Delayed seroma formation at the latissimus dorsi donor site

Seroma formation is known as the most common complication of reconstruction using the latissimus dorsi muscle flaps. Although the development of a seroma in the immediate or acute postoperative period is a fairly common consequence after latissimus dorsi harvest, it is unusual for a fluid collection to recur several years after the procedure. To the best of our knowledge, there has been no report regarding very late seroma formation in the English literature. Here, we present a delayed development of seroma at the latissimus dorsi donor site of a patient 4.5 years postoperatively.     

Preventing seroma in the latissimus dorsi flap donor site with fibrin sealant

Donor site seroma continues to be the most common complication of latissimus dorsi flap reconstruction. Numerous preventive methods and treatments have been described. The use of fibrin sealant in the donor site before closure may be an effective means of seroma prevention. The authors evaluated the efficacy of fibrin sealant in conjunction with closed suction drainage in a series of 17 latissimus flap donor sites. They also determined their approximate institutional seroma rate with a retrospective chart review of 20 donor sites. The fibrin sealant patients had a seroma rate of 11.8% compared with a rate of 35% among the untreated patients (P = 0.047). This compares favorably with seroma rates as high as 79% described in the literature. In conclusion, the use of fibrin sealant in the latissimus flap donor site appears to be effective in preventing seroma.     

Triamcinolone reduces seroma re-accumulation in the extended latissimus dorsi donor site.

BACKGROUND: The incidence of donor site seroma after autologous latissimus dorsi (ALD) breast reconstruction is in the order of 70%. In the majority of cases the seroma recurs following an initial aspiration. We designed a double-blind randomised controlled trial to test the hypothesis that an intracavity injection of the anti-inflammatory corticosteroid triamcinolone would inhibit seroma re-accumulation. METHODS: We recruited 52 ALD breast reconstructions in 49 patients, of whom 41 involved immediate reconstruction and 11 delayed reconstruction. Patients exhibiting seromas at their first postoperative visit were randomised to receive either intracavity triamcinolone 80 mg (Group A, n=29) or saline (Group B, n=23), following seroma aspiration. We recorded the incidence of wound complications, total time (days) and number/volume of subsequent aspirations to dryness. RESULTS: Triamcinolone significantly reduced the need for any further aspiration (A=16/29, B=22/23), total number of aspirations (A: median=1, interquartile range=0-1; B: median=4, interquartile range=2-5; P<0.0001), total volume aspirated (A: median=30 ml, interquartile range=0-80; B: median=325 ml, interquartile range=199-550; P<0.0001), and total time to dryness (A: median=12 days, interquartile range 7-17; B: median=37 days, interquartile range 20-49; P<0.0001). The incidence of adjuvant chemotherapy (A=16/29, B=9/23) and radiotherapy (A=16/29, B=10/23) was similar, and there was no effect upon donor site complications (Group A=4/29, Group B=2/23, P=0.725). The mean follow-up time for patients in the steroid group was 264 days compared to 254 days for those in the placebo group. Steroid injections were well tolerated, and there were no infective complications. CONCLUSION: Following initial aspiration, intracavity injection of triamcinolone significantly reduced seroma re-accumulation after ALD breast reconstruction.     

Functional donor site morbidity following latissimus dorsi muscle flap transfer

The latissimus dorsi flap is highly versatile and reliable, making it a commonly transferred muscle flap. This study evaluated the subjective donor site morbidity, with special attention to activities of daily living. A review of 85 consecutive female patients who underwent latissimus dorsi muscle transfer was performed. Patients were mailed detailed questionnaires concerning cosmesis, use of the shoulder, time to return to work, weakness, and multiple specific activities of daily living. Up to 39% of patients reported at least moderate weakness, 50% experienced back numbness/tightness, and 22% of patients rated their scar as unacceptable. A significant number of patients had difficulty with vigorous activities of daily living (P < 0.05) compared with more sedentary activities. We conclude that latissimus harvest is not totally without postoperative donor site morbidity, and patients should be counseled accordingly prior to flap transfer.     

Randomized clinical trial on the effect of fibrin sealant on latissimus dorsi donor‐site seroma formation after breast reconstruction (Br J Surg 2012; 99: 1381–1388)

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Preventive effects on seroma formation with use of the harmonic focus shears after breast reconstruction with the latissimus dorsi flap

Background: Postoperative seroma is the most common complication of latissimus dorsi (LD) flap surgery for breast reconstruction. The use of EC for elevation of the flap might cause additional risk for seroma formation by injuring surrounding lymph vessels due to heat dispersion. There is a possibility that seroma formation can be prevented by using alternative devices such as harmonic focus (HF) shears that can dissect the tissue simultaneously with sealing the lymph vessels.

Methods: Forty-eight patients who underwent breast reconstruction with LD flaps since August 2011 up to April 2015 were enrolled. They were retrospectively split into two groups: 24 in group HF, 24 in group EC (conventional electrocautery). The primary outcome measures were rate of seroma formation and total volume of drain discharge and indwelling period of drainage at the anterior chest and donor site. Secondary outcome measures were length of hospital stay and duration of surgery.

Results: The incidence of seroma was 45.8% in the EC group and 20.8% in the HF group. The total volumes of the drain discharge and indwelling period of drainage in the back (donor site) were significantly decreased in the HF group. The length of the hospital stay and surgical time was significantly shorter for the HF group.

Conclusions: The use of HF shears on the LD flap donor site is helpful for reducing seroma formation, the length of the drainage period, the surgical time, and the length of the hospital stay.     

Effect of quilting sutures on seroma formation post-abdominoplasty

Quilting sutures have been shown to be effective in reducing seroma in latissimus dorsi donor wounds. This technique has been adapted to the closure of abdominoplasty flaps. Seventy-four female patients aged 25 to 76 who underwent abdominoplasty over eight years were reviewed retrospectively. In the first 40 consecutive patients, no quilting sutures were used, in the subsequent 34 patients, abdominal closure was performed with quilting sutures. Primary outcome measures were the incidence of seroma, number of times aspirated and total volume aspirated. Secondary outcome measures were haematoma formation, return to theatre, necrosis, dehiscence, infection and late revision. Six of 34 (17.6%) patients who had quilting sutures placed developed clinically obvious seroma compared to ten of 40 (25%) not quilted. There was no significant difference in the number of times the seroma was aspirated or the volume aspirated between the two groups. Three patients in the ‘quilted’ group developed small postoperative haematomas, managed conservatively. All four patients who developed a haematoma in the 'non-quilted' group returned to theatre for evacuation. There is no statistically significant difference in the incidence of seroma formation after abdominoplasty with or without quilting sutures.     

扩大背阔肌肌皮瓣乳房再造术后供区并发症的探讨

目的 探讨扩大背阔肌肌皮瓣再造乳房术后供区的并发症及其防治.方法 自1999年5月至2004年11月,为88例患者采用扩大背阔肌肌皮瓣再造乳房后,从主观和客观两方面分析供区并发症的发生原因以及术后功能情况的评估.结果 术后1例血肿,7例血清肿（其中2例有包囊形成）,5例轻度皮缘表皮脱落,1例干性皮肤坏死,2例翼状肩,无感染和瘢痕增生.术后功能无明显受限,不影响日常生活.结论 扩大背阔肌肌皮瓣乳房再造术后并发症主要是血清肿,严重并发症少,并可以防止或减少,患者容易接受,是值得在东方人中推广使用的乳房再造方法.     

Dealing with the non-healing; donor site defect following latissimus dorsi myocutaneous flap in breast reconstruction

We present two cases of donor site morbidity following immediate breast reconstruction using the extended latissimus dorsi myocutaneous flap. Early post operative dehiscence occurred in both cases, followed by a prolonged period of expectant and conservative management. Plastic surgical intervention involved exploration and removal of significant epithelial lined cavities and reconstruction using local flaps to solve this complication.     

Segmental latissimus dorsi free flap: clinical applications

For 15 years, the latissimus dorsi muscle has enjoyed a consistent reputation with reconstructive surgeons as a reliable pedicle or free flap transferred with or without a skin island. Previous laboratory investigation has delineated the neurovascular intramuscular anatomy. The segmental latissimus transfer makes use of the intramuscular anatomy such that a lateral segment of the muscle is denervated and transferred with the thoracodorsal vascular pedicle while the medial segment of the muscle remains in situ innervated normally and perfused by the dorsal perforating branches of the ninth, tenth, and eleventh intercostal vessels. In this article we report our results using segmental free flap transfer of the latissimus dorsi muscle in 11 patients. Electromyographic studies have been performed more than a year postoperatively to document the function of the residual latissimus left in situ. Our clinical observations show that the segmental free transfer of the latissimus dorsi muscle can be accomplished with little risk in those situations not requiring the entire muscle, and that the portion of the muscle not transferred continues to function well and improves the contour of the back.     

Harvesting of the latissimus dorsi muscle: A small animal model for seroma formation

A common complication of soft tissue dissection and muscle harvesting is seroma formation. In order to manage and understand the formation of seromas, we developed a small animal model for seromas in the Sprague Dawley rat. Skin flaps and subcutaneous tissue were elevated and the latissimus dorsi muscle was harvested in 20 animals. Eighteen of the 20 rats (90%) formed clinically significant seromas. Sixteen animals had associated skin flap necrosis and 12 required serial drainage for recurrent seromas. At necropsy, gross capsular formation occurred in all animals who developed seromas. Microscopically, a fibrous capsule enveloping the seroma was seen associated with a focal chronic inflammatory cell infiltrate. We conclude: (1) Elevation of the latissimus dorsi muscle in the rat is a reliable and practical animal model for seroma formation; (2) Sequelae of clinically significant seromas are often as severe as skin flap necrosis; (3) An inflammatory reaction may be associated with seromas. © 1995 Wiley-Liss, Inc.     

Hematoma in a latissimus dorsi donor site 21 months after surgery

Following strenuous upper extremity exertion, a 40-year-old man experienced pain and swelling in a latissimus dorsi donor site 21 months following harvest and microsurgical transfer of the muscle. Examination and aspiration proved the mass to be a hematoma, and 595 cc of blood were evacuated with resolution of swelling. Late hematoma in a latissimus dorsi donor site must be distinguished from ventral hernia and can be managed by aspiration.     

Donor site morbidity: standard versus partial latissimus dorsi free flap

Over the last 7 years 128 latissimus dorsi free flaps have been performed at the BG Unfallklinik in Murnau. Since 1995, the use of a partial latissimus dorsi, sized according to the defect that has to be covered, leaving a functional remnant has continuously increased. We compared the donor site morbidity after standard and after partial latissimus dorsi flap in a small group of 10 patients each (n=20). The mean follow-up time was 18 and 24 months, the mean age of the patient 42.5 and 43.6 years. The evaluation included complaints, subjective loss of strength, scar length, ROM of the shoulder, and measured loss of strength, taking into account the patient’s dominant side. The acceptance of the donor area by the patients was very good in both groups. It was found that the loss of strength after partial latissimus dorsi is less evident than after standard latissimus dorsi. The scar length was independent of the type of flap chosen. There was no loss in range of movement. In both groups it was found that if the flap was taken from the non-dominant side the difference in strength to the dominant side was more than if the flap was taken from the dominant side. We could not see a causal relationship between age and the amount of strength lost. Because of the decreased donor site morbidity we think the partial latissimus dorsi flap should be used instead of the standard latissimus whenever possible. Received: 9 March 1998 / Accepted: 3 June 1999