BACKGROUND: Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND.
METHODS: A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method.
RESULTS: A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen.
CONCLUSIONS: To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.

OBJECTIVE: Previous studies have identified the added value of flap fixation in reducing seroma formation and its sequelae after mastectomy. The seroma reduction after mastectomy (SAM)-trial proved that sutures were superior to tissue glue. In this article, we will elaborate on the results of the SAM-trial to provide a clear surgical guideline.
METHODS: All patients in the suture flap fixation cohort from the SAM-trial were analyzed if details regarding flap fixation were available. The most optimal number of sutures was determined using a receiving operator characteristics curve. The incidence of seroma formation between patients receiving the most optimal number of sutures and patients receiving fewer sutures was compared.
RESULTS: The most optimal number of sutures proved to be 15. Patients with ≥15 sutures had a lower incidence of seroma formation at every time frame during follow-up. There was a significant difference at 6 weeks (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.09-8.56), 3 months (OR: 4.62, 95% CI: 1.34-12.92), and 1 year postoperatively (OR: 20.48, 95% CI: 2.18-192.22). Ten days and 6 months postoperatively did not differ significantly.
CONCLUSIONS: Flap fixation in general, but also the surgical technique influences the incidence of seroma formation after mastectomy. Results suggest a minimum of 15 sutures, spaced approximately 3.7 cm apart.

Implant texture is an important factor influencing implant selection for breast augmentation. Natrelle Biocell implants are characterized by macrotextured shell surfaces containing irregularly arranged concavities with large open-pore diameters and depths. These properties facilitate adhesion of the implant to the surrounding tissue, thereby promoting implant immobilization. Relative to implants with other surfaces, macrotextured implants offer low rates of capsular contracture; low rates of malposition, rotation, and rippling; and high rates of patient satisfaction. However, macrotextured implants are associated with a slightly higher risk of double capsule and late seroma. The surgeon can minimize these risks with straightforward techniques that encourage tissue adhesion. This report presents experience-based recommendations to optimize the effectiveness of Biocell anatomic implants. The authors discuss the application of best practices to all aspects of the breast implantation process, from implant selection and surgical planning to operative technique and postoperative management. LEVEL OF EVIDENCE 3.

BACKGROUND: Although uncommon, Morel-Lavallée lesions (also called closed degloving injuries) are associated with considerable morbidity in trauma patients. There is lack of consensus regarding proper management of these lesions. Management options include nonoperative therapies, along with percutaneous and operative techniques. We sought to define the factors associated with failure of percutaneous aspiration to better identify patients requiring immediate operative management.
METHODS: We retrospectively searched our prospectively collected database for patient records containing the terms Morel-Lavallée, closed degloving injury, or posttraumatic seroma from February 2, 2004, through December 23, 2011. Treatment methods included compression wraps or observation (nonoperative management), percutaneous aspiration, or operative management with incision/drainage or formal debridement of skin and soft tissues that resulted in wound vacuum-assisted closure placement and/or split-thickness skin graft (operative management). The treatment groups were compared using univariate analysis and χ testing.
RESULTS: We identified 79 patients with 87 Morel-Lavallée lesions in the setting of trauma. Most were caused by motor vehicle collisions (25%). No difference was observed between the treatment groups in sex, body mass index, anticoagulation treatment, diabetes mellitus, smoking history, or alcohol use. The percutaneous aspiration group had higher rates of recurrence (56% vs. 19% and 15% in nonoperative and operative groups, respectively). The percentage of patients who had aspiration of more than 50 mL of fluid was higher for lesions that recurred than for lesions that resolved (83% vs. 33%, p = 0.02).
CONCLUSIONS: Aspiration of more than 50 mL of fluid from Morel-Lavallée lesions was much more common among lesions that recurred (83%) than among those that resolved (33%). We therefore recommend that aspiration of more than 50 mL of fluid from a Morel-Lavallée lesion prompts operative intervention. We have now adopted this as a practice management guideline.
METHODS: Therapeutic/care management study, level III.

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BACKGROUND: The goal of this consensus is to establish an algorithm for the management of patients who develop a late or delayed periprosthetic fluid collection. A work group of practicing plastic surgeons and device industry physicians met periodically by teleconference and discussed issues pertinent to the diagnosis and management of late periprosthetic fluid collections in patients with breast implants. Based on these meetings, treatment recommendations and a treatment algorithm were prepared in association with an editorial assistant.
METHODS: The work group participants discussed optimal care approaches developed in their private practices and from evidence in the literature.
RESULTS: The consensus algorithm and treatment and management recommendations represent the consensus of the group.
CONCLUSIONS: The group concluded that late periprosthetic fluid collection (arbitrarily defined as occurring ≥ 1 year after implant) is an infrequently reported occurrence (0.1 percent) after breast implant surgery and that, at a minimum, management should include clinically indicated ultrasound-guided aspiration of fluid, with appropriate cultures and cytologic testing. Further evaluation and additional treatment is recommended for recurrence of periprosthetic fluid collection after aspiration, or clinical suspicion of infection or neoplasia.

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BACKGROUND: The authors previously compared the local tissue rearrangement, breast reduction, and latissimus dorsi flap reconstruction techniques for repairing partial mastectomy defects and showed the benefits of breast reduction.
METHODS: In this study, the authors focused solely on factors influencing outcome in 41 patients who underwent repair of a partial mastectomy defect using breast reduction.
RESULTS: Tumor location had a significant effect on the design of the parenchymal pedicle (p = 0.05). Most repairs were performed with an inferior pedicle. Fifty percent of the lower outer and central quadrant tumors required an amputative design with a free nipple graft. The complication rates for immediate and delayed repair were 24 and 50 percent, respectively. The superior pedicle was associated with the highest complication rates. Tumors in the upper outer quadrant of the breast were associated with the highest complication rate (35 percent). Ninety percent of patients with planned repairs had a viable nipple-areola complex (p = 0.05) and did not require a free nipple graft. More favorable cosmetic outcomes were achieved using an inferior pedicle; less favorable cosmetic outcomes were achieved for tumors in the upper inner quadrant of the breast. Larger defects did not result in less favorable cosmetic outcomes than smaller defects. Only 7 percent of patients had a positive tumor margin. Five percent of patients developed local breast cancer recurrence after a mean follow-up of 36 months.
CONCLUSIONS: The authors provide practical guidelines for repairing a partial mastectomy defect using breast reduction that should minimize the occurrence of complications and optimize the cosmetic outcome.