Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bl

Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Reynaldo O. Joson, MD, MS Surg
Collator / Researcher / Rapporteur
Division of Surgical Oncology
UPM Centennial Professorial Chair (2008)

Objectives:
1) To share UPM-PGH Department of Surgery’s
experience with morbidities following modified
radical mastectomy (MRM) for patients with
breast cancer;
2) To provide updates on clinical management
(prevention, detection, and treatment) of common
morbidities following MRM.

Contents:
1) Concept of morbidities following MRM;
2) Common morbidities following MRM (experience
from PGH; Division’s consultants; literature);
3) How to prevent, detect, and treat common
morbidities following MRM (Division consultants’
evidence-process based recommendations).

Methodologies:
1) Statistics and data gathering (local and foreign);
2) Review of literature on the concept and how to
prevent, detect, and treat;
3) Consensus-gathering among Division’s
consultants (Drs. Dofitas, de la Peňa, Cabaluna,
Kho, Bisquera, Espiritu, Lim, Uy, de la Paz, and
Joson)

For Division of Surgical Oncology

Concept
Operational Definition of Mastectomy
Morbidities

Concept and Operational Definition
Morbidities occurring as a result of modified radical
mastectomy [MRM] (total mastectomy and
axillary dissection).
Undesirable effects short of death or mortality.
Complications, side-effects, and adverse events may
be used interchangeably with “morbidities” as
long as no mortality has occurred.

(derived from survey of Division’s consultants)
Some mastectomy morbidities are
INEVITABLE, such as the incisional scar and incisional pain
CONTROLLABLE / PREVENTABLE TO A CERTAIN DEGREE,
such as seroma, numbness of medial aspect of arm, and
lymphedema
HIGHLY CONTROLLABLE / PREVENTABLE, such as flap
necrosis, wound dehiscence, infection, and bleeding /
hematoma

(derived from survey of 10 Division’s consultants)
Mastectomy
morbidities
Inevitable Controllable to
a certain
degree
Highly
controllable /
preventable
Seroma 7 3
Bleeding / hematoma 10
Infection 10
Flap necrosis 10
Dehiscence 10
Numbness 4 6
Chronic incisional
pain
5 5

Mastectomy
morbidities
a certain
degree
Highly
controllable /
preventable
Hypertrophic scar -
keloids
3 7
Dog ears 4 6
Lymphedema 6 4
Local recurrence 2 8

Mastectomy
morbidities
a certain
degree
Highly
controllable /
preventable
Hypertrophic scar -
keloids
3 7
Dog ears 4 6
Lymphedema 6 4
√ √ √

Mastectomy
morbidities
a certain
degree
Highly
controllable /
preventable
Hypertrophic scar -
keloids
3 7
Dog ears 4 6
Lymphedema 6 4
√ √ √
ALWAYS control / prevent AS MUCH AS
POSSIBLE.
ALWAYS inform patients of risk
PREOPERATIVELY!

Scope of Lecture
Limited to operative morbidities, those
directly related to the operation of a
modified radical mastectomy.
SEROMA, INFECTION, HEMATOMA, FLAP
NECROSIS, LATERAL DOG-EAR DEFORMITY
Anesthetic and other types of morbidities
such as those associated with patient and
pharmacologic factors excluded.

Common morbidities following MRM
(statistics on frequency)
Experience from PGH
Division’s consultants
Literature

Common Morbidities Following MRM
(PGH GS1 data – 04-07)
MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535)
Seroma - - 5 (1.3%) 5 (0.9%)
Graft loss - - - 2 (0.3%)
SSSI - - 6 (1.5%) 6 (1.1%)
Axillary vein injury - - - 2 (0.3%)
Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%)
Flap Necrosis - 1 (0.2%) - 2 (0.3%)
Pneumothorax 2 (0.3%) - - -
HAP - 2 (0.5%) - -
AMI - - - 1(0.1%)

MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535)
Seroma - - 5 (1.3%) 5 (0.9%)
Graft loss - - - 2 (0.3%)
SSSI - - 6 (1.5%) 6 (1.1%)
Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%)
Flap Necrosis - 1 (0.2%) - 2 (0.3%)
Note 1: Hematoma, infection, and seroma are the relatively
more common mastectomy morbidities as seen in the PGH GSI
data.

MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535)
Seroma - - 5 (1.3%) 5 (0.9%)
Graft loss - - - 2 (0.3%)
SSSI - - 6 (1.5%) 6 (1.1%)
Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%)
Flap Necrosis - 1 (0.2%) - 2 (0.3%)
Note 2: NO reports of sensory loss, chronic pain, dehiscence and
lymphedema (as seen in consultants’ experience as reflected in
the survey of Division’s consultants).

Surveyed Data from GSI Consultants on Top 3-5 Mastectomy
Morbidities – July 10, 2008 (1 – being most common)
Consultant 1 2 3 4 5
1 seroma hematoma wound
infection
flap
necrosis
chronic
incisional
pain
2 seroma hematoma flap
necrosis
wound
infection
lymphedema
of the arm
3 seroma wound
infection
wound
dehiscence
flap
necrosis
hematoma
4 sensory
loss,
median
aspect of
arm
seroma hematoma
5 seroma hematoma infection

6 seroma flap
necrosis
(edge)
hematoma wound
infection
wound
dehiscence
7 seroma infection hematoma flap
necrosis
8 seroma chronic
incisional
pain
hematoma wound
infection
flap
necrosis
necrosis
10 numbness,
arm
seroma hematoma wound
infection
flap
necrosis

6 seroma flap
necrosis
(edge)
hematoma wound
infection
wound
dehiscence
necrosis
8 seroma chronic
incisional
pain
hematoma wound
infection
flap
necrosis
necrosis
10 numbness,
arm
infection
flap
necrosis
Note:
With reports of sensory loss,
chronic pain, dehiscence and
lymphedema as morbidities
(NOT seen in PGH GSI data).

6 seroma flap
necrosis
(edge)
hematoma wound
infection
wound
dehiscence
necrosis
8 seroma chronic
incisional
pain
hematoma Wound
infection
flap
necrosis
necrosis
10 numbness,
arm
infection
flap
necrosis
Note:
Seroma, hematoma, and
infection are within the top
5 most common
mastectomy morbidities.

(Review of Literature)
Because it is a peripheral soft tissue organ,
many wound complications related to breast procedures
are relatively minor and
frequently are managed on an outpatient basis.
It therefore is difficult to establish accurate incidence rates
for these events.
Ref: Complications in Breast Surgery. Angelique F. Vitug, Lisa A.
Newman. Surg Clin N Am (2007) 87:431–451.

Common morbidities following MRM
Incidence rates
Overall morbidity 30%
Seroma 10 to 80%*
Infection 1% to 20% [3.8% - meta-ana > 2500 pts]**
Hematoma 2-10%
Ref: Vitug AF, Newman LA. Complications in Breast Surgery. Surg Clin N Am 2007;
87:431–451.
*Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. Eur J Surg
Oncol 2003; 29(9):711–7.
**Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound
infection following breast surgery. J Antimicrob Chemother 1993;31(Suppl B):43–8.

How to prevent, detect, and treat common
morbidities following MRM
Survey of Consultants’ Practices and
Recommendations
Review of Literature
Consensus-gathering
Evidence-process-based Recommendations

Postmastectomy
Seroma
Physical Examination
Signs for Pattern Recognition
Bulge under the flaps with signs
suggestive of presence of fluid such as
fluctuancy and fluid wave

Postmastectomy
Seroma
Diagnostic Procedures (if
needed) and Positive
Findings
Needle aspiration –
yellowish, nonsanguinous
fluid

Postmastectomy
Seroma
Prevention Treatment
Seroma Avoid fluid accumulation under
the flaps
Continual drainage until
fluid accumulation stops

Mastectomy Morbidities: Prevention and Treatment
Management Principles
the flaps
GS1 Division’s Recommended Practice:
Closed tube suction drain at axillary space
Medial drain indicated if there is a significant cavity
after laying down of flaps prior to wound repair
Drain removed if output is less than 50 cc past 24 hours
(assumption: tube functional)
Drain may stay as long as needed if NO indication to remove
it such as dysfunctionality and infection.

the flaps
GSI Division’s Recommended Practice:
Needle aspiration of seroma until fluid accumulation stops.
Usually weekly or as required by patient’s symptoms.
NOT DAILY.

Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
Recommendation: Repeated Aspirations
How frequent?
Daily or based on patient symptoms?
Conclusion: DAILY aspiration of symptomatic seroma
did NOT result in swifter resolution!
Anand R, Skinner R, Dennison G, Pain J. A prospective randomised trial of two
treatments for wound seroma after breast surgery. Euro J Surg Oncol, 2003;
28(6):620 - 622
RCT [36 patients]

Postmastectomy
Seroma
Process - Pathophysiology
(collection of serum in a cavity)
Reabsorption / re-
establishment of
lymphatic channels
Cavity for fluid accumulation
Transected lymphatic
vessels cause serum
fluid entry into cavity

Postmastectomy Seroma
Reabsorption / re-
establishment of
lymphatic channels
vessels cause serum
Minimize
transection!
Just have to
wait!
Minimize
and avoid if
possible!
Minimize
and avoid!

N=90 patients Incidence of
seroma
Duration of seroma
(until resolution)
NO drainage 97% 16% (2-3 weeks)
84% (4 weeks)2-day drainage 86%
Prolonged closed-
suction drainage (10
days)
73%
Talbot ML, Magarey CJ. Reduced use of drains following axillary lymphadenectomy for
breast cancer. ANZ J Surg 2002;72(7):488–90.
Drainage is
advised to avoid
seroma!
(unless there is
NO cavity!)

Postmastectomy Seroma
Reabsorption / re-
establishment of
lymphatic channels
vessels cause serum
Minimize
transection!
Just have to
wait!
Minimize and avoid if possible!
OBLITERATION
Chemical / Mechanical Means!

OBLITERATION OF CAVITY by Chemical Manuevers
Sclerosing agents (tetracycline)
Bovin thrombin
Fibrin glue, sealants, patches
Steroids
LIMITED SUCCESS / INCONSISTENT RESULTS
COST
AVAILABILITY

OBLITERATION OF CAVITY by Mechanical Means
Axillary padding
External compression
External garment
do NOT significantly reduce incidence of seroma!

Obliteration of Cavity by Mechanical Means
Axillary padding does NOT significantly reduce incidence of
seroma.
RCT [135 patients] Incidence of seroma aspiration
Axillary padding (4 days) 2.9
Catheter drainage with no
padding
1.8
Classe J, Dupre P, Francois T, et al. Axillary padding as an alternative to closed
suction drain for ambulatory axillary lymphadenectomy. Arch Surg 2002;137:169–73.

External compression does NOT significantly reduce
incidence of seroma.
RCT N Amount of
drainage
(P = 0.48)
Number of days
with drain (P =
0.69)
No. of seroma
aspiration
(P <0.01)
Catheter drainage with
compression dressing
(4 days)
66 490 cc 6.4 2.9
Catheter drainage with
no compression
dressing
69 517 cc 6.1 1.8
O' Hea BJ, Ho MN, Petrek JA: External compression dressing versus standard dressing
after axillary lymphadenectomy. Am J Surg 1999, 177:450-453.

External garment does NOT significantly reduce incidence of
seroma.
Chen CY, Hoe AL, Wong CY. The effect of a pressure garment on post-surgical
drainage and seroma formation in breast cancer patients.
Singapore Med J. 1998 Sep;39(9):412-5.
RCT- Use of a pressure garment
NO improvement in post-operative drainage
“One of the patients in the pressure garment group was
unable to tolerate the warmth and discontinued wearing the
garment in the third post-operative day.”

Axillary padding, external garment, and external compression
do NOT significantly reduce incidence of seroma.
Chen CY, Hoe AL, Wong CY. The effect of a pressure garment on post-surgical
drainage and seroma formation in breast cancer patients.
Singapore Med J. 1998 Sep;39(9):412-5.
RCT- Use of a pressure garment
NO improvement in post-operative drainage
“One of the patients in the pressure garment group was
unable to tolerate the warmth and discontinued wearing the
garment in the third post-operative day.”
RECOMMENDATION
- DON’T USE. NOT
RELIABLE!
FOR PATIENT’S
COMFORT!

Obliteration of dead space by mechanical means
Suture flap fixation
surgical technique for securing flaps
to underlying tissues to close the dead space with sutures

RCT [39 patients] Incidence of seroma
Suture flap fixation (with
drain)
5 (25%)
Catheter drainage only 17 (85%)
Coveney EC, O’Dwyer PJ, Geraghty JG, O’Higgins NJ. Effect of closing dead
space on seroma formation after mastectomy–a prospective randomized clinical
trial. Eur J Surg Oncol 1993;19:143–6.

RCT [190 patients] Incidence of seroma
Suture flap fixation (no
drain)
61
Catheter drainage 55
Purushotham AD, McLatchie E, Young D, George WD, Stallard S, Doughty J, et al.
Randomized clinical trial of no wound drains and early discharge in the treatment
of women with breast cancer. Br J Surg 2002;89:286–92.

Division’s Recommended Practice:
Drain removed if output is less than 50 cc past 24 hours
(assumption: tube functional)
Drain may stay as long as needed if NO indication to remove
it such as dysfunctionality and infection.

Postmastectomy
Infection
Erythema on the skin; pus
needed) and Positive Findings
Needle aspiration – pus

Infection Aseptic technique
Antibiotics, if warranted
Antibiotics during
cellulitis stage
Drainage with or without
antibiotics for abscess

Mastectomy Morbidities: INFECTION
Prophylactic antibiotics in MRM
DISPARATE RESULTS !!!
But MOST show positive effect!!!!!

Positive effect
-single dose of preoperative antibiotic (usually a
cephalosporin, administered approximately 30min before
surgery) will effectively reduce infection rate by 40% or more
- Platt et al. meta-analysis (with antibiotics used in high risk
cases) reduced the infection rate by 38%!
Platt R, Zaleznik DF, Hopkins CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy
and breast surgery. N Engl J Med 1990;322(3):153–60.
Platt R, Zucker JR, Zaleznik DF, et al. Prophylaxis against wound infection following
herniorrhaphy or breast surgery. J Infect Dis 1992;166(3):556–60.
Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound
infection following breast surgery. J Antimicrob Chemother 1993;31(Suppl B):43–8.
Tran CL, Langer S, Broderick-Villa G, et al. Does reoperation predispose to postoperative
wound infection in women undergoing operation for breast cancer? Am Surg 2003;69(10):
852–6.

NEGATIVE EFFECT
Wagman et al. – cephalosporin – placebo 118 breast cancer
patients (5% vs 8%).
Gupta et al. – amoxicillin/clavulinic acid – placebo
(17.7% vs 18.8%)
Wagman LD, Tegtmeier B, Beatty JD, et al. A prospective, randomized double-blind
study of the use of antibiotics at the time of mastectomy. Surg Gynecol Obstet 1990;
170(1):12–6.
Gupta R, Sinnett D, Carpenter R, et al. Antibiotic prophylaxis for post-operative wound
infection in clean elective breast surgery. Eur J Surg Oncol 2000;26(4):363–6.

http://www.pcs.org.ph/?s=documents
EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC
PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES
2000
BREAST SURGERY
Antibiotic prophylaxis is recommended for the following
elective breast surgical procedures: (Grade A
Recommendation)
Mastectomy
Axillary lymph node dissection
Reduction mammoplasty
Excisional biopsy and lumpectomy

http://www.pcs.org.ph/?s=documents
EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC
PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES
2000
BREAST SURGERY
Cefazolin 2 grams IV (Grade A Recommendation) single dose
(Grade C Recommendation)
Cefuroxime 1.5 grams IV single dose is recommended as an
alternative (Grade C Recommendation)

M Cunningham, F. B., K Handscomb (2006).
"Prophylactic antibiotics to prevent surgical site infection
after breast cancer surgery."
Cochrane Database of Systematic Reviews . Art. No.: CD005360. DOI:
10.1002/14651858.CD005360.pub2. Cochrane Database of Systematic
Reviews 2006, Issue 2. Art. No.: CD005360. DOI:
10.1002/14651858.CD005360.pub2. (Issue 2).

M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to
prevent surgical site infection after breast cancer surgery." Cochrane
Database of Systematic Reviews.
Infection rates for surgical treatment of breast cancer are
documented at between 3% and 15%, higher than average for
a clean surgical procedure.
There is no current consensus on prophylactic antibiotic use
in breast cancer surgery.

Main results
Six studies - pre-operative antibiotic compared with no
antibiotic or placebo.
Pooling of the results demonstrated that prophylactic
antibiotics significantly reduce the incidence of surgical site
infection for patients undergoing breast cancer surgery
without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89).

The review is NOT able to establish which antibiotic is most
appropriate.

Use of prophylactic antibiotics in MRM
Because of disparate results, and in an attempt to
minimize cost, many clinicians have adopted the practice of
limiting antibiotic
prophylaxis to high-risk patients!
GSI Division
conducting RCT
study at the
moment!

Infection
GSI Division consultants’ recommendations on
Prevention
Aseptic technique
Prophylactic antibiotics only in high-risk patients
Diabetes mellitus (>200mg/dL)
Obesity (BMI >40)
With other co-morbidity

Postmastectomy
Hematoma
Bulge under the flaps with
discoloration on the skin (red,
blue, violaceous) suggestive of
blood accumulation
needed) and Positive Findings
Needle aspiration – blood

Bleeding /
hematoma
Meticulous hemostasis during
dissection and prior to wound
closure
Control of bleeding
Evacuation of hematoma

Mastectomy Morbidities: HEMATOMA / BLEEDING
NOT ABLE
to find literature on
METICULOUS HEMOSTASIS
during mastectomy!

Mastectomy Morbidities: HEMATOMA / BLEEDING
Division consultants’ recommendations on Prevention
Meticulous hemostasis during dissection
Ligate transected blood vessels ≥ 2mm in diameter
Cauterize fully transected vessels which will not be ligated
Ligate and cauterize transected blood vessels right away
Strict and on the spot hemostasis during axillary dissection
Checking of hemostasis prior to wound closure

Postmastectomy
Flap Necrosis
Blackish to black discoloration on
the flap

FLAP NECROSIS
Flap
necrosis
NOT too thin a flap
About 0.5 to 1 cm thick
subcutaneous layer on the flap
(for vascular supply)
Debridement

Postmastectomy
Lateral Dog-Ear Deformity
(Redundant axillary fat pad)
Frequent, particularly in patients
with large body habitus and
large breast
Unsightly and source of long-term
discomfort
Need to prevent as much as
possible.

Lateral Dog-ear Deformity
Tear-drop shaped incision
Mirza M, S. K., Fortes-Mayer K. and W. M. H. (2003). "Tear-drop incision for
mastectomy to avoid dog-ear deformity." Ann R Coll Surg Engl. 85(2):131.

Lateral Dog-ear Deformity
Sliding-suturing
(Devalia Technique)
Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. An oncoplastic
technique to reduce the formation of lateral 'dog-ears' after mastectomy. Int Semin
Surg Oncol. 2007 Dec 17; 4:29.

Email: rjoson@maniladoctors.com.ph
Cell no. 0918-8040304
THANK YOU
FOR YOUR KIND
ATTENTION!

Division of Surgical Oncology
UPM Centennial Professorial Chair (2008)
THANK YOU
FOR YOUR KIND
ATTENTION!

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