Management of chronic seromas: A novel surgical approach with the use of vacuum assisted closure therapy

Abstract

Postoperative seroma is a common complication of many surgical procedures in which anatomical dead space has been created. A particular case of lesion in which seroma occurs is the Morel‐Lavallée lesion (MLL), which is an uncommon closed soft‐tissue degloving injury that develops after high‐energy trauma or crush injury where shearing forces separate the subcutaneous tissue from the underlying fascia. The diagnostic evaluation begins with an adequate history and physical examination, followed by instrumental research with ultrasonography, computed tomography, and magnetic resonance imaging. Postoperative seromas and MLLs share a similar pathology and natural evolution as both injuries, once chronic, develop a pseudobursa; thus, the authors think that the same treatment algorithm may be suitable for both the lesions. Several strategies for the treatment of post‐surgical and post‐traumatic seromas have been described in the literature, ranging from conservative measures for acute and small injuries to surgical management and sclerotherapy for chronic and large ones. Despite some seromas resolving with conventional management, lesion recurrence is a matter of concern. The authors present their experience in the treatment of both post‐surgical and post‐traumatic chronic seromas not responsive to conservative treatments by surgical drainage of the seroma, capsulectomy, and application of vacuum‐assisted closure therapy to allow granulation tissue formation, dead spaces obliteration, and wound healing. Primary wound closure with closed suction drain placement and an elastic compression bandaging are finally performed. From 2014 to 2019, a total of 15 patients (9 females and 6 males) were treated for recurrent chronic seromas with the proposed surgical approach. Five cases were MLLs, while 10 cases were postoperative seromas. The patients were between 33 and 79 years old, and they were followed up at 4 weeks and 3 and 6 months after surgery. All 15 patients with chronic seromas not responsive to conservative treatment showed a complete resolution of the lesions with the proposed treatment approach with no evidence of lesion recurrence, proving its effectiveness.

1. INTRODUCTION

Seroma is a common postoperative complication of breast surgery, abdominal wall surgery, and post‐bariatric body contouring. It is a serous fluid collection that develops following surgical procedures or traumas in which anatomical dead spaces have been created. ¹ , ²

Seroma formation is a multifactorial process. Several mechanisms have been identified, and they include disruption of lymphatic and blood vessels; creation of dead space; inflammation, which increases with the use of electrocautery; and shearing forces between superficial flaps and underlying tissues. ³ Hence, the composition of seroma fluid is a mixture of lymph, plasma, and inflammatory exudate. ⁴ Small seromas tend to resolve spontaneously, while untreated chronic seromas develop a fibrous capsule, known as pseudobursa, around the effusion. ³ , ⁵

A particular case of lesion in which seroma occurs is the Morel‐Lavallée lesion (MLL), which was first described in 1853 by the French physician Maurice Morel‐Lavallée. ⁶ It is an uncommon closed soft‐tissue degloving injury that develops after a high‐energy trauma or crush injury where shearing forces separate the hypodermis from the underlying fascia. ⁷ , ⁸ As a result, the disruption of lymphatics and blood vessels leads to the accumulation of blood, lymph, and necrotic debris in the cavity created between the superficial and deep tissues. Over time, the blood is reabsorbed and substituted with serosanguinous fluid. Finally, an inflammatory reaction leads to the formation of a pseudocapsule as the lesion becomes peripherally surrounded by fibrous tissue. ⁹ , ¹⁰

The lesions typically occur over the great trochanter and the proximal third of the anterolateral thigh. Other anatomical locations include the gluteus, the lumbar flank, the lumbar sacrum, the pelvic girdle, and the hip. The timing of presentation of these lesions ranges from few hours or days to months or years after the initial trauma. ¹⁰ The diagnostic evaluation begins with an adequate history and physical examination, which shows a soft fluctuant area associated with hypermobile skin and hypoesthesia. Complications such as contour deformity or skin necrosis may be found. ¹⁰ , ¹¹ Ultrasonography, computed tomography, and magnetic resonance imaging, which is the imaging modality of choice, are performed in order to characterise and diagnose long‐standing lesions. ¹² Mellado and Bencardino classified MLLs into six types based on magnetic resonance imaging (MRI) characteristics, lesion appearance, and presence or absence of a capsule. However, this system cannot be used to guide treatment. ¹³

Postoperative seromas and MLLs share a similar pathology and natural evolution as both injuries, once chronic, develop a pseudobursa. ⁷ Thus, we think that the same treatment algorithm may be suitable for both lesions.

Preventive measures to reduce postoperative seroma formation aim to obliterate dead space and decrease shear forces. They include closed suction drains, quilting and progressive tension sutures, use of fibrin and talc, and reduction of surgical site movement. ¹ , ¹⁴ , ¹⁵ Despite these efforts, seromas may occur and require an adequate management.

Several strategies for the treatment of post‐surgical and post‐traumatic seromas have been described in the literature, ranging from conservative measures for acute and small injuries to surgical management and sclerotherapy for chronic and large ones. ⁸ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹

The authors present their experience in the treatment of both post‐surgical and post‐traumatic chronic seromas not responsive to conservative treatments by surgical drainage of the fluid collection, capsulectomy, and application of vacuum‐assisted closure (VAC) therapy, regardless of skin viability, to promote wound healing.

2. PATIENTS AND METHODS

From September 2014 to December 15, 2019, patients were treated for recurrent chronic seromas. Five cases were MLLs, while 10 cases were postoperative seromas. The latter ensued after the following surgical procedures: one axillary and four inguinal lymph node dissections, four abdominoplasties, and one elastofibroma dorsi removal. Six patients were males, and nine were females. Patients' age ranged between 33 and 79 years. Follow‐up visits were scheduled at 4 weeks and 3 and 6 months after surgery.

All the patients were treated with the following surgical approach: under local or locoregional anaesthesia, a longitudinal incision was made over the lesion, followed by capsulectomy and debridement of the surfaces of the cavity until bleeding was initiated in order to induce a healing response. The rim of scar tissue of the margins of the wound was removed to obtain healthy tissue. Haemostasis and irrigation with normal saline were then carefully performed. After that, VAC therapy was applied, regardless of skin viability, in order to promote granulation tissue growth, dead spaces obliteration, and healthy tissue restoration (Figure 1). Once viable tissue had been restored, primary wound closure with closed suction drain placement and elastic compression bandaging was performed.

FIGURE 1.

Extension of chronic seroma a) before and b) after V. A. C. therapy

3. RESULTS

All 15 patients with postoperative or post‐traumatic recurrent chronic seromas were treated with the proposed surgical approach. Lesion size was assessed on ultrasonography (USG) or MRI before treatment in all cases (Figure 2). The time of the persistence of the lesion until treatment ranged from 1 month to 4 years. The mean volume of fluid drained at the time of surgery was 250.5 cc. Careful debridement and control of haemostasis were performed in all cases. VAC therapy was applied at −125 mmHg negative pressure for 20.5 ± 5.5 days and was changed, on average, every 3 to 5 days (Table 1). After this period, primary wound closure with closed suction drain placement was performed. Drains were removed after 8 ± 2.5 days (range 7‐12 days). Lesions with small loss in tissue after VAC therapy were not primarily closed but were healed by secondary intention. Closure of these wounds occurred 2 months after VAC removal. Compression dressing was performed in all patients. Twelve patients (80%) completed the 6‐month follow up, while the remaining three patients (20%) attended until the 3‐month follow up. All patients showed resolution of seromas, and lesions did not recur. No complications were found.

FIGURE 2.

MRI image of MLL a) sagittal, b) axial, c) coronal section

TABLE 1.

Patients	Age (years)	Sex	Lesion size on USG or MRI (cm)	Etiopathogenesis	Lesion duration before treatment (months)	Volume of fluid drained at the time of surgery (cc)	Days of V.A.C. therapy
1	79	F	9x5x7,5 (USG)	Postoperative seroma after lymphadenectomy	48	700	25
2	73	M	9x3x2 (MRI)	MLL	1	113	20
3	38	M	21x1x8 (USG)	MLL	12	100	25
4	36	F	6x4x8 (USG)	Postoperative seroma after abdominoplasty	6	255	20
5	62	F	13x6x7 (USG)	Postoperative seroma after lymphadenectomy	12	345	23
6	46	M	12x3x5 (USG)	MLL	4	122	15
7	41	F	5x3x7 (USG)	Postoperative seroma after abdominoplasty	9	130	18
8	33	F	7x2x11 (USG)	Postoperative seroma after abdominoplasty	8	162	22
9	54	F	4x1x2,5 (USG)	Postoperative seroma after lymphadenectomy	3	115	10
10	43	M	24x5x13 (MRI)	MLL	10	523	26
11	66	M	8x3x5 (USG)	Postoperative seroma after lymphadenectomy	7	180	21
12	44	F	11x2x9 (USG)	Postoperative seroma after elastofibroma dorsi removal	13	335	20
13	39	F	10x4x9 (USG)	Postoperative seroma after abdominoplasty	11	220	24
14	55	M	17x2x8 (USG)	MLL	7	217	20
15	48	F	7x4x6 (USG)	Postoperative seroma after lymphadenectomy	5	240	18

Abbreviations: F, female; M, male; USG, ultrasonography; MRI, magnetic resonance imaging; MLL, Morel‐Lavallée lesion; V.A.C, vacuum assisted closure.

4. DISCUSSION

Postoperative seroma is a common complication of many surgical procedures, whereas MLL is a rare injury in which seroma may occur. Several strategies have been described for the treatment of these lesions, ranging from non‐operative to operative approaches. The treatment algorithms proposed are based on the timing of presentation and the size of the lesions. Acute and small lesions are usually treated with conservative measures, which consist of aspiration followed by compression bandaging. Chronic and large injuries or recurring seromas require a surgical management, sometimes associated with sclerotherapy, in order to remove the necrotic material and to obliterate dead space, respectively. ¹⁵ , ¹⁶

In post‐traumatic lesions with underlying fractures, the surgical approach may depend on the fracture type: if the effusion is associated with closed fractures, percutaneous drainage is required, followed by fracture fixation; in case of open fractures, open drainage becomes the treatment of choice.

Compared with surgery, a percutaneous approach reduces the risk of infection and flap necrosis. Therefore, the initial treatment should be the percutaneous drainage with sclerotherapy. If the lesion persists, then open debridement, primary wound closure, and compression dressing with or without sclerotherapy are required. ¹⁶ , ¹⁷ If this treatment also fails, the last choice remains open drainage followed by secondary intention healing. ¹⁷ Open debridement, instead, is the primary choice of treatment for chronic lesions with skin necrosis or infection. ¹⁶ , ¹⁷ Closed suction drains are placed during surgical procedures and removed when the output is less than 30 mL over 24 hours. ¹⁶ Sclerotherapy aims to obliterate dead space by using chemical agents such as talc, doxycycline, ethanol, erythromycin, and fibrin glue. These sclerosing substances induce an inflammatory reaction that leads to tissue adhesion. ¹⁸ , ¹⁹

Despite some seromas resolving with conventional management, lesion recurrence is a matter of concern. The fluid collection becomes persistent when the balance between fluid production and evacuation is compromised. Therefore, pseudo‐capsule formation, lesion location, and surgical technique are important risk factors for recurrence. ¹⁶

The retrospective analysis of Nickerson et al ⁸ found that the lesion size also affects the recurrence rate. In particular, they found that aspiration of more than 50 mL of fluid from MLLs was associated with a higher recurrence rate. Hence, in these cases, they recommended operative intervention. For large lesions with skin necrosis, they recommended formal debridement followed by wound VAC placement. The wound was then closed primarily or with a split‐thickness skin graft.

Although conventional treatments have proven their effectiveness in resolving seromas, lesion recurrence remains a primary concern. Hence, we have developed the following algorithm for the treatment of post‐surgical or post‐traumatic seromas. For small acute lesions, we recommend conservative management, with aspiration and compression dressing. If the lesions recur and become chronic, developing a pseudo‐capsule, then we recommend a surgical approach. Capsulectomy and debridement are performed, followed by careful haemostasis and irrigation of the cavity. VAC therapy is then applied, regardless of skin viability, to allow granulation tissue growth and to induce a healing response. Later, we perform a primary wound closure with closed suction drain placement and an elastic compression bandaging.

Closed suction drains are placed in order to reduce further dead space and to promote the adhesion of the surfaces of the residual space. Even cases with seromas that lasted for 4 years healed with a single surgical procedure. Despite these results, we recognise that the need of a second surgery after VAC removal and the small sample size are limitations of this study. We therefore recommend this approach as an effective option for the treatment of these lesions as it leads to resolution of seromas in all the cases without subsequent recurrences.

5. CONCLUSION

Postoperative or post‐traumatic chronic seromas that recur after conventional treatments showed complete resolution with our treatment approach, proving its effectiveness. Hence, we suggest that VAC therapy plays a central role in the management of these lesions as it restores healthy tissue with no evidence of lesion recurrence.

Marangi GF, Segreto F, Morelli Coppola M, Arcari L, Gratteri M, Persichetti P. Management of chronic seromas: A novel surgical approach with the use of vacuum assisted closure therapy. Int Wound J. 2020;17:1153–1158. 10.1111/iwj.13447