Although not life threatening, treating seroma is a significant medical expense to the patient and can result in morbidity such as pain, frequent aspiration, decreased mobility, wound dehiscence, infection, prolonged hospitalization, delayed wound healing, arm swelling, skin flap necrosis, and reoperation. The mechanism of seroma formation has been explained as a shearing effect of the cutaneous surfaces on the underlying musculature. The oozing of small vessels and the creation of a cavity caused by the removal of tissue also influences seroma formation. Seroma has been reported to be the most common complication following a latissimus dorsi flap transfer. The reported incidence varies from less than 1% [2
] to up to 56% [3
], and most authors quote between 3% and 10% [1
The use of a suction drain at the latissimus dorsi donor site is routine, but drains are associated with their own complications. Not only do drains restrict activity and delay the return to normal function; they are also associated with infection, nerve injury, and flap necrosis. Seroma also frequently occurs after drain removal. Many previous studies have demonstrated that the drain fails to prevent seroma formation; the incidence of seroma requiring aspiration ranges from 15% to 83% following drain removal. Some surgeons believe these fluid collections can be treated using "benign neglect" [7
], but most surgeons tend to aspirate significant seromas. Slavin [8
] demonstrated that fluid collections greater than 75 to 100 mL may lead to wound dehiscence, implant exposure, discomfort, and infection and thus suggested draining such seromas. Intervention for seromas usually consists of needle aspiration or drainage, but this technique always carries the risk of iatrogenic complications such as pneumothorax or hemothorax.
Variousapproaches have been taken in an attempt to reduce seroma formation including external compression, arm immobilization, flap-tacking sutures, avoidance of electrocautery, use of fibrin sealant, talc poudrage [9
], and the quilting technique [10
]. Recently, minimal access harvesting of the latissimus dorsi flap has been attempted to minimize donor site seroma [11
]. None of these techniques have been proven in a clinical situation or have gained popularity. The talc poudrage tended to cause complications associated with the chronic inflammatory response. Recently, a quilting technique is commonly utilized to reduce seroma formation, and studies have shown this method to be effective in a clinical setting [10
]. However, this technique contributes to lengthening the operative time by approximately 20 minutes. The quilting sutures need to be placed very accurately, especially when large skin paddles are harvested; otherwise, donor-site closure cannot be achieved.
Fibrin sealant, a two-component tissue adhesive composed of fibrinogen and thrombin, has been used in a number of surgical settings primarily to achieve hemostasis and to seal tissues. The process by which fibrinogen and thrombin combine in the presence of factor XIII and calcium chloride to form fibrin sealant has been described extensively in the literature [12
]. The mode of action of the fibrin sealant is two-pronged: it reduces the dead space between two planes by means of tissue adhesion, which coapts the elevated skin flap to the underlying tissues, and it reduces hematoma and serous oozing from the involved surfaces by enhancing hemostasis and blocking the lymph channels responsible for drainage into the operative site. The fibrin forms a strong bond that interlocks with the molecular structure of surgically damaged tissue and seals open tissue channels. The sealant effect is dependent on the fibrinogen concentration and clotting time on the thrombin concentration.
Several human clinical studies have been performed with commercial fibrin sealants in patients undergoing breast surgery (not breast reconstruction, but other procedures such as mastectomy or axillary dissectionwith conflicting results. Some studies have reported that fibrin sealant was found to be effective in reducing either wound drainage or length of hospital stay [13
]. In contrast, fibrin sealant was not found to be effective in other studies [15
Few studies have been performed in a clinical setting to demonstrate the efficacy of fibrin sealant in reducing complications of large surgically created dead spaces similar tothe latissimus dorsi donor site. We designed this study with the fibrin sealant as the only variable, excluding any other procedure that may influence the result. The study was limited to patients 30 years or older, in whom the risk of breast cancer is higher, and is also the recommended age for a routine screening test. As mentioned above, we excluded all the systemic factors and other procedures that might influence the volume of drainage. Consequently, it is meaningful that our study represents the largest population among the studies related to the latissimus dorsi donor site and the fibrin sealant as a single variable. A possible reason for the result that fibrin sealant had no effect in reducing seroma is that the fibrin sealant itself may elicit a tissue reaction, similar to a foreign body reaction, causing more fluid secretion. Another possible explanation is that the glue started to dissolve and was evacuated by the suctions during the surgery or by the drains. Different donor site surface areas and delayed wound closure might also have contributed to the result.
The fact that the patients' BMI and weight of the removed tissue had a correlation with the drain output volume demonstrates that the large surface area of the latissimus dorsi donor site should be taken into consideration in deciding on the dose of fibrin sealant. The optimal dose per unit area should be calculated along with the exact donor site surface area.
Seroma is a frustrating complication of many surgical procedures. We have shown that in immediate breast reconstruction with the latissimus dorsi myocutaneous flap, the fibrin sealant did not significantly decrease the drain output or hospitalization stay. In conclusion, because the benefits from the fibrin sealant are not clear, the use of fibrin sealant must be fully discussed with the patients before its use, as part of informed consent.