Systematic review and meta-analysis of the use of quilting to prevent seroma formation after mastectomy

Objective: Mastectomy is still a rational option for many women with breast cancer. However, the extensive dissection will lead to a large dead space beneath the flap that hampers the adherence to the tissue bed, which increase the seroma rate. Including flap quilting, several surgical techniques have been used to obliterate the dead space. However, there are conflicting results in the effectiveness at reducing the incidence of seroma. This meta-analysis was conducted to better assess the role of the use of quilting in seroma formation after mastectomy. Data sources, methods of study selection: An extensive literature search was performed in the PubMed, Embase and Cochrane databases. Pooled Odds ratio (OR) with 95% confidence intervals (CI) was analyzed. Tabulation, integration and results: A total of 8 trials involving 984 patients were included. Flap quilting showed seroma rate benefit of 20.1% vs 38.4% (OR 0.24, 95% CI 0.10–0.59, p = 0.002). Conclusion: Quilting significantly decreased the seroma rate in patients with breast cancer undergone mastectomy, and flap quilting is a valuable option for patients.

Breast cancer; Mastectomy; Seroma; Quilting

[1] Harbeck N, Gnant M. Breast cancer. The Lancet. 2017; 389: 1134– 1150.

[2] Lipshy KA, Neifeld JP, Boyle RM, Frable WJ, Ronan S, Lotfi P, et al. Complications of mastectomy and their relationship to biopsy technique. Annals of Surgical Oncology. 1996; 3: 290–294.

[3] Ram B, Chattopadhyay B, Sarkar DK. Seroma formation after mastectomy. Indian Journal of Surgical Oncology. 2011; 2: 251.

[4] Srivastava V, Basu S, Shukla VK. Seroma formation after breast cancer surgery: what we have learned in the last two decades. Journal of Breast Cancer. 2012; 15: 373–380.

[5] Agrawal A, Ayantunde AA, Cheung KL. Concepts of seroma for- mation and prevention in breast cancer surgery. ANZ Journal of Surgery. 2006; 76: 1088–1095.

[6] Aitken DR, Hunsaker R, James AG. Prevention of seromas fol- lowing mastectomy and axillary dissection. Surgery, Gynecology & Obstetrics. 1984; 158: 327–330.

[7] Almond LM, Khodaverdi L, Kumar B, Coveney EC. Flap Anchoring Following Primary Breast Cancer Surgery Facilitates Early Hospital Discharge and Reduces Costs. Breast Care. 2010; 5: 97– 101.

[8] Najeeb E, Rashid R, Zaffar S. Effect of Flap Fixation Technique in Modified Radical Mastectomy on Incidence of Postoperative Seroma Formation. Journal of the College of Physicians and Surgeons–Pakistan. 2019; 29: 410–413.

[9] Purushotham AD, McLatchie E, Young D, George WD, Stallard S, Doughty J, et al. Randomized clinical trial of no wound drains and early discharge in the treatment of women with breast cancer. The British Journal of Surgery. 2002; 89: 286–292.

[10] Granzier RWY, van Bastelaar J, van Kuijk SMJ, Hintzen KFH, Heymans C, Theunissen LLB, et al. Reducing seroma formation and its sequelae after mastectomy by closure of the dead space: the interim analysis of a multi-center, double-blind randomized controlled trial (SAM trial). The Breast. 2019; 46: 81–86.

[11] Al-Shalah MAN. Role of quilting technique of mastectomy flap in prevention and reduction of seroma complication in breast cancer patients. Biomedical Research. 2018; 29: 2342–2346.

[12] Kottayasamy Seenivasagam R, Gupta V, Singh G. Prevention of seroma formation after axillary dissection–a comparative randomized clinical trial of three methods. The Breast Journal. 2013; 19: 478–484.

[13] Yu J, Forouhi P. Quilting of flaps substantially reduces seroma formation following mastectomy (MX) or axillary clearance (ANCL). European Journal of Surgical Oncology. 2012; 38: 454.

[14] Trefoux-Bourdet A, Body G, Jacquet A, Hébert T, Kellal I, Marret H, et al. Quilting suture after mastectomy in prevention of postoperative seroma: a prospective observational study. Gynaecology Obstetrics Fertility. 2015; 43: 205–212. (In French)

[15] Khater A, Elnahas W, Roshdy S, Farouk O, Senbel A, Fathi A, et al. Evaluation of the Quilting Technique for Reduction of Postmastectomy Seroma: a Randomized Controlled Study. International Journal of Breast Cancer. 2015; 2015: 287398.

[16] Nadeem M, Deen Q, Qasim KF. Comparison of efficacy of flap anchoring with suction drains alone after modified radical mastectomy. Pakistan Journal of Medical and Health Sciences. 2017; 11: 384–386.

[17] Sakkary MA. The value of mastectomy flap fixation in reducing fluid drainage and seroma formation in breast cancer patients. World Journal of Surgical Oncology. 2012; 10: 8.

[18] Gong Y, Xu J, Shao J, Cheng H, Wu X, Zhao D, et al. Prevention of seroma formation after mastectomy and axillary dissection by lymph vessel ligation and dead space closure: a randomized trial. American Journal of Surgery. 2010; 200: 352–356.

[19] Coveney EC, O’Dwyer PJ, Geraghty JG, O’Higgins NJ. Effect of closing dead space on seroma formation after mastectomy–a prospective randomized clinical trial. European Journal of Surgical Oncology. 1993; 19: 143–146.

[20] Kuroi K, Shimozuma K, Taguchi T, Imai H, Yamashiro H, Ohsumi S, et al. Pathophysiology of seroma in breast cancer. Breast Cancer. 2005; 12: 288–293.

[21] van Bemmel AJM, van de Velde CJH, Schmitz RF, Liefers GJ. Pre- vention of seroma formation after axillary dissection in breast cancer: a systematic review. European Journal of Surgical Oncology. 2011; 37: 829–835.

[22] LARSEN BB, HUGAN C. Fixation of skin flaps in radical mastectomy by subcutaneous sutures; observations. AMA Archives of Surgery. 1955; 71: 419–423.

[23] Chilson TR, Chan FD, Lonser RR, Wu TM, Aitken DR. Seroma prevention after modified radical mastectomy. The American Surgeon. 1992; 58: 750–754.

[24] Garnier JM, Hamy A, Classe JM, Laborde O, Sagot P, Lopes P, et al. A new approach to the axilla: functional axillary lymphadenectomy and padding. Journal de Gynécologie Obstétrique et Biologie de la Reproduction. 1993; 22: 237–242. (In French)

[25] O’Dwyer PJ, O’Higgins NJ, James AG. Effect of closing dead space on incidence of seroma after mastectomy. Surgery, Gynecology & Obstetrics. 1991; 172: 55–56.

[26] Classe J, Dupre PF, François T, Robard S, Theard JL, Dravet F. Axillary padding as an alternative to closed suction drain for ambulatory axillary lymphadenectomy: a prospective cohort of 207 patients with early breast cancer. Archives of Surgery. 2002; 137: 169–172; discussion 173.

[27] Schuijtvlot M, Sahu AK, Cawthorn SJ. A prospective audit of the use of a buttress suture to reduce seroma formation following axillary node dissection without drains. The Breast. 2002; 11: 94–96.