Management of complications of prosthetic breast reconstruction

Risk factors and prevention

Tumescent mastectomy technique creates a relatively hemostatic hydrodissection plane facilitating a rapid, sharp elevation of mastectomy skin flaps by the breast surgery team. The tumescent solution typically includes 1 mL of 1% epinephrine, leading some surgeons to hypothesize that it may constrict vessels intra-operatively, which subsequently bleed once the epinephrine has worn off. Despite this theoretical concern, several studies, including a recent meta-analysis, have not demonstrated a significant difference in hematoma rates with tumescent mastectomy. Intravenous ketorolac, a potent nonsteroidal anti-inflammatory drug, has also not demonstrated an increased propensity for hematoma following breast surgery, although many surgeons anecdotally continue to avoid its use.

Recently some groups have begun to explore tranexamic acid (TXA) to prevent hematoma formation. TXA inhibits the activation of fibrinogen thus preventing degradation of fibrin clots and blocks the activation of platelets by plasmin thereby preserving platelets for clot formation. A recent retrospective cohort study in implant-based breast reconstruction demonstrated a significantly lower hematoma rate (0.46% vs. 2.9%) when TXA was used after controlling for age, hypertension, and implant pocket location.

Presentation and management

In the postoperative period, hematomas may present as ecchymosis, fluctuant expansion of the skin envelope, increased and bloody drain output, and/or hemodynamic instability ( Fig. 25.3 ). Initial management should revolve around ensuring the stability of the patient, and can include obtaining a hemoglobin, ensuring intravenous access, and resuscitation with fluids and/or blood products as indicated. Small hematomas may be managed with gentle compression and observation, although this must be weighed against potential decreased perfusion to the mastectomy skin flaps. Imaging is typically not indicated; however, a bedside ultrasound with or without aspiration may be useful in differentiating between hematomas or other fluid collections, particularly in the setting of a late or unusual presentation.

For a rapidly expanding hematoma, urgent operative intervention is typically indicated to control the blood loss. Even in less severe cases, a hematoma in the breast pocket may further compromise the already tenuous mastectomy flap perfusion, serve as a culture medium for bacterial proliferation, and/or potentially contribute to the development of capsular contracture, justifying the need for surgical intervention. The incisions are re-opened and all clotted blood is evacuated from the pocket. The wound bed is copiously irrigated with several liters of warm irrigation and all bleeding vessels are identified and controlled. Placement of a large bore drain is recommended by most surgeons.

Risk factors

Commonly reported risk factors for seroma formation include a high BMI and the use of an acellular dermal matrix (ADM). Surgical trauma to the wound bed results in lymphatic disruption, tissue injury, and niduses of non-viable tissue and fatty debris that trigger inflammatory pathways. This is further exacerbated by the foreign body response to the implant and ADM ( Video 25.1 ) and potential subclinical microbial contamination. A meta-analysis of the risks of ADM use in immediate tissue expander-based breast reconstruction demonstrated a relative risk of 2.7 in the ADM group compared to those undergoing reconstruction without ADM. Advances in the types and processing of ADM materials appears to affect seroma formation with several studies reporting differences in complication rates among the various devices.

Prevention

Egress of the serous fluid into the wound bed is initially controlled with the use of postoperative drains, although there is sparse literature to guide evidence-based decisions on the number of drains and the optimal duration of use. Following drain removal, if the rate of fluid production is greater than its resorption, a seroma will begin to form ( Fig. 25.4 ). This has the greatest potential to become clinically significant in high BMI patients with larger skin flaps as there is a greater volume of dead space in which the seroma can accumulate.

Several techniques have also been reported to minimize seroma formation. Dead space following mastectomy is particularly common in the lateral breast gutter in obese patients or those with extensive lymph node dissection. Judicious intra-operative expander fill and/or appropriate implant volume selection can fill this dead space – although this must be weighed against the risk of mastectomy flap necrosis. Similarly, gentle external compression with bandages or a soft surgical bra may be helpful to moderate fluid accumulation. New implant technologies including dual-port tissue expanders provide a means for surgeons to safely aspirate fluid out of the breast pocket. Additional recommendation within the literature include ensuring the appropriate “polarity” of the ADM to facilitate its incorporation and soaking it prior to implantation to remove proinflammatory additives. Although there is a relatively extensive body of evidence on the use of quilting sutures and fibrin glues in the setting of abdominoplasty and latissimus dorsi donor sites, these strategies have not been rigorously studied in implant-based breast reconstruction.