The Role Of Triamcinolone In Seroma Prevention In Extended Latissimus Dorsi Flap In Breast Reconstruction

doi:10.21203/rs.3.rs-3101973/v1

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The Role Of Triamcinolone In Seroma Prevention In Extended Latissimus Dorsi Flap In Breast Reconstruction

https://doi.org/10.21203/rs.3.rs-3101973/v1

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Background: Seroma remains a common complication of surgeries involving the extended latissimus dorsi flap (ELDF) for breast reconstruction. However, there are several methods that have been used to treat seroma. This study aims to evaluate the efficacy of topical administration of triamcinolone acetonide in reducing seroma incidence in breast reconstruction surgeries.

Methods: Cross sectional study was conducted at Al-Mouwasat University Hospital in Damascus-Syria. Between 2022-2023 including patients who came to the breast unit clinic seeking for breast reconstruction. 20 patients were injected with triamcinolone acetonide 80 mg on the fifth and seventh day of the surgery through the drain tube in the donor site. And the drain was removed directly on the seventh day of surgery. Follow up continued till 3 month post operation to report the seroma cases and other complications.

Results : Mean age was 47 years (range 30-60), mean body mass index (BMI) was 26 kg/m2, 11 flaps were for immediate reconstructions, and 9 cases were for delayed reconstruction. one case of seroma (n=1) 5% was reported , mastectomy flap necrosis was in 3 cases (15%), breast flap seroma was seen in just one case ( 5%) .

Conclusion: triamcinolone acetonide is considered easy and not expensive method for preventing seroma, therefore we recommend the topical usage of triamcinolone acetonide for prevention of seroma at the donor site of extended latissimus dorsi flap.

Trial registration: researchregistry9062

Seroma remains a common complication of surgeries involving the extended latissimus dorsi flap for breast reconstruction. The incidence of seroma post latissimus dorsi flap in breast reconstruction varies between 5–80%.^1–3 Although seroma is not typically life-threatening, it can cause significant morbidity and inconvenience for patients, making it an important topic for study and clinical practice. However, there are several methods that have been used to treat seroma, including aspiration, compression bandages, sclerotherapy ,the use of quilting sutures, fibrin sealants, tissue glue, and triamcinolone acetonide .^4–5 This study aims to evaluate the efficacy of the topical application of triamcinolone acetonide method in reducing seroma incidence in breast reconstruction surgery.

20 patients who underwent breast reconstruction with extended latissimus dorsi flap between 1/1/2022 till 1/1/2023 were included in this study. All patient were injected topically with triamcinolone acetonide with a dosage of 80 mg on the fifth and seventh day post surgery through the drain tube in the donor site. And the drain was removed directly on the 7^th day of surgery. The follow up last for 3 months after surgery to report the seroma cases and other complications. A Cross sectional study was conducted at Al Mouwasat University Hospital in Damascus-Syria, including the patients who revised the breast unit clinic seeking for breast reconstruction.

Inclusion criteria:

Mastectomy patients.
Age 18-60 years.
The interval of at least one year between the end of radiotherapy and the planned reconstruction in cases of delayed reconstruction.
Oncologist confirmation that there is no active or recurrent neoplastic lesion.

Exclusion criteria:

Patients younger than 18 years, or older than 60 years
Previous breast reconstruction surgeries
Patients under complementary treatment or who have not completed treatment radiotherapy for a full year.

Surgical technique:

- The flap was drawn and its dimensions measured with images taken before the surgical procedure. Patients underwent general anesthesia. They were given 1g of ceftriaxone about 20 minutes before surgery, and antibiotics continued for one week after the surgery. The patient was placed in a lateral position, except in cases of bilateral reconstruction where the patient placed in a prone position. Dissection was performed at a level above the fascia, leaving a thickness of approximately 1cm of skin at the site of dissection to ensure the greatest amount of adipose tissue is taken above the muscle extension. The vascular pedicle of the flap was isolated without cutting its nerve supply. The flap was transferred and fixed with non-absorbable sutures along the inframammary fold from medial to lateral. Silicone implants were never used in this study. Concerning the Closure: For the wound, two arches of quilting sutures were taken between the dissected skin flap and the tissues underneath , in addition to placing drains and then closing in two layers. On the fifth day after surgery, 80mg of triamcinolone acetonide was injected topically through the drain in the donor site, and on the seventh day, another dosage of 80mg of the same drug injected and the drain was removed immediately.

20 patients were included in this study. Mean age was 43 years (range 30-60), mean body mass index (BMI) was 26 kg/m2, 11 flaps were for immediate reconstructions, and 9 were for delayed reconstructions. we reported one case of seroma (n=1) 5% , Mastectomy flap necrosis (n=3) 15%, breast flap seroma (n=1) 5% as shown in table 1.

TABLE 1:

43	Age( median) in years
26	Body mass index (kg/m²)
	Operative data
20	ELDF (N)
11	Immediate reconstruction
9	Delayed reconstruction
	Complications:
1	seroma
3	Mastectomy flap necrosis
0	Hematoma
1	Breast flap seroma

Table 1: shows the summarized data of the patients

Several factors have been identified as potential contributors to the development of seroma after latissimus dorsi flap in breast reconstruction. These include surgical technique, patient age, comorbidities, and use of drains⁶. However, there are several other methods that have been used to treat seroma, including aspiration, compression bandages, sclerotherapy ,the use of quilting sutures, fibrin sealants, and tissue glue.

Quilting sutures, also known as progressive tension sutures, involve the placement of sutures that attach the skin flap to the underlying muscle or fascia. In a systematic review by Sajid et al., five studies including 440 patients were analyzed as the authors concluded that quilting donor sites significantly reduced the incidence of seroma formation after LD Flap.⁷

Fibrin sealants and tissue glues are emerging methods that have recently used in combination with quilting sutures. In a meta-analysis by Lee and Mun, they found a further reduction in overall rate of seroma formation, days to drain removal, when the application of fibrin glue to donor sites is combined with quilting sutures ^7–8 .

Triamcinolone injections have been used to reduce seroma by decreasing inflammation and promoting tissue healing. Several studies have reported a reduction in seroma rates with the use of triamcinolone injections.^2,5 What we did in this study, despite the small number of patients anticipating in, the wide surface of dissection and the resulting inflammatory reaction that incites fluid gathering and the formation of seroma, and therefore we investigated the hypothesis that the use of triamcinolone would reduce the inflammatory and reproductive phases in the natural process of wound healing. So we injected the donor site on the fifth and seventh day through the drain, and removed the drain on the seventh day, regardless of the production. As a result, out of 20 cases, only one case that the seroma appeared with follow –up and was managed by repeatedly aspiration. The explanation of this phenomenon is the fact that this situation was in the beginnings and the excessive dissection and the so -called development of the learning curve. Tghizadeh, et al in 2008 tested the role of Triamcinolone, but after the formation of the Seroma to reduce the number of times the aspiration. And found that using triamcinolone reduced the median total number of subsequent aspirations required per patient until seroma resolution in the steroid group was 1 comparing to the control group which need to 4 aspiration to be resolved. and the overall complication was 10.7% ².

Additionally, HART et al. in 2017 conducted a randomised control trial on different methods of treating seroma after LDF, one of his groups treated with only triamcinolon acetonide, but it was immediately at the end of surgery and 11 patients out of 26(37.9%) developed seroma through the follow-up⁵.

This study was performed to determine the efficacy of topical application of triamcinolone acetonide in reducing the sroma incidence after ELDF in breast reconstruction surgeries. This method is considered easy and not expensive technique for prevention of seroma. Consequently, we recommend the usage of triamcinolone acetonide injection in the prevention of seroma at the donor site of ELDF. On the other side, further research is needed to determine the optimal approach for preventing and managing seroma post extended latissimus dorsi flap in breast reconstruction surgeries.

Authors’ contributions:

yacoub Alajy: prepared the manuscript in all phase.

The two other authors revised the manuscript.

Data Availability:

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Acknowledgements:

Not Applicable

Declaring conflicts of interests:

The authors declare that they have no competing interests

Ethics approval and consent to participate:

This study was approved by the Ethics Committee of

Al-Mouwasat University Hospital in Damascus University, Syria , Scientific Research and -Studies, with MD-130623- H5 ID Number (attached as an image)

.Written informed consent was obtained from all patients. All methods were carried out in accordance with relevant guidelines and regulations.

Consent For Publication:

N/A

Funding :

No funding

Competing interests:

The authors declare that they have no competing interests

Bailey SH, Oni G, Guevara R, et al. Latissimus dorsi donor-site morbidity: the combination of quilting and fibrin sealant reduce length of drain placement and seroma rate. Ann Plast Surg. 2012;68:555–8.
Taghizadeh R, Shoaib T, Hart AM, et al. Triamcinolone reduces seroma reaccumulation in the extended latissimus dorsi donor site. J Plast Reconstr Aesthet Surg. 2008;61:636–42.
Gruber S, Whitworth AB, Kemmler G, et al. New risk factors for donor site seroma formation after latissimus dorsi flap breast reconstruction: 10-year period outcome analysis. J Plast Reconstr Aesthet Surg. 2011;64:69–74.
Dancey AL, Cheema M, Thomas SS. A prospective randomized trial of the efficacy of marginal quilting sutures and fibrin sealant in reducing the incidence of seromas in the extended latissimus dorsi donor site. Plast Reconstr Surg. 2010;125:1309–17.
Hart AM, Duggal C, Pinell-White X, Losken A. "A prospective randomized trial of the efficacy of fibrin glue, triamcinolone acetonide, and quilting sutures in seroma prevention after latissimus dorsi breast reconstruction." Plastic and reconstructive surgery 139, no. 4 (2017): 854e–63.
Jeon BJ, Lee TS, Lim SY, et al. Risk factors for donor-site seroma formation after immediate breast reconstruction with the extended latissimus dorsi flap: A statistical analysis of 120 consecutive cases. Ann Plast Surg. 2012;69:145–7.
Sajid MS, Betal D, Akhter N, Rapisarda IF, Bonomi R. Prevention of postoperative seroma-related morbidity by quilting of latissimus dorsi flap donor site: A systematic review. Clin Breast Cancer. 2011;11:357–63.
Lee KT, Mun GH. Fibrin sealants and quilting suture for prevention of seroma formation following latissimus dorsi muscle harvest: A systematic review and meta-analysis. Aesthetic Plast Surg. 2015;39:399–409.

No competing interests reported.

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The Role Of Triamcinolone In Seroma Prevention In Extended Latissimus Dorsi Flap In Breast Reconstruction

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