Wound Care and Complications of Mastectomy

Care of the Postmastectomy Wound

The various operative techniques used in the treatment for breast carcinoma are described elsewhere in this text. Complications after any operation can be minimized with thorough preoperative evaluation, meticulous technique, hemostasis, and wound closure. In addition to the standard oncologic evaluation, preoperative evaluation includes assessment of the patient’s overall physiologic condition, with particular emphasis on tolerability of anesthesia, uncontrolled diabetes, hypertension, anemia, coagulopathy, and steroid dependency.

Technique at operation and wound closure is an essential part of wound repair. Meticulous hemostasis must be confirmed before closure. Closed-suction drains should be placed into the mastectomy wound site, because most patients will develop a seroma. We prefer closed-suction catheter drainage of the mastectomy wound, commercially available as Blake (Ethicon, Johnson & Johnson Health Care Systems, Piscataway, NJ) or Jackson-Pratt tubing (Baxter Healthcare, Deerfield, IL), and each system should be appropriately placed at operation to allow superomedial and inferolateral positioning to ensure thorough, dependent aspiration. After the wound is closed, the tubing is connected to a closed-suction system to ensure removal of all wound contents (e.g., clots, serum). Suction catheter drainage, as a rule, is necessary for 5 to 10 days postoperatively. Earlier removal of the catheters is allowed only when the function of this closed-system technique is compromised. Routinely, catheters are removed only when less than 30 mL of serous or serosanguineous drainage is evident for two consecutive 24-hour intervals.

The skin is closed in two layers using absorbable suture. Thereafter, the skin margins may be covered with strips of surgical tape or wound adhesive. A light, dry gauze dressing is applied to the incision. Pressure dressings over the dissected skin flaps are unnecessary and do not decrease the amount and rate of seroma formation. Negative-pressure wound therapy may have a role in reducing postmastectomy wound complications, particularly in those having prosthetic breast reconstruction. Postoperatively, the wound is carefully inspected with regard to flap adherence, and the patient is encouraged to resume preoperative activity.

In most circumstances, the breast cancer patient is allowed to begin the gradual resumption of presurgical activities. Younger women usually regain full range of motion of the arm and the shoulder soon after drain removal, whereas some older patients may require intense (supervised) exercise for several months before attaining their former levels of activity. Visits from volunteers of the American Cancer Society or the Visiting Nurse Association are of particular value for psychosocial and physical recovery of the postmastectomy patient.

Complications of Mastectomy

Mastectomy has traditionally been a safe operation with low morbidity and mortality. Although the incidence of postoperative complications is low, physicians should be aware of the morbidity unique to mastectomy and axillary node dissection.

An analysis of National Surgical Quality Improvement Program data recently reported that return to the operating room was the most common morbidity after breast surgery, followed by superficial and deep surgical site infections. Complications can lead to readmissions after mastectomy. A recent report demonstrated a readmission rate of 5.59% after breast surgery, with infections being the most common indication for readmission. A detailed review of complications after mastectomy is outlined in the following sections.

Wound Infection

Wound infection after mastectomy has been reported to be between 1% and 20%. A large 2012 study from the Mayo Clinic reported infection rates between 2.7% and 8.0% depending on the definition of wound infection used. Infectious complications have been shown to be more common in patients having bilateral mastectomy than unilateral mastectomy.

Infection of the mastectomy wound or ipsilateral arm may represent serious morbidity in the postoperative patient and produces an immediate disability that may progress to late extensive tissue dissection that creates thin, devascularized skin flaps. Thereafter, progressive tissue necrosis provides a medium that supports bacterial proliferation with invasive tissue infection. Early debridement of obviously devascularized tissue is an important prophylactic adjunct to prevent progressive invasive infection. When abscess formation does occur, attempts should be made to culture the wound for aerobic and anaerobic organisms, with immediate Gram stain of identifiable strains to document the bacterial contaminant. The predominant organisms are Staphylococcus aureus and Staphylococcus epidermidis .

A meta-analysis examining five prospective randomized controlled trials of preoperative prophylactic antibiotics versus placebo demonstrates that prophylactic antibiotics in breast surgery substantially reduce the incidence of postoperative wound infections without any adverse sequelae from the antibiotic administration. We currently use a first-generation cephalosporin before the incision (given intravenously within 30 minutes before the incision) in patients undergoing a mastectomy. Furthermore, it is suggested that reducing postoperative infections is important to prevent delays in adjuvant therapy and reduce cost.

Recent data have suggested that drain antisepsis may have an important role in reducing wound infections after breast surgery. Degnim and colleagues demonstrated that drain bulb irrigation with a dilute sodium hypochlorite solution can significantly reduce bacterial colonization of the drain ( Fig. 37.1 ). Furthermore, in a randomized trial, the technique of drain bulb irrigation combined with the use of chlorhexidine disc dressing was associated with a significant reduction in postoperative infections in breast cancer patients.