Please read my blog on seromas to know what they are and why we care. Just know a seroma is a collection of fluid that can form under your skin after a tummy tuck (or breast reduction, mastectomy, facelift– anytime you create a space during surgery.) We don’t like them. And they can be tough to treat. Prevention is key.
This is an article in my journal Plastic and Reconstructive Surgery from Feb 2021, “Local Triamcinolone Treatment Affects Inflammatory Response in Seroma Exudate of Abdominoplasty: A Randomized Controlled Trial.” In the article they discuss how a leading complication of abdominoplasty is a seroma, which they list as 15-43%. They discuss the issues of a seroma and the difficulty in treating one. They discuss how other fields have described using local corticosteroids to reduce seroma rates, and they wondered if we plastic surgeons could benefit from it as well.
Study:
- Prospective, randomized controlled trial. 60 patients total, in 3 arms of study.
- They were mostly female, age in mid 40s, BMI around 28, and average resection weight of around 2000g.
- The techniques were standard tummy tucks and fleur de lis.
- They looked at peak cumulative seroma volume over a 4 week follow up.
- Technique: They did use cautery. They preserved Scarpas fascia. The did NOT use progressive tension sutures (which I think gives me a lot of pause in interpreting this study). They used 80mg dose of triamcinolone diluted in 10cc of saline immediately used before skin closure. They did not use drains in the third group to avoid removal of the steroid fluid by the drain.
- Fluid amount was assessed by ultrasound.
- The three arms:
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- ONE had 3 drains, removing when less than 30cc or on Day 5
- TWO had no drains and no steroid
- THREE had no drains and steroid
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Findings:
Statistically significant lower fluid in the group with the steroid. When looking at local inflammatory factors, IL 6 and MMP-9 were decreased, which they think correlated clinically with the decrease in seroma. This was particularly marked in the first week after surgery. They think the steroid effect is mostly during that week. (Its half life is 18-36 hours).
My thoughts?
Seromas are tough, and I like to do everything I can to fight them. I love this study was prospective, controlled, and randomized. And the patient base had an average of almost 2000g of resection done (which for you to understand, is a moderate to pretty big abdominoplasty.) Their theory and findings are to be applauded.
My issue is that they didn’t do some of the things we would normally do, particularly progressive tension / quilting sutures (which I have found in my own practice made a sizeable difference) and drains. I get why they didn’t use the drains- they didn’t want to suck out the steroid- but it makes me wonder if there is some other way of employing the steroid.
They do touch on the big other question with steroids, which is that steroids can inhibit healing and make one more prone to wound infections, particularly with higher and more frequent steroid doses.
They don’t talk about doing liposuction during the tummy tuck, which I do on almost every patient. The importance of this is that when doing liposuction, you use tumnescent fluid before suctioning. This leaves a ton of fluid in the tissue. Would that dilute the steroid? And this fluid is a big part of why I still use drains. I see a lot of fluid for the first day or two, and then it dramatically tapers. I did appreciate their theory of drains causing an increase of seroma volume, stating “the negative pressure gradient generated by closed suction drains could maintain drainage of minor lymph and blood vessels.” I only tend to use one drain placed very low, but I am curious to see if there is any other data on drains.
So?
I am always trying to improve my techniques. As I state, what I do now differs from what I did a year ago. I blog in part because I am always reading, attending meetings, and trying to do better. Seromas are not to be underestimated. As for using steroid injections in my patients, I am not sure yet what the right answer is- I would love to see infection rates in these patients. I would like to see a trial where they do common seroma prevention techniques, so we can compare the steroid effect in a patient who also got progressive tension suture/drain/txa/garment/etc.