The extended latissimus dorsi flap is safe, reliable, and popular for breast reconstruction. However, donor site seroma has been reported in up to 80% of patients who undergo breast reconstruction with extended latissimus dorsi flap [5
]. Patients who have suffered from seroma need repetitive aspiration in a postoperative clinical review. Occasionally, aspiration fails to remove seromas, which then requires reoperation to facilitate debridement of fibrinous loculations. Prevention of seromas decreases patient morbidity and the additional cost for treatment. The reduction of seroma also avoids delaying adjuvant chemotherapy and radiotherapy.
The cause of seroma seems to be multifactorial, although the etiology of seroma formation remains unknown. Schwabegger et al. [7
] suggested that the use of electrocautery is a major causative factor in seroma formation after harvesting a latissimus dorsi flap, and it was postulated that thermal damage to tissue increases the incidence of seroma. We performed electrocautery with a Colorado needle to decrease thermal injury. Even if thermal injury had contributed to seroma formation in our patients, a single surgeon performed the flap harvest, thus this should not affect the group comparison. Taghizadeh et al. [21
] reported that immediate breast reconstruction contributed to a higher rate of initial seroma, and they assumed that this resulted from axillary nodal dissection. Jain et al. [22
] and Watt-Boolsen et al. [23
] suggested that seroma could be plasma filtrates, either in the form of protein-poor transudates or a lymphatic leak. Alternatively, they proposed that it may be secondary to increase capillary permeability, resulting in protein-rich exudates, which are often observed during the inflammatory phase of wound healing. Interestingly, several studies have been shown that drains can act as irritants by prolonging the inflammatory phase, thus contributing to seroma formation [19
Seroma formation occurs from extensive surgical dissection and disruption of tissue that results in a dead space while communicating with other areas of dissection following a mastectomy, axillary lymph node dissection, and LD muscle harvest [5
]. Fibrin sealant and quilting sutures partly aim to restore the integrity of tissue planes and remove dead space. Saltz et al. [13
] reported that fibrin sealant used in various surgical circumstances reduced seroma formation. Recently, Ali et al. [19
] and Dancey et al. [20
] have reported that a combination of fibrin sealant and quilting sutures reduced seroma formation, frequency of aspiration, and length of the drainage period, which was superior to the use of quilting sutures alone. The cost of fibrin sealant is approximately ￦315,000 (about 280USD) for each 4 mL kit. This cost is offset by reduced drainage and postoperative visits. Moreover, the decrease in a patient's inconvenience and discomfort is invaluable.
Titley et al. [11
] described a quilting technique performed in 10 patients who underwent a latissimus dorsi harvest. They quilted the skin flaps to the underlying tissue using 2/0 polydioxanone interrupted sutures every 3 to 4 cm in multiple layers. Seroma rates reduced from 56% to 0% after the quilting technique was used. Daltrey et al. [17
] reported on a randomized trial of 108 patients who underwent classic and extended latissimus dorsi harvest. They performed multi-layered quilting using 2/0 vicryl interrupted sutures 3 to 4 cm apart in multiple layers. Seroma rates was reduced from 95% to 83%. Following these studies, Gisquet et al. [18
] described that quilting sutures were also effective for reducing donor site seroma.
Several authors have presented the shearing effect of skin flaps against the underlying structures and dead space between the two planes [10
]. Quilting sutures eliminate dead space and shearing forces; their use reduced seroma in our study from 76% to 42.9%.
This is the first study comparing a fibrin sealant only group to a combination of fibrin sealant and quilting suture group. We have shown that the combination of fibrin sealant and quilting suture is significantly superior to fibrin sealant alone for reducing the seroma rate, seroma volume, total drainage amount, and length of drain indwelling period with proportionately fewer aspirations. It also led to a decrease in postoperative visits for aspirations, which decreased the patients' discomfort and inconvenience as well. However, it did not affect the length of hospital stay.
Multidisciplinary preventative strategies for reducing seroma should be designed and implemented depending on the predisposing risk factors. This study proposes that a combination of fibrin sealant and quilting sutures for an extended LD donor site closure may be an effective procedure to avoid donor-site seroma and related morbidity. However, our study is retrospective; thus, a major multicenter randomized controlled trial is required to provide powerful and reliable evidence.