Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 68, e40ee42
CORRESPONDENCE AND COMMUNICATION Spontaneous late haematomas at latissimus dorsi flap donor sites: An unusual complication of breast reconstruction
Dear Sir, We present a case series of four patients treated by one surgeon who developed spontaneous late haematomas at the latissimus dorsi (LD) flap donor site more than a year following immediate breast reconstruction. While donor site haematoma post LD flap breast reconstruction is well documented in the first few days following surgery, there is a paucity of literature on haematomas presenting months or years after flap harvest. A case report exists of a haematoma precipitated by strenuous physical activity 21 months after free LD flap reconstruction,1 another of a chronically expanding haematoma following anticoagulation two years post-surgery2 and there is one report of a haematoma occurring 13 years after surgery at the LD donor site which was not associated with any obvious precipitating factors.2 There have, however, been no such reports in patients undergoing breast reconstruction, the commonest indication for LD flap reconstruction. Four breast reconstruction patients who developed late haematomas were identified from the senior author’s database. The LD myocutaneous flaps were raised at the time of skin sparing mastectomy using a standard horizontal skin ellipse and division of the tendon with total muscle harvest but preservation of the thoracodorsal nerve. The back donor site wound was closed in 3 layers using 2/0 PDS to Scarpa’s fascia followed by 3/0 monocryl to the deep dermal and subcutaneous tissues over two 15 Fr suction drains (Blake Drains, Ethicon, Edinburgh). These were left in situ for five days and the patients discharged home after their removal. None of the four patients had co-morbidities or smoked.
An example of a late haematoma is illustrated in Figure 1. Timelines of clinical events after LD flap breast reconstruction for patients 1e4 are shown in Figure 2. The remarkable aspects of the cases herein presented are the long time-interval between surgery and the occurrence of the haematoma as well as their long duration. In contrast to two of the three previous reports none of our patients had obvious precipitating factors such as anticoagulation or a history of trauma or strenuous exertion. From our small case series it is difficult to determine the aetiologies of these haematomas. An additional difficulty in this respect is that an individual surgeon’s experience of such haematomas is likely to be small. We, however, postulate that persistent friction between the two layers of LD donor site cavity is a likely mechanism. Shear stress between subcutaneous fat and fascia has been proposed before and it has also been suggested that the LD site is especially prone to this.2 The chronic nature of the problem may be a related to the irritant nature of the initial bleeding itself3; granulation tissue surrounds the haematoma which is itself highly vascularized with capillaries and this leads to recurrent bleeds thereafter. Histological examination of the sac excised from patient 1 did show signs of chronic inflammation which would support this hypothesis. Another possible aetiology is continuation of the factors responsible for seroma formation, which is a common postoperative sequela at the LD donor site. It has been postulated by others that haematoma and seroma formation have the same aetiology2 and thus, theoretically, similar risk factors. If this were the case then one would expect late haematoma to be more common. Importantly, a large retrospective study4 of LD flap breast reconstruction in overweight and obese patients showed no impact of patient BMI on donor site haematoma risk. None of our patients were obese; indeed three of them had rather low BMIs. The use of quilting sutures reduces seroma formation5 and it may be possible this helps prevent subsequent late haematoma formation. None of the patients presented here had quilting during their surgery and perhaps this might be a factor. However, most surgeons do not quilt the donor sites but late haematomas such as we report are very rare. The specific causes remain unclear and therefore prevention is very difficult. However reconstructive and breast surgeons must be aware of this.
http://dx.doi.org/10.1016/j.bjps.2014.09.050 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Correspondence and communication
Figure 1
e41
Aspiration of 100 ml haematoma from the donor site of Patient 1 twelve months after surgery.
Figure 2 Graphs showing volume of haematoma aspirated from the donor site after initial LD flap breast reconstruction. Notable clinical events are also marked on the time axis for patients 1e4.
In conclusion, late haematomas have a significant impact on medium term recovery and can be a cause of patient anxiety. In our series surgical evacuation and sac excision was required in three of the four cases of late haematoma formation more than a year postoperatively. It is important that reconstructive and ablative breast surgeons are aware of this unusually late complication so that they can council their patients accordingly.
Conflict of interests statement None of the authors have any conflicts of interest or received funding from any source for this report.
Ethical approval N/A.
References 1. Lineaweaver WC, Buncke GM, Buncke HJ. Hematoma in a latissimus dorsi donor site 21 months after surgery. Ann Plast Surg 1988 Aug;21(2):143e4. 2. Watanabe K, Morihisa Y, Gotanda K, et al. A case of a chronic expanding hematoma that developed in a latissimus dorsi muscle flap donor site. J Plast Reconstr Aesthet Surg 2013 Jun; 66(6):872e4.
e42
Correspondence and communication
3. Reid JD, Kommareddi S, Lankerani M, et al. Chronic expanding hematomas. A clinicopathologic entity. JAMA 1980 Nov 28; 244(21):2441e2. 4. Yezhelyev M, Duggal CS, Carlson GW, et al. Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients. Ann Plast Surg 2013 May;70(5): 557e62. 5. Daltrey I, Thomson H, Hussien M, et al. Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation. Br J Surg 2006;93:825e30.
Jack E. Brooker School of Clinical Medicine, University of Cambridge, United Kingdom Kai Yuen Wong
Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, United Kingdom Charles M. Malata Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, United Kingdom Cambridge Breast Unit, United Kingdom Postgraduate Medical Institute, Anglia Ruskin University (Chelmsford & Cambridge), United Kingdom E-mail addresses: [email protected], [email protected] 11 May 2014
CORRESPONDENCE AND COMMUNICATION Spontaneous late haematomas at latissimus dorsi flap donor sites: An unusual complication of breast reconstruction
Dear Sir, We present a case series of four patients treated by one surgeon who developed spontaneous late haematomas at the latissimus dorsi (LD) flap donor site more than a year following immediate breast reconstruction. While donor site haematoma post LD flap breast reconstruction is well documented in the first few days following surgery, there is a paucity of literature on haematomas presenting months or years after flap harvest. A case report exists of a haematoma precipitated by strenuous physical activity 21 months after free LD flap reconstruction,1 another of a chronically expanding haematoma following anticoagulation two years post-surgery2 and there is one report of a haematoma occurring 13 years after surgery at the LD donor site which was not associated with any obvious precipitating factors.2 There have, however, been no such reports in patients undergoing breast reconstruction, the commonest indication for LD flap reconstruction. Four breast reconstruction patients who developed late haematomas were identified from the senior author’s database. The LD myocutaneous flaps were raised at the time of skin sparing mastectomy using a standard horizontal skin ellipse and division of the tendon with total muscle harvest but preservation of the thoracodorsal nerve. The back donor site wound was closed in 3 layers using 2/0 PDS to Scarpa’s fascia followed by 3/0 monocryl to the deep dermal and subcutaneous tissues over two 15 Fr suction drains (Blake Drains, Ethicon, Edinburgh). These were left in situ for five days and the patients discharged home after their removal. None of the four patients had co-morbidities or smoked.
An example of a late haematoma is illustrated in Figure 1. Timelines of clinical events after LD flap breast reconstruction for patients 1e4 are shown in Figure 2. The remarkable aspects of the cases herein presented are the long time-interval between surgery and the occurrence of the haematoma as well as their long duration. In contrast to two of the three previous reports none of our patients had obvious precipitating factors such as anticoagulation or a history of trauma or strenuous exertion. From our small case series it is difficult to determine the aetiologies of these haematomas. An additional difficulty in this respect is that an individual surgeon’s experience of such haematomas is likely to be small. We, however, postulate that persistent friction between the two layers of LD donor site cavity is a likely mechanism. Shear stress between subcutaneous fat and fascia has been proposed before and it has also been suggested that the LD site is especially prone to this.2 The chronic nature of the problem may be a related to the irritant nature of the initial bleeding itself3; granulation tissue surrounds the haematoma which is itself highly vascularized with capillaries and this leads to recurrent bleeds thereafter. Histological examination of the sac excised from patient 1 did show signs of chronic inflammation which would support this hypothesis. Another possible aetiology is continuation of the factors responsible for seroma formation, which is a common postoperative sequela at the LD donor site. It has been postulated by others that haematoma and seroma formation have the same aetiology2 and thus, theoretically, similar risk factors. If this were the case then one would expect late haematoma to be more common. Importantly, a large retrospective study4 of LD flap breast reconstruction in overweight and obese patients showed no impact of patient BMI on donor site haematoma risk. None of our patients were obese; indeed three of them had rather low BMIs. The use of quilting sutures reduces seroma formation5 and it may be possible this helps prevent subsequent late haematoma formation. None of the patients presented here had quilting during their surgery and perhaps this might be a factor. However, most surgeons do not quilt the donor sites but late haematomas such as we report are very rare. The specific causes remain unclear and therefore prevention is very difficult. However reconstructive and breast surgeons must be aware of this.
http://dx.doi.org/10.1016/j.bjps.2014.09.050 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Correspondence and communication
Figure 1
e41
Aspiration of 100 ml haematoma from the donor site of Patient 1 twelve months after surgery.
Figure 2 Graphs showing volume of haematoma aspirated from the donor site after initial LD flap breast reconstruction. Notable clinical events are also marked on the time axis for patients 1e4.
In conclusion, late haematomas have a significant impact on medium term recovery and can be a cause of patient anxiety. In our series surgical evacuation and sac excision was required in three of the four cases of late haematoma formation more than a year postoperatively. It is important that reconstructive and ablative breast surgeons are aware of this unusually late complication so that they can council their patients accordingly.
Conflict of interests statement None of the authors have any conflicts of interest or received funding from any source for this report.
Ethical approval N/A.
References 1. Lineaweaver WC, Buncke GM, Buncke HJ. Hematoma in a latissimus dorsi donor site 21 months after surgery. Ann Plast Surg 1988 Aug;21(2):143e4. 2. Watanabe K, Morihisa Y, Gotanda K, et al. A case of a chronic expanding hematoma that developed in a latissimus dorsi muscle flap donor site. J Plast Reconstr Aesthet Surg 2013 Jun; 66(6):872e4.
e42
Correspondence and communication
3. Reid JD, Kommareddi S, Lankerani M, et al. Chronic expanding hematomas. A clinicopathologic entity. JAMA 1980 Nov 28; 244(21):2441e2. 4. Yezhelyev M, Duggal CS, Carlson GW, et al. Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients. Ann Plast Surg 2013 May;70(5): 557e62. 5. Daltrey I, Thomson H, Hussien M, et al. Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation. Br J Surg 2006;93:825e30.
Jack E. Brooker School of Clinical Medicine, University of Cambridge, United Kingdom Kai Yuen Wong
Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, United Kingdom Charles M. Malata Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, United Kingdom Cambridge Breast Unit, United Kingdom Postgraduate Medical Institute, Anglia Ruskin University (Chelmsford & Cambridge), United Kingdom E-mail addresses: [email protected], [email protected] 11 May 2014
