuvant therapy 3, 6
• Avoid multiple blind aspirations without imaging guidance as this increases risk of complications 1
• In breast reconstruction cases, seroma-related infection can lead to implant loss in approximately 2% of cases 6
• Large seromas may obscure small residual calcifications on post-operative mammograms in breast cancer patients 2

The evidence suggests that while prevention through surgical techniques like quilting sutures and appropriate drain management is ideal, ultrasound-guided aspiration remains the most effective treatment for established symptomatic seromas 1, 3, 8.