What is the recommended treatment for a patient with a persistent seroma in the right buttock, status post Brazilian Butt Lift (BBL), with non-odorous drainage and no signs of infection, but stable vital signs?

Management of Persistent Seroma Following Brazilian Butt Lift

For this patient with a persistent, non-infected seroma 6 months post-BBL, serial ultrasound-guided aspiration via the seroma cavity should be performed, and if this fails after multiple attempts, percutaneous instillation of fibrin sealant offers definitive treatment with a 100% success rate for refractory seromas. 1

Initial Management Approach

Serial Aspiration Protocol

• Continue with serial ultrasound-guided needle aspiration as the primary management strategy, as this remains the most successful conservative approach for persistent seromas 2, 3
• Perform aspirations in an outpatient setting, completely evacuating the seroma cavity at each session 1
• Avoid prolonged drain placement beyond 3 weeks, as this increases infection risk without improving outcomes 3
• Monitor closely for signs of infection development after each aspiration, as fluid accumulation increases infection risk even in initially sterile seromas 3

Key Clinical Monitoring Points

• Screen for fluid reaccumulation between aspiration sessions through physical examination 3
• Document seroma volume at each aspiration to track response 1
• Watch for development of infection signs: fever, purulent drainage, erythema, or systemic symptoms, as fluid collections can become secondarily infected 4, 3
• Obtain wound cultures if any signs of infection develop to guide antibiotic therapy 4

Definitive Treatment for Refractory Seromas

Fibrin Sealant Instillation

If the seroma persists despite 4-6 weeks of serial aspirations (which defines it as refractory), proceed with percutaneous instillation of fibrin sealant 1:

• Completely aspirate the seroma cavity first 1
• Dilute thrombin concentration to 5 IU/ml to increase polymerization time 1
• Instill 20 ml of fibrin sealant through a dual-lumen catheter into the evacuated cavity 1
• This technique achieved 100% resolution in refractory seromas versus only 23% success with continued aspiration alone (p = 0.0077) 1
• Single treatment is typically sufficient with no recurrence 1

Alternative Sclerotherapy Option

Tetracycline sclerotherapy can be considered as an alternative for persistent seromas that fail conservative management 5:

• Provides rapid resolution without major complications 5
• Simpler technique than fibrin sealant but less evidence in the plastic surgery literature 5

Rifampin Pocket Irrigation

For seromas associated with implant-based reconstruction (relevant given BBL involves fat grafting), Rifampin solution irrigation of the pocket may reduce lymphorrhea by 50% 6:

• This technique is particularly useful when there is prolonged lymphatic drainage 6
• Can be performed during aspiration procedures 6

Risk Factors and Prevention Considerations

Patient-Specific Factors

The following increase seroma risk and may explain persistence 6, 2, 3:

• Higher body mass index and body weight 2, 3
• Smoking status 6
• Larger volume of fat transfer 3

Surgical Technique Factors

• Use of synthetic mesh materials increases seroma risk 6
• Extent of tissue dissection correlates with seroma formation 2
• Electrocautery use during dissection increases risk 2

Critical Pitfalls to Avoid

Infection Prevention

• Do not allow seromas to persist untreated, as prolonged fluid collections significantly increase infection risk and can lead to fat graft loss 6, 3
• If infection develops, obtain cultures and initiate empiric broad-spectrum antibiotics covering gram-positive organisms including MRSA, gram-negative organisms, and anaerobes 4
• For purulent drainage or signs of infection, empiric outpatient options include: clindamycin, TMP-SMX, or doxycycline/minocycline 4

Aspiration Technique

• Always use sterile technique during aspiration to prevent introducing infection 3
• Avoid very early drain removal (within 24 hours) as this paradoxically increases seroma formation 2
• Do not leave drains in place longer than 3 weeks, as this increases infection risk without benefit 3

When to Escalate Care

Hospitalization and surgical consultation are indicated if the patient develops 4:

• Systemic signs: fever, tachycardia (>100 bpm), hypotension
• Pain disproportionate to physical findings
• Rapid progression of symptoms
• Skin changes suggesting deeper infection (violaceous bullae, hemorrhage, sloughing)

Treatment Timeline

At 6 months post-procedure with ongoing seroma, this qualifies as refractory 1. The patient has already exceeded the typical timeframe for conservative management success. Proceed directly to fibrin sealant instillation rather than continuing indefinite serial aspirations, as the likelihood of spontaneous resolution is minimal and continued aspiration alone has only a 23% success rate 1.