Learning from Abdominoplasty to Reduce the Seroma Rate following Deep Inferior Epigastric Perforator Flap with Umbilectomy

Dear Sir,

We read with interest the article by Lakatta et al regarding the use of progressive tension sutures (PTS) in the abdominal closure during deep inferior epigastric perforator (DIEP) flap-based breast reconstruction.[1] In this retrospective comparative single-center study of 241 consecutive patients, who underwent also umbilectomy, significantly fewer complications were recorded in the PTS group. Interestingly, the seroma rate was reduced from 7.1 to 0%, the wound formation rate from 21.7 to 7%, and the infection rate from 9.1 to 2.3%. Although only the overall and wound complication rates reached statistical significance, the authors concluded that PTS use mitigates seroma formation and donor site morbidity.

Practicing medicine and particularly surgery in the current era of evidence-based medicine, we strive not only for better surgical and aesthetic outcomes, but also for better and faster patient recovery and increased patient safety.[2] Therefore, we appreciate authors' efforts to improve patient outcomes in the commonly performed DIEP flap breast reconstruction.

In a meta-analysis we showed that certain preventive measures, namely Scarpa's fascia preservation, tissue adhesives, and use of PTS, significantly reduce the seroma and infection rates, time to drain removal, and the length of hospital stay following abdominoplasty.[3] Given the similar donor site closures between abdominoplasty and DIEP flap, these measures could be also successful in reducing seroma rates in DIEP flap with umbilectomy.

The prophylactic use of PTS minimizes the dead space and shearing forces between the flap and the underlying fascia, while this abdominal flap fixation may be also responsible for fewer wound complication rates. The considerable but not significant reduction of seroma rates reported herein could be attributed not only to the small sample size of the PTS group, but also to other causes. No sample size calculation is reported, and thus, the study may be underpowered to identify a difference in seroma rates. Additionally, the rather low seroma rate of 7% in the non-PTS group affects this outcome, while a multivariate regression analysis, that could reveal which patient and surgical characteristics predict the seroma formation, was not conducted.

Reviewing also the abdominoplasty literature, a recent clinical trial showed that the seroma rate was reduced to 3.5% by placing PTS, with 11 such sutures being as efficient at preventing seroma as the usage of 22 PTS, with the additional benefit of reduced surgical time (13 instead of 30 minutes, respectively).[4] Consequently, reducing donor site complications rate by incorporating PTS use, while remaining efficient in terms of operation duration, is an important aspect of DIEP flap reconstruction. During abdominal flap closure, we use a continuous PTS to enhance the midline from the xiphoid down to the umbilicus instead of interrupted PTS and seven to eight PTS to stabilize the remaining abdominal flap.[5]

Overall, we will agree with the authors that Level 1 evidence, obtained from properly designed controlled trials, is necessary to cement the clinical benefits of PTS use in abdominally based breast reconstruction. Until then, we should all work collaboratively, contributing with our creative ideas, techniques, and studies to the advancement of our specialty.

Publikationsverlauf

Accepted Manuscript online:
14. August 2023

Artikel online veröffentlicht:
20. September 2023

• References

• 1 Lakatta AC, Steppe C, Teotia SS, Haddock N. Reduction in seroma rate following DIEP flap with umbilectomy utilizing progressive tension sutures. J Reconstr Microsurg 2023; DOI: 10.1055/a-2086-0072.
• 2 Seretis K, Bounas N. The efficacy of different nerve blocks on postoperative pain and sequelae in patients undergoing abdominoplasty: a network meta-analysis. Aesthet Surg J 2023; 43 (05) NP325-NP336
• 3 Seretis K, Goulis D, Demiri EC, Lykoudis EG. Prevention of seroma formation following abdominoplasty: a systematic review and meta-analysis. Aesthet Surg J 2017; 37 (03) 316-323
• 4 Bromley M, Marrou W, Charles-de-Sa L. Evaluation of the number of progressive tension sutures needed to prevent seroma in abdominoplasty with drains: a single-blind, prospective, comparative, randomized clinical trial. Aesthetic Plast Surg 2018; 42 (06) 1600-1608
• 5 Seretis K. Applying art and science in lipoabdominoplasty: technical and safety considerations. Plast Aesthet Res 2021; 8: 51