Breast Seroma

A Seroma is a pocket of clear fluid which sometimes can develop after surgery.

Seromas are very common after a breast cancer surgical procedure. They can also develop following axillary surgery if there has been metastasis and lymph node involvement.

In addition, breast seroma can also occur after:-

Breast reduction surgery
Mastectomy
Breast reconstruction surgery
Breast biopsy surgery
Plastic surgery
Breast augmentation surgery (breast implant)
Plastic reconstructive surgery
Any other surgery in any part of the body including liposuction and body contouring surgeries.

Did you know that seroma is the most common complication following a tummy tuck?

Is that serious?

No, it is NOT a serious complication.

How are Seromas detected?

seroma ultrasound post breast cancer surgery — This Ultrasound shows fluid (the dark area) in a breast

A seroma may show up on imaging tests such as ultrasound and mammogram. This most often happens after treatment of breast cancer .

So, seromas may possibly cause some concern about a developing ‘lump’ or problem after treatment. However, more commonly, seromas are usually quite visible and palpable.

Seromas have no relation to ‘cancer cells’ and there is no increase in breast cancer risk whatsoever. But, seromas can complicate and extend the recovery period as the serous fluid may need draining.

What causes a seroma?

Seromas may also increase the likelihood of ‘surgical site
seroma infection‘ (SSI). Doctors will need to monitor, and in some cases treat, seromas.

However, this condition is not unique to the breast but can develop anywhere in the body after any trauma or surgery. They can also occur following radiation therapy.

There are a couple of different ways seromas form. Blood is made up of a combination of serum (which is part of the blood plasma and is liquid) and red blood cells. Sometimes the red blood cells ‘settle’ downward, causing separation from the serum. The serum then collects into a ‘seroma’.

Another way seromas develop is from ‘leaky’ blood vessels. If there is a tiny tear in the lining of a blood vessel or capillary, this allows the serum to escape, but not the red blood cells.

Dying or injured cells can also trigger the inflammatory process which can contribute to the buildup of fluids.

Seromas often ‘remain’ following a breast hematoma

Seromas are different from breast hematomas, which contain red blood cells, and breast abscesses which contain pus.

However, sometimes seromas can ‘remain’ following the development of a hematoma. The ultrasound image above is likely one of these ‘remnant’ seromas following a hematoma.

How common is a seroma following breast cancer treatment?

There is a considerable difference of opinion as to the rate of seroma development. In addition, there is even more confusion regarding the possible factors that cause seromas.

Indeed, it is uncertain whether it is the treatment or patient characteristics, that might predispose a woman to developing a seroma post surgery.

From the available data, one might suggest the overall likelihood of developing seromas following breast cancer surgical treatment is between 16% and 35%. So, maybe 1 out of every 4 women, or thereabouts.

There is really no way to predict this, and the only consistent factor influencing the likelihood of seromas seems to be the extent of the surgery.

Factors that influence the likelihood of developing Seromas following breast cancer surgical treatments

Scientists and clinical studies test many different ideas to try and see what factors influence the probability of seroma development.

Many studies claim to have evidence of an increase in risk factors for developing breast seromas. However, the only factor which seems to have a consistent and verifiable bearing is the extent of the surgery.

So specialists estimate that a woman who undergoes a modified radical mastectomy (MRM) is about 2 to 3 times more likely to develop a seroma than a woman who has breast-conserving surgery (BCS). This seems logical.

Other Unproven factors for seroma development

So, doctors consider many ideas as risk factors for developing seromas. These ideas include just about every conceivable aspect of the procedure and the patient.

Some clinical studies have looked at factors of the blood, these include:-

Anemia
Blood transfusion
Blood loss during surgery.

Others studies consider the technical aspects of the surgery itself. These include the:-

Type of scalpel
Angle of the incision
Anesthestic
Various aspects of suturing
Latissimus dorsi flaps
Use of ‘adhesive glues’
Type and pressure of the dressing
Whether the area is immobilized
Amount of time that the area is immobilized (for shoulder surgeries)
Length of the operation
Type of seroma drainage (closed suction drain versus static drain, multiple channel vs. multiple holes)
Use of a fibrinolysis inhibitor.

Only the severity of breast surgery has a proven bearing on seroma development

Other studies suggest that the risk of seromas following breast cancer surgical treatment may increase if the patient has an underlying condition. For example, hypertension, diabetes or a history of breast biopsies.

Studies have also looked at radiation treatment and neoadjuvant chemotherapy therapies.

Also, studies have examined specific histological features including:-

The size and grade of tumor
Hormone receptor status
Lymph node status (positive or negative for breast cancer metastasis)
Number of lymph nodes removed (in axillary surgery)

In addition, medics have considered more general health issues that may increase the risk for seromas and these include:-

Body-type
Size of the breasts
Age
Body weight
Smoking.

Again, none of the above factors has been proven to have any consistent influence on the risk of seromas. However, the one exception seems to be the severity of surgery. Modified Radical Mastectomy (MRM) versus Breast-conserving Surgery (BCS)

Treatments of seroma

The good news is that for small seromas the body will gradually re-absorb the excess fluid. So, most surgeons view seromas as an unavoidable nuisance rather than a serious complication.

However, the reabsorption can take many days or even weeks. Sometimes a ‘knot‘ of calcified soft tissue remains after the seroma has dissipated. This calcification may show up on follow-up imaging studies, but is of no health concern whatsoever.

However, sometimes the accumulation of fluid in a seroma can be excessive, causing the skin to stretch and to sag causing a skin flap.

This can be uncomfortable for the patient and prolong the recovery time in the hospital and the general healing process. In these situations, your doctor may drain the seroma by fine-needle aspiration, but this can take several attempts.

In more serious cases, where there is wound dehiscence, it may be necessary for incision and/or the insertion of drainage tubes.

I drain seromas with needle aspiration, all the time.

Seromas versus hematoma, is kind-of decided once you aspirate the fluid into a syringe, and see the color. If the fluid is yellow, call it a seroma. If very red, call it hematoma. In-between, call it whatever you want.

Yes, they gradually go away without aspiration. Yes, things get back to normal quicker if they are aspirated.

Questions and Answers

Where does the fluid in seromas come from?

Sometimes the fluid is from a hematoma (bleeding) that separates into blood clots and yellow fluid (serum). Other times, it’s a leak of yellow fluid (lymphatic fluid) from the tissues, “just because”.

Because why? I guess something made capillaries leaky. The capillary endothelial cells lining the blood vessels got sick. How? Maybe during surgery, the tissues were compressed , or their blood supply was interrupted.

When will seroma go away?

Eventually, or sooner if someone will agree to aspirate it. Do seromas return? Yes, but usually much smaller the second time.

How to prevent seromas?

I believe direct hand pressure on wounds is the best. I believe tissues wounded by surgery then stitched together, should not be massaged or pushed in different directions. You have to give time, for undisturbed cut tissue edges to rejoin to each other otherwise there could be a problem on suture removal.

Research studies suggest that a quilting suture of the dead space may help prevent seromas following surgery

In addition, surgical compression pads and drainage tubes following larger surgeries reduces the risk.

For easing the discomfort at home, heat or a heating pad may be applied to the area for short intervals. Please avoid overheating though.

Are seromas dangerous?

No.

Are seromas painful?

Yes, often they stretch the surrounding tissue, stretching nerve endings, which send complaining signals to the brain, which the brain interprets as pain.

Can Seromas be avoided?

Seromas are less likely to occur if a small drain is placed at the wound site on surgery and removed when any fluid stops draining. However, seromas can still occur after drain removal.

What are the signs and symptoms of seroma?

Seroma symptoms include swelling at, or near, the wound site with leakage of clear or yellowish fluid. Sometimes this is accompanied by redness and mild pain (or tenderness) at the site.

Seromas often appear as a large lump or a large cyst. If a seroma is not regularly drained it can sometimes cause a hardened lump of scar tissue.

References

Boostrom SY, Throckmorton AD, Boughey JC, Holifield, AC, Zakaria S, Hosking TL, Degnim AC. (2008) Incidence of clinically significant seroma after breast and axillary surgery. American Society of Clinical Oncology: Proceedings of 2008 Breast Cancer Symposium.
Pogson CJ, Adwani A, Ebbs SR. (2003) Seroma following breast cancer surgery. Eur J Surg Oncol. 2003;29:711–717. https://www.sciencedirect.com/science/article/pii/S0748798303000969
Hashemi E, Kaviani A, Najafi M, Ebrahimi M, Hooshmand H, Montazeri A. (2004) Seroma formation after surgery for breast cancer. World J Surg Oncol. 2004; 2: 44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC543447/
Woodworth PA, McBoyle MF, Helmer SD, Beamer RL. (2000) Seroma formation after breast cancer surgery: incidence and predicting factors. Am Surg. 2000;66:444–450. https://www.ncbi.nlm.nih.gov/pubmed/10824744
McCaul JA, Aslaam A, Spooner RJ, Louden I, Cavanagh T, Purushotham AD. (2000) Aetiology of seroma formation in patients undergoing surgery for breast cancer. Breast. 2000;9:144–148. https://www.ncbi.nlm.nih.gov/pubmed/14731838
Chourmouzi D, Vryzas T, Drevelegas A. (2009) New spontaneous breast seroma 5 years after augmentation: a case report. Case Journal, 2009, 2:7126. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769339/
Kuroi K, Shimozuma K, Taguchi T, Imai H, Yamashiro H, Oshumi S, Saito S. (2006) Evidence-Based Risk Factors for Seroma Formation in Breast Surgery. Japanese Journal of Clinical Oncology 2006 36(4):197-206 https://www.ncbi.nlm.nih.gov/pubmed/16684859
Forouhi P, Dixon JM, Leonard RC, Chetty U. (1995) Prospective randomized study of surgical morbidity following primary systemic therapy for breast cancer. Br J Surg 1995;82:79–82 https://www.ncbi.nlm.nih.gov/pubmed/7881965

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