What are the management options for a seroma?

Management of Seroma

For symptomatic seromas, ultrasound-guided aspiration is the primary intervention and should be performed serially as needed, while asymptomatic seromas require only monitoring without therapeutic intervention. 1

Initial Assessment and Diagnostic Approach

Ultrasound is the imaging modality of choice for evaluating seromas, as it can be performed at bedside, is inexpensive, and allows for simultaneous aspiration if needed. 1 While ultrasound effectively detects fluid collections, it cannot always differentiate between seroma, hematoma, or abscess—if findings are indeterminate, proceed to CT or MRI for better characterization. 1

Key clinical features to assess:

• Timing: Seromas typically develop within the first week following surgery 2
• Symptoms: Look for breast swelling, asymmetry, sensation of fullness, or signs of infection (fever, increasing pain, erythema) 2, 1
• Risk factors: Acellular dermal matrices, lymph node surgery, delayed reconstruction, prepectoral reconstruction, higher BMI, and larger breast size increase seroma risk 3, 2, 4

Management Algorithm

For Asymptomatic Seromas:

• Do not intervene therapeutically to avoid unnecessary procedural risks 1
• Implement regular monitoring with follow-up ultrasound to assess for changes in size or characteristics 1
• Screen patients for signs of infection including fever, increasing pain, or erythema 1

For Symptomatic Seromas:

Primary Management: Serial Ultrasound-Guided Aspiration

• Ultrasound-guided aspiration significantly reduces procedural complications compared to blind aspiration and is the treatment of choice 1
• For breast reconstruction with tissue expanders, aspiration via the expander port site in clinic is effective and safe 4
• Continue tissue expander inflation during serial aspirations to reduce the seroma pocket size 4
• Recurrent transcutaneous aspiration remains the only consistently successful management approach 5

Drain Management (If Present):

• Remove drains when output is <30 ml daily, ideally not surpassing 7-14 days of use 3
• Avoid prolonged drain placement beyond 3 weeks, as this increases infection risk 4
• Keep surgical bulb at gravity at all times to prevent drained fluid from re-entering the surgical pocket 3
• Screen for fluid accumulation after drain removal 4

For Infected Seromas:

Surgical incision and drainage is 100% effective and should be the definitive treatment for infected seromas, as it results in faster discharge (3 versus 5 days) and fewer total hospital days compared to aspiration or antibiotics alone. 6

• Initial conservative management with IV antibiotics alone has a 52.4% failure rate 6
• US-guided aspiration of infected seromas has a 27.8% failure rate 6
• Ultimately, 62.5% of infected seromas require surgical management 6

For Chronic/Recurrent Seromas:

Sclerotherapy with doxycycline is an effective solution for chronic seromas that fail serial aspiration, particularly when used with negative pressure wound therapy systems. 7 For persistent sterile collections (seromas, lymphoceles), intracavitary instillation of sclerotherapy agents such as ethanol, doxycycline, or tetradecyl sulfate achieves high success rates in shortening catheterization periods. 3

Special Considerations

Post-Reconstruction Seromas:

• Seromas between acellular dermal matrix and implant are relatively isolated from the host's immune system, increasing infection probability 3
• Early expansion of tissue expanders decreases seroma pocket size but must be balanced against risk of skin flap necrosis 3
• There is no difference in infection or explantation rates between seroma and no-seroma patients when managed appropriately 4

Prevention of Secondary Infection:

• Place drains through subcutaneous tunnels 3
• Consider chlorhexidine-impregnated dressing at drain exit sites, exchanged weekly 3
• Use daily antiseptic solution within surgical bulb to decrease bacterial colonization 3

Critical Pitfalls to Avoid

• Never perform multiple blind aspirations without imaging guidance, as this increases complication risk 1
• Do not manipulate collections near vascular structures without proper imaging guidance to avoid vascular injury 1
• Avoid very early drain removal within 24 hours, as this paradoxically increases seroma formation 5
• Do not confuse subcutaneous seroma with other fluid collections in different anatomic spaces, as management differs 8
• For patients with cirrhosis or coagulopathy undergoing aspiration, monitor closely for bleeding complications 1