Effect Of Flap Fixation On Seroma Formation After Modified Radical Mastectomy

INTRODUCTION

One in every ten new cancer diagnoses in women is breast cancer, which is the most frequent non-cutaneous malignancy. It is estimated that breast cancer is the second leading cause of mortality for women worldwide Breast conserving surgery and various forms of mastectomies with or without reconstruction play an important part in the therapy of operable breast cancer .¹

Necrosis of surgical skin flaps, wound dehiscence, surgical site infection, and seroma formation, are all reported postoperatively. The most common post-operative complication following breast cancer surgery is seroma, which is a clinically obvious subcutaneous collection of serous fluid within a surgical cavity which constitutes about 30 percent of overall complications, late wound healing, infection, necrosis of skin flap as well as patient pain all have the potential to exacerbate seroma production.²

Repeated punctures of the skin to remove seroma fluid can cause infection in the area where they are performed. In rare cases where infection occurs, a seroma may cause a delay in the initiation of chemotherapy.³

Women in Egypt have enormous breasts, which leads to increased fluid outflow following mastectomy because of the large raw areas .⁴

Seroma formation's pathogenesis is a mystery. The emergence of seroma is influenced by a wide range of circumstances. Postoperative seroma production may be facilitated by the establishment of dead space. The main reason for seroma formation is that damaged lymphatics and small blood vessels continue to leak into dead space after surgery.⁵

After breast surgery, accumulation of fluid is more common due to a variety of other circumstances. If the dissection is extensive, for example, there will be a lot of empty space under the flaps. As a result of abnormalities in the chest wall, flaps have a difficult adhering, particularly in the deep axillary fossa. Shearing forces are created by the constant movement of the chest wall caused by breathing and using the shoulder, which delays the adherence of the flap.⁶

Serum oozing and Lymph leakage should be minimized in an ideal wound closure, as well as dead space being eliminated, and fluid being removed quickly once it occurs. As a result, various flap fixation or wound drainage methods and restrictions on postoperative shoulder movement have been implemented.⁷

Mechanical closure of the dead space after axillary dissection for breast cancer can help to limit seroma formation, but it cannot completely eliminate it. Patients without drains were discharged earlier with flap fixation compared to closed suction drainage, but there was no change in seroma rates between the two methods.⁸

The amount of fluid drained from the flap fixation group was much lower and quilting the skin flaps reduced surgical site infections and seroma formation.⁹

PATIENTS AND METHODS

Thirty breast cancer women who were planned for modified radical mastectomy with axillary lymphadenectomy underwent this prospective randomized study from January to July 2021 at the Department of General Surgery, Al-Azhar University Hospitals. All patients were given a full assessment that included a detailed medical history, a thorough physical exam, laboratory tests, and an imaging study, biopsy to all patients.

Each of the thirty patients was assigned to one of 2 groups: either the study (15 patients) or the control group (15 patients).

Classic known modified radical mastectomy was standardized for all patients of the two groups with the operation being done under general anesthesia

In the study group:

There are numerous stitches in total. Fine absorbable sutures (vicryl 3/0) were used to sew rows of 3 cm apart between the subcutaneous tissues of the skin flaps and the underlying muscles at various points on the flap and at the wound edge. 

Closed suction drains were used:

Control group:

Suction drains were also employed to seal the wound conventionally. Every day, the amount of fluid evacuated, and the color of the fluid were noted. Drains were removed when the flow rate dropped below 40 cc/24 hours or the drained fluid became infected, regardless of how much had been drained in the previous days.

Patients were examined clinically for presence of seroma one week after drain removal

Following the removal of the drains, a chest wall ultrasonography was conducted to determine whether any collections had occurred.

Total fluid drained, duration, and formation of seroma have all been tracked down and analyzed.

Statistical methods

SPSS version 15 was used to analyze the collected data (SPSS Inc., Chicago, IL, USA). Statistics such as mean and standard deviation (SD) were used for quantitative information, and percentages were used for qualitative information. For quantitative variables, the independent student test was used to determine the significance of the difference, while the Chi square or Fisher's exact test was used to determine the significance of the difference. P-values of 0.05 and lower were considered statistically significant for this study.

RESULTS

Table 1: Comparison between studied groups as regard operative data (MW: Mann Whitney U test, T: independent sample T test; NS: p-value higher than 0.05 is non-significant).When it comes to operative statistics, this table doesn't demonstrate any statistically significant differences (p-value > 0.05) between the groups investigated (volume of tumor mass removed, number of positive LNs removed, total number of LNs removed, and area of skin removed).

Table 2: Comparison between studied groups as regard tumor characteristics. (X2: Chi-square test. NS: p-value higher 0.05 is considered non-significant). There is no statistically significant difference (p-value > 0.05) in tumor features between the groups tested, as shown in this table (histological types, tumor state, T stage, N stage and Neoadjuvant chemotherapy).

Table 3: Comparison between studied groups as regard post-operative data. (S: p-value lower than 0.05 is considered significant.; HS: p-value lower than 0.001 is considered highly significant.; T: independent sample T-test.NS: p-value > 0.05 is considered non-significant.) This table shows as far as drained serous fluid, there was no statistically significant difference (p-value > 0.05) between the groups tested in the last three days. Difference between groups in terms of drained serous fluid in the last day that is statistically significant (p-value 0.05). The difference between the groups tested in terms of the day the drain was removed and the total amount of serous fluid that was drained was highly significant (p-value 0.001).

Table 4: Association between seroma formation and tumor characteristics in cases group.This table shows that there was no association between the frequency of seroma and tumor characteristics. However, this could not be proved statistically due to the small number of cases in the group that developed seroma (n = 2).

Table 5: Correlation study between total amount of drained serous fluid and tumor characteristics in cases group. (r: Pearson correlation coefficient). This table shows: This is statistically significant. Between the total amount of drained serous fluid and the excised skin area, there was a positive association (r = 0.62) . The difference is statistically significant (p-value = 0.038). In case group, there was a positive connection (r = 0.53 between the total amount of drained serous fluid and the total amount of tumor mass removed). Total amount of drained serous fluid and number of positive LNs in cases group showed statistically significant (p-value = 0.022) and Positive correlation (r = 0.85). Total amount of drained serous fluid and total number of LNs removed in cases group showed non statistical significant (p-value = 0.058) Positive correlation (r = 0.49). Between total amount of drained serous fluid and T stage in cases group, there was Statistically significant (p-value = 0.015) Positive correlation (r = 0.61). Between total amount of drained serous fluid and tumor state in cases group, there was No statistical significant (p-value = 0.071) Positive correlation (r = 0.47).

Table 6: Comparison between studied groups as regard frequency of seroma formation. (X²: Chi-square test.; S: p-value lower than 0.05 is considered significant. Statistically significant (p-value 0.05) differences between study groups are shown in this table as regards the frequency of seroma development.