What is the best management approach for a post-mastectomy patient with a hematoma?

Post-Mastectomy Hematoma Management

Hematomas after mastectomy require immediate surgical evacuation when signs of airway compromise or significant tension on the skin are present; needle aspiration should be avoided due to infection risk. 1, 2

Immediate Recognition and Assessment

Critical Warning Signs

• Monitor for the DESATS criteria: Difficulty swallowing/discomfort, increase in Early warning score, Swelling, Anxiety, Tachypnea/difficulty breathing, and Stridor 1
• Most hematomas present within the first 24 hours postoperatively, with 82% diagnosed on postoperative day 0 or 1 3
• Hourly observations are essential for the first 6 hours after surgery 1
• Stridor is a late sign of airway compromise and indicates immediate intervention is required without delay 1

Common Hematoma Locations

• Pectoralis muscle (50% of cases) 3
• Axillary region (21.4% of cases) 3
• Subcutaneous tissues 4

Management Algorithm

When Airway Compromise or Significant Skin Tension is Present

Immediate bedside evacuation using the SCOOP approach: 1

1. Skin exposure
2. Cut sutures
3. Open skin
4. Open muscles (superficial and deep layers)
5. Pack wound

• Administer supplemental oxygen and position patient head-up immediately 1
• Notify senior anesthetist without delay 1
• A post-surgical emergency box must be available at bedside containing equipment for opening the wound 1

Formal Surgical Evacuation (Standard Approach)

For hematomas without airway compromise but requiring intervention: 2

• Perform formal surgical evacuation rather than needle aspiration to avoid introducing skin flora into the pocket and subsequent infection risk 2
• Achieve meticulous hemostasis with cautery of all bleeding sites 2
• Perform thorough pocket irrigation to remove debris and identify persistent bleeding 2
• Consider antibiotic-soaked sponges for tamponade during the procedure 2

Risk Factors and Prevention

Identified Risk Factors

• Individual surgeon variability is the only measurable independent risk factor (odds ratio 2.54-3.58) 3
• No definitive preoperative, operative, or oncologic characteristics predict hematoma formation 3
• African American race and increased comorbidities are associated with unplanned return to care 5

Preventive Strategies That Reduce Hematoma Rates

Evidence-based measures that decreased hematoma revision rates from 9.2% to 4.1%: 6

• Perioperative administration of tranexamic acid 6
• Intraoperative elevation of blood pressure to at least 120 mmHg before wound closure 6
• Bedrest and continuous compression bandage without removal for 12 hours postoperatively 6
• Meticulous hemostasis focused on chest wall musculature given its propensity as the primary bleeding source 3

Critical Pitfalls to Avoid

• Never delay surgical intervention when airway compromise is developing - waiting for stridor is inappropriate as this is a late sign 1
• Never perform needle aspiration of suspected hematomas due to infection risk from introducing skin flora 1, 2
• Never manage hematomas conservatively when airway compromise is present or developing 1
• Avoid inadequate hemostasis during initial surgery, particularly at the pectoralis muscle and axillary regions where most hematomas originate 3
• Do not discharge patients without proper education on drain care, pain management, and 24-hour access to medical care 5

Adjunctive Therapies

Hyperbaric Oxygen Therapy (HBOT)

• HBOT may be beneficial for mitigating post-mastectomy complications including hematoma, though evidence is limited to Level III-V studies 7
• HBOT improves tissue oxygenation and vascularization, potentially aiding wound healing after hematoma evacuation 7
• Consider HBOT as adjunctive therapy for complicated cases with poor wound healing following hematoma management 7

Follow-up Considerations

• Hematoma formation produces changes that make physical examination difficult and may lead to evolving scar tissue that complicates mammographic interpretation long-term 4
• Late hematomas (years after surgery) are rare but can occur with traceable trauma; these require thorough evaluation and formal surgical management 8
• Overall hematoma rates after mastectomy with immediate reconstruction range from 0-5.1% in contemporary series 5