Causes and preventive measures of subcutaneous effusion after breast cancer surgery

Breast cancer is one of the most common malignant tumors in women. Surgery is the most effective means of treating breast cancer. Postoperative subcutaneous effusion is the most common complication after breast cancer surgery. It is common in the axilla, subclavian, costal arch and sternum. Although it does not directly affect the patient's life, it can affect the early implementation of postoperative adjuvant therapy and increase the economic and psychological burden on patients.

Therefore, it is of great clinical significance to prevent the occurrence of subcutaneous effusion after breast cancer surgery. From May 2000 to June 2006, our department performed 108 cases of radical mastectomy for breast cancer, including 65 cases of standard radical mastectomy and 43 cases of modified radical mastectomy; 86 cases of longitudinal incision and 22 cases of transverse incision. According to the causes of subcutaneous effusion, prevention measures were taken during the operation and postoperative treatment, and a total of 16 cases occurred. The criteria for determining subcutaneous effusion, the causes of occurrence and preventive measures are introduced as follows.

1. Criteria for determining subcutaneous effusion

Subcutaneous effusion is defined as a localized bulge or fluctuant mass at the surgical site and non-coagulated fluid withdrawn by puncture [2].

2 Causes of occurrence

2.1 Exudation from surgical wound Radical surgery for breast cancer is wide-ranging, with a large wound surface and incomplete electrocoagulation hemostasis, resulting in a lot of exudation after surgery.

2.2 During the operation, the lymphatic vessels were damaged and not ligated completely, resulting in a large amount of lymphatic extravasation, especially the axillary and subclavian lymphatic systems, which are the main causes of postoperative subcutaneous effusion.

2.3 The use of electrosurgery to peel off the flap during surgery can burn the subcutaneous fat tissue, which can liquefy the fat and increase exudation after surgery. At the same time, the use of electrosurgery to peel off the flap can easily cause the fat tissue under the flap to be uneven in thickness, and even form pedicled fat sags. These fat sags are prone to necrosis and liquefaction due to coagulation, forming subcutaneous effusions [3].

2.4 The accumulation of air under the skin flap and the inappropriate pressure applied by the chest strap bandage did not exert the pressure effect, resulting in a loose adhesion between the skin flap and the chest wall.

2.5 Improper placement of the drainage tube, such as being too thin, old, or having the tube wall compressed, or blood clot blockage, can cause the drainage tube to be blocked, or it can be removed too early, causing the exudate in the surgical area to not be drained out in time and form fluid accumulation.

3 Treatment methods

Based on the above causes of effusion, our department has adopted the following measures to prevent subcutaneous effusion and achieved good results.

3.1 The flap design should be reasonable and moderate, and the skin margins on both sides should be kept 5 cm away from the edge of the tumor. Excessive resection will cause excessive tension and ischemic necrosis of the flap, while excessive retention will leave dead space on the wound surface, which may cause subcutaneous effusion.

3.2 The thickness of the subcutaneous fat retained in the flap should be appropriate. The fat tissue remaining in the surgical field should be removed before suturing the incision, which can reduce the occurrence of fat liquefaction and necrosis.

3.3 During the operation, the blood vessels and lymphatic vessels must be ligated carefully and fully to reduce the leakage of blood and lymph.

3.4 Reduce the power of the electric knife during surgery to prevent wound burns and reduce tissue fluid exudation.

3.5 Postoperative compression At the end of the operation, a negative pressure suction device should be used to suck out the accumulated air under the flap, so that the flap is close to the chest wall. After the operation, the surgical wound is appropriately bandaged with a chest belt; at the same time, cotton pads are placed in the depressed areas of the armpits and anterior chest where fluid accumulation is prone to occur. This can eliminate dead space and prevent exudate and hematoma. Note that the chest belt bandage should not be too tight, and the patient should not feel tight; too tight often restricts breathing, compresses the flap, affects the blood circulation of the flap, and can accelerate flap necrosis. It is better to open the chest belt pressure bandage for the first time 72 hours after the first dressing change, so that the flap and the surgical wound have enough time to fit closely. The chest belt bandage is generally continuous for 10 days.

3.6 Adequate drainage Place a drainage tube in the axilla and the costal arch to fully drain the axilla, parasternal and chest wall, three locations where fluid is easily accumulated [4]. The drainage tube uses continuous negative pressure suction to: (1) fully drain the accumulated blood and fluid; (2) allow the skin flap to fit closely with the surgical wound, promote early adhesion and capillary regeneration. Care should be taken to ensure that the drainage tube is unobstructed, and the time for removal is 48 to 72 hours, which can be extended to 5 days if necessary.

3.7 Other scientific and effective use of antibiotics after surgery to prevent wound infection. Remove the stitches 10 to 12 days after surgery to prevent the incision from splitting due to excessive tension.

3.8 Rehabilitation exercises can only be conducted 7 days after surgery to guide the patient to perform scientific exercises on the affected limb, such as lifting, combing hair, etc., to prevent scar adhesion and promote functional recovery of the affected limb.