CASE REPORT Lymphatic Mapping in the Treatment of Chronic Seroma: A Case Series

Publisher:Open Science Company, LLCMichael Singer, BS, Kristen Aliano, MD, Steven Stavrides, PA, and Thomas Davenport, MD

CASE REPORT Lymphatic Mapping in the Treatment of Chronic Seroma: A Case Series

Publisher:Open Science Company, LLC
Michael Singer, BS, Kristen Aliano, MD, Steven Stavrides, PA, and Thomas Davenport, MD

Keywords

June 2015

CASE REPORT
Lymphatic Mapping in the Treatment of Chronic Seroma: A Case Series
Michael Singer, BS, Kristen Aliano, MD, Steven Stavrides, PA, and Thomas Davenport, MD
Long Island Plastic Surgical Group, Garden City, NY
Correspondence: msinger@lipsg.com
Keywords: seroma, lymphatic mapping, lymphocele, allergy, arthroplasty

Objective:Seromas or lymphoceles are common postoperative complications. This series presents 3 patients with lower extremity seromas refractory to treatment that required lymphatic mapping and lymphatic ligation for closure, and in 1 case, diagnosis. Methods: Lymphatic mapping procedure consisted of intraoperative injection of subcutaneous tissue with methylene blue distal to the seroma with observation of dye effluence from transected or injured lymphatics draining into area of seroma. Results:In 2 patients, methylene blue dye absorption into lymphatic vessels allowed for optimized visual identification of lymphatic leak and contrast against surrounding tissues. In the third patient, where no lymphocele leak was found, the study was diagnostic and helped to find an alternate etiology for the recurrent seroma. Conclusion: Lymphatic mapping with methylene blue dye is an effective tool in the evaluation and diagnosis of chronic seroma.

Seromas are a mass or tumefaction caused by localized accumulation of serum within tissues or organs that occur secondary to surgery or blunt trauma where significant tracts of lymphatic tissue have been removed, injured, or occluded. This condition is characterized by palpable, fluctuant mass and confirmed by ultrasonography. Serous seepage or impaired lymphatic drainage may result in passive leak into adjacent compartments which may persist. Accumulated serous fluid may require multiple aspirations or drain placement and sometimes surgery to repair the area. Complications include infection, wound dehiscence, or in rare cases calcification of the seroma capsule.¹ Seromas resolve slowly and are often refractory to conventional treatment with prolonged drainage, multiple aspirations, and local pressure.² Large seromas may cause edema of the extremities, pain, unsatisfactory cosmetic outcomes, and can become a chronic draining wound.³^,⁴

METHODS

Three patients were treated for symptomatic seroma or lymphocele following surgery. All 3 patients had a longstanding seroma refractory to treatment with dressings, negative pressure vacuum-assisted closure therapy, or surgery to excise and close the seroma capsule. The lymphatic mapping procedure consisted of intraoperative injection of subcutaneous tissue with methylene blue distal to the seroma with observation of dye effluence from transected or injured lymphatics draining into the seroma. Diagnoses were made on the basis of medical history, physical examination, and positive lymphatic mapping findings at the time of operation. A summary of subjects’ demographics, diagnoses, treatment methods, and outcomes can be found in Table I.

Table 1. Patient demographics, findings, and outcomes

	Patient 1	Patient 2	Patient 3

Age, y	63	64	54
Gender (M/F)	M	F	F
Diagnosis	Recurrent seroma postcyst excision	Seroma postmelanoma excision	Seroma hematoma postarthroplasty
Lymphatic mapping finding (+/−)	+	+	−
Treatment	Ligation	Ligation	N/A
Resolution	No recurrence	No recurrence	Total hip arthroplasty replacement

FIRST CASE

The first patient (Fig 1) was a 63-year-old male with a history of dorsal cyst excision of the right foot and subsequent chronic seroma requiring multiple aspirations. The patient had undergone a previous seroma excision and closure with subsequent recurrence. The patient then underwent an excision procedure including lymphatic mapping and ligation of leaking lymphatics. First, the subcutaneous space distal to the seroma was injected with 50% methylene blue dye. Draining lymphatics were identified by their bluish appearance and location of the leak was identified by discharge of dye into the wound. The leaking lymphatic vessel was visualized and ligated with absorbable suture, and no further leaking was observed. No intraoperative complications occurred and no hypersensitivity to methylene blue was noted. A Jackson-Pratt drain was placed to provide aspiration after closure and the patient was taken to the post-anesthesia care unit in stable condition. The drain was removed on post-operative day 3 and there was no recurrence of seroma.

Figure 1. First Patient. A. Pre-operative tracing of lymphatic. B. Intra-operative visualization of dye-injected lymphatic. C. Post-surgical closure and resolution.

SECOND CASE

The second patient (Fig 2) was an otherwise healthy 70-year-old woman with previous history of biopsy-proven malignant melanoma of the left posterior popliteal fossa. An open draining seroma refractory to treatment with negative pressure therapy and dressings developed subsequent to wide-local excision of the melanoma. The patient was taken to the operating room where lymphatic mapping proceeded with 5 cc methylene blue dye injection into the first web space of the foot. Draining lymphatic vessels were clearly identified by their bluish appearance and were readily preserved. The lymphatic leak was ligated, the wound was closed, and a drain was placed. No intraoperative complications occurred, no hypersensitivity to methylene blue was observed, and the patient was taken to the post-anesthesia care unit in stable condition. The drain was removed on post-operative day 4 and the wound healed well without incident.

Figure 2. Second patient. A. Pre-operative effluence from incision-site. B. Intra-operative visualization of dye-injected lymphatic. C. Drain placement and closure. D. Post-operative resolution.

THIRD CASE

The third patient (Fig 3) was a 54-year-old woman presenting with chronic mixed seroma-hematoma post-total hip arthroplasty that persisted after multiple aspirations and 2 excision procedures with drain placement. The patient was taken to the operating room where lymphatic mapping commenced with subcutaneous methylene blue injection into the dorsum of the patient's left foot. Exploration of the wound proceeded through the tensor fascia lata (TFL) and despite the presence of some lymphatics in the wound no lymphatic leak was identified. A deep draining area was found extending to the area beneath the TFL and surrounding the implant. A Jackson-Pratt drain was placed into this area and the TFL was reclosed over the drain. Subsequently, the superficial compartment was excised using a 15 scalpel blade and Bovie cautery and the entire seroma was closed using quilting sutures. Cultures and lymphatic mapping results were negative, indicating a potentially disparate etiology for this chronic seroma that led to refinement of a differential diagnosis. Suspicion of an inflammatory reaction was confirmed by a positive finding after completion of a chromium allergy test. The implanted prosthesis was then exchanged and resolution of the seroma followed.

Figure 3. Third patient. A. Intra-operative dye injection of superficial dorsal lymphatic. B. Serous fluid accumulation due to chromium allergy.

RESULTS

Lymphatic mapping in 2 of 3 patients contributed to diagnosis and allowed for enhanced visualization, ligation, and resolution of chronic seromas. In the third patient, lymphatic mapping produced a negative result, thus aiding in refinement of the differential diagnosis. Further assessment of the third patient determined that the chronic seroma was in fact accumulated serous fluid secondary to arthroplasty-derived metal allergy. In all 3 patients, lymphatic mapping led to a diagnosis of either lymphatic leakage or the ruling out of lymphatic leakage, which ultimately led to correct diagnosis of a metal allergy in one patient.

DISCUSSION

Seroma is a post-surgical complication characterized by accumulation of exudative fluid secondary to undermining of the dermis, dead space formation, shearing force between underlying tissues and flaps, and transection of lymphatic or blood vessels responsible for interstitial fluid absorption.⁵ Incidence of seroma, lymphocele, and lymphorrhea is reduced when preference is given to vertical over oblique incisions, use of quilting sutures, and drain placement.⁶ Preventative techniques include reducing electrocautery usage,⁷ quilting and progressive tension (Baroudi) sutures,⁸^-¹⁰ ligating perforating vessels,¹¹ intraoperative fibrin or adhesive use,¹² corticosteroids,¹³ diuretics,¹⁴ compression garments, endoscopic harvest, and drainage placement.⁹^,¹⁵ However, conflicting evidence exists for the efficacy of prophylactic fibrin sealant,¹⁶^-¹⁸ quilting sutures,¹⁹ steroid use,²⁰ and sclerotherapy.²¹^-²³ Drain placement may reduce post-operative hematoma but not seroma incidence.⁹^,²⁴ Additional risk factors exist which cannot be controlled by the surgeon, including prior scarring, body mass index, significant weight loss,²⁵ voluminous post-surgical drainage,²⁶ and excised skin weight.²⁷^,²⁸ Complications include infection, wound dehiscence, flap necrosis, and scarring.²⁹^,³⁰ Chronic seroma may lead to formation of a fibrous capsule, tissue calcifications, or pseudobursa that is associated with adverse outcomes and often requires surgical intervention.²⁵^,³¹ Therapeutic management of seroma includes initial treatment with serial aspiration and followed by drain placement.¹⁸ Further options for rectifying seroma include fibrin sealants,³²^-³⁴ sclerotherapy,²²^,²⁶^,³⁵^,³⁶ serial aspiration,³⁷^,³⁸ corticosteroid injection,³⁹^,⁴⁰ lymphatic mapping with ligation,⁴¹^-⁴³ and surgical capsulectomy.⁴⁴^,⁴⁵Lymphatic mapping is traditionally used in sentinel-node biopsy when assessing mammary carcinoma progression in patients exhibiting clinically negative axillary lymph nodes while undergoing breast conservation treatment.⁴⁶^,⁴⁷ Methylene blue is a dye used in histology or as a contrast agent⁴⁸ and is used here similarly to isosulfan blue in intraoperative lymphatic mapping for direct visualization of vessels to assist ligation.⁴¹^-⁴³^,⁴⁹^,⁵⁰ Lymphatic mapping has also been used to visualize lymphatics for lymph node transfer and lymphovenous anastomosis in the treatment of lymphedema.⁵¹

In this series, lymphatic mapping allowed for prime visualization of lymphatic leak into seromas. In the third case, lymphatic mapping produced a negative result for seroma, which assisted in refining the differential diagnoses. Further examination determined that seroma was actually serous fluid accumulation from inflammation. Hallab et al⁵² and Thomas et al⁵³ reported an increased rate of metal allergy incidence in patients with failed implants.⁵²^,⁵³ Though detrimental outcomes are rare, nickel, chromium, and cobalt are known allergens implicated in allergic contact dermatitis, irritant skin-toxicity, delayed hypersensitivity eczema, and lymphocyte-dominant peri-prosthetic inflammation.⁵³^-⁵⁷

CONCLUSION

Lymphatic mapping using methylene blue dye is an effective tool in intraoperative visualization of lymphatic vessels and ligation of lymphatic leaks. Prosthesis-derived metal allergy may mimic a chronic lymphatic leak as both can cause edema of the extremities, localized swelling, tenderness, and pain as reported in the literature. While the number of patients in this series is limited, these encouraging results indicate that lymphatic mapping may be useful in both the treatment of chronic seromas and the diagnosis of recurrent fluid collections with confounding etiology.

REFERENCES

1. Leitner DW, Sherwood RC. Inguinal lymphocele as a complication of thighplasty. Plast Reconstr Surg. 1983;72:878-81.

2. Nichter LS, Morgan RF, Dufresne CR, Lambruschi P, Edgerton MT. Rapid management of persistent seromas by sclerotherapy. Ann Plast Surg. 1983;11:233-6.

3. Abalmasov KG, Malinin AA. 2004. Pathogenesis and treatment strategies for lymphorrhea and lymphocele after vascular surgeries on the lower extremities [in Russian]. Khirurgiia. pp. 23–30.

4. Seelig MH, Klingler PJ, Oldenburg WA. Treatment of a postoperative cervical chylous lymphocele by percutaneous sclerosing with povidone-iodine. J Vasc Surg. 1998;27:1148-51.

5. Bercial ME, Sabino Neto M, Calil JA, Rossetto LA, Ferreira LM. Suction drains, quilting sutures, and fibrin sealant in the prevention of seroma formation in abdominoplasty: which is the best strategy?. Aesthetic Plast Surg. 2012;36:370-3.

6. Hamed O, Muck PE, Smith JM, Krallman K, Griffith NM. Use of vacuum-assisted closure (VAC) therapy in treating lymphatic complications after vascular procedures: new approach for lymphoceles. J Vasc Surg. 2008;48:1520-3, 1523.e1-4.

7. Porter KA, O’Connor S, Rimm E, Lopez M. Electrocautery as a factor in seroma formation following mastectomy. Am J Surg. 1998;176:8-11.

8. Coveney EC, O’Dwyer PJ, Geraghty JG, O’Higgins NJ. Effect of closing dead space on seroma formation after mastectomy: a prospective randomized clinical trial. Eur J Surg Oncol. 1993;19:143-6.

9. Titley OG, Spyrou GE, Fatah MF. Preventing seroma in the latissimus dorsi flap donor site. Br J Plast Surg. 1997;50:106-8.

10. Arantes HL, Rosique RG, Rosique MJ, Melega JM. The use of quilting suture in abdominoplasty does not require aspiratory drainage for prevention of seroma. Aesthetic Plast Surg. 2010;34:102-4.

11. Skillman JM, Venus MR, Nightingale P, Titley OG, Park A. Ligating perforators in abdominoplasty reduces the risk of seroma. Aesthetic Plast Surg. 2014;38:446-50.

12. Toman N, Buschmann A, Muehlberger T. Fibrin glue and seroma formation following abdominoplasty [in German]. Chirurg. 2007;78:531-5.

13. Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications. J Am Coll Surg. 2002;195:694-712.

14. Matarasso A. Abdominolipoplasty: a system of classification and treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg. 1991;15:111-21.

15. Schwabegger A, Ninkovic M, Brenner E, Anderl H. Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg. 1997;38:594-7.

16. Neuss H, Raue W, Koplin G, Schwenk W, Reetz C, Mall JW. Intraoperative application of fibrin sealant does not reduce the duration of closed suction drainage following radical axillary lymph node dissection in melanoma patients: a prospective randomized trial in 58 patients. World J Surg. 2008;32:1450-5.

17. Miri Bonjar MR, Maghsoudi H, Samnia R, Saleh P, Parsafar F. Efficacy of fibrin glue on seroma formation after breast surgery. Int J Breast Cancer. 2012;2012:643132.

18. Butler CE. Treatment of refractory donor-site seromas with percutaneous instillation of fibrin sealant. Plast Reconstr Surg. 2006;117:976-85.

19. McCarthy C, Lennox P, Germann E, Clugston P. Use of abdominal quilting sutures for seroma prevention in TRAM flap reconstruction: a prospective, controlled trial. Ann Plast Surg. 2005;54:361-4.

20. Okholm M, Axelsson CK. No effect of steroids on seroma formation after mastectomy. Dan Med Bull. 2011;58:A4241.

21. Nichter LS, Morgan RF, Dufresne CR, Lambruschi P, Edgerton MT. Rapid management of persistent seromas by sclerotherapy. Ann Plast Surg. 1983;11:233-6.

22. Moritz RK, Reich-Schupke S, Altmeyer P, Stucker M. Polidocanol foam sclerotherapy of persisting postoperative seromas after varicose vein surgery: a series of six cases. Phlebology. 2013;28:341-6.

23. Rice DC, Morris SM, Sarr MG, et al. Intraoperative topical tetracycline sclerotherapy following mastectomy: a prospective, randomized trial. J Surg Oncol. 2000;73:224-7.

24. Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau P, Mimoun M. Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results. Plast Reconstr Surg. 2000;106:1614-8, discussion 1619-23.

25. Hay-Roe V. Seroma after lipoplasty with abdominoplasty. Plast Reconstr Surg. 1991;87:997-8.

26. Throckmorton AD, Askegard-Giesmann J, Hoskin TL, et al. Sclerotherapy for the treatment of postmastectomy seroma. Am J Surg. 2008;196:541-4.

27. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg. 2008;122:280-8.

28. Di Martino M, Nahas FX, Barbosa MV, et al. Seroma in lipoabdominoplasty and abdominoplasty: a comparative study using ultrasound. Plast Reconstr Surg. 2010;126:1742-51.

29. Reddick LP. Seroma after latissimus dorsi myocutaneous flap for breast reconstruction. Plast Reconstr Surg. 1990;85:826.

30. Kulber DA, Bacilious N, Peters ED, Gayle LB, Hoffman L. The use of fibrin sealant in the prevention of seromas. Plast Reconstr Surg. 1997;99:842-9, discussion 850-1.

31. Zecha PJ, Missotten FE. Pseudocyst formation after abdominoplasty: extravasations of Morel-Lavallee. Br J Plast Surg. 1999;52:500-2.

32. Wattin GR, Van Loock K. Sprayed fibrin glue in lipoabdominoplasty and abdominoplasty. Plast Reconstr Surg. 2011;128:378e-9e.

33. Weinrach JC, Cronin ED, Smith BK, Collins DR, Jr, Cohen BE. Preventing seroma in the latissimus dorsi flap donor site with fibrin sealant. Ann Plast Surg. 2004;53:12-6.

34. Saltz R, Sierra D, Feldman D, Saltz MB, Dimick A, Vasconez LO. Experimental and clinical applications of fibrin glue. Plast Reconstr Surg. 1991;88:1005-15, discussion 1016-7.

35. Ali-Khan AS, Orlando A, Kenealy J. Erythromycin sclerotherapy in the management of seroma. J Plast Reconstr Aesthetic Surg. 2009;62:e55-8.

36. Laverson S. Polidocanol for refractory seroma. Plast Reconstr Surg. 1999;104:1212.

37. Wiener M, Mackie I, Ralston DR. Drainage of large or symptomatic seromas: let the vacuum do the work. J Plast Reconstr Aesthetic Surg. 2007;60:573-4.

38. Anand R, Skinner R, Dennison G, Pain JA. A prospective randomised trial of two treatments for wound seroma after breast surgery. Eur J Surg Oncol. 2002;28:620-2.

39. Taghizadeh R, Shoaib T, Hart AM, Weiler-Mithoff EM. Triamcinolone reduces seroma re-accumulation in the extended latissimus dorsi donor site. J Plast Reconstr Aesthetic Surg. 2008;61:636-42.

40. Axelsson CK, Quamme GM, Lanng C, et al. Local injection of methylprednisolonacetat to prevent seroma formation after mastectomy. Dan Med J. 2012;59:A4482.

41. Cakmak A, Akyol C, Can OS, Hazinedaroglu SM. Identification of post-transplant lymphocele using lymphatic mapping with isosulphane blue. Clin Transplant. 2009;23:137-9.

42. Jones RM, Hart AM. Surgical treatment of a Morel-Lavallée lesion of the distal thigh with the use of lymphatic mapping and fibrin sealant. J Plast Reconstr Aesthetic Surg. 2012;65:1589-91.

43. Stadelmann WK. Intraoperative lymphatic mapping to treat groin lymphorrhea complicating an elective medial thigh lift. Ann Plast Surg. 2002;48:205-8.

44. Stanczyk M, Grala B, Zwierowicz T, Maruszynski M. Surgical resection for persistent seroma, following modified radical mastectomy. World J Surg Oncol. 2007;5:104.

45. Matsui Y, Yanagida H, Yoshida H, Imamura A, Kamiyama Y, Kodama H. Seroma with fibrous capsule formation requiring a surgical resection after a modified radical mastectomy: report of a case. Surg Today. 1998;28:669-72.

46. Song KH, Stein EW, Margenthaler JA, Wang LV. Noninvasive photoacoustic identification of sentinel lymph nodes containing methylene blue in vivo in a rat model. J Biomed Opt. 2008;13:054033.

47. Langer S, Guenther JM, Haigh PI, Difronzo LA. Lymphatic mapping improves staging and reduces morbidity in women undergoing total mastectomy for breast carcinoma. Am Surg. 2004;70:881-5.

48. Chopra A. 3,7-bis(dimethylamino)-phenothiazin-5-ium chloride. Molecular Imaging and Contrast Agent Database (MICAD). Bethesda (MD): National Center for Biotechnology Information (US); 2004.

49. Stadelmann WK, Tobin GR. Successful treatment of 19 consecutive groin lymphoceles with the assistance of intraoperative lymphatic mapping. Plast Reconstr Surg. 2002;109:1274-80.

50. Kwaan JH, Bernstein JM, Connolly JE. Management of lymph fistula in the groin after arterial reconstruction. Arch Surg. 1979;114:1416-8.

51. Suami H, Chang DW. Overview of surgical treatments for breast cancer-related lymphedema. Plast Reconstr Surg. 2010;126:1853-63.

52. Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001;83-A(3):428-36.

53. Thomas P, Braathen LR, Dorig M, et al. Increased metal allergy in patients with failed metal-on-metal hip arthroplasty and peri-implant T-lymphocytic inflammation. Allergy. 2009;64:1157-65.

54. Warmuth IP, Beltrani VS. Metal (hardware) implant “Allergy”. Immunology and allergy clinics of North America. 1997;17:487-505.

55. Hostynek JJ, Hinz RS, Lorence CR, Price M, Guy RH. Metals and the skin. Crit Rev Toxicol. 1993;23:171-235.

56. Thyssen JP, Menne T, Schalock PC, Taylor JS, Maibach HI. Pragmatic approach to the clinical work-up of patients with putative allergic disease to metallic orthopaedic implants before and after surgery. Br J Dermatol. 2011;164:473-8.

57. Kubba R, Taylor JS, Marks KE. Cutaneous complications of orthopedic implants: a two-year prospective study. Arch Dermatol. 1981;117:554-60.


JOURNAL INFORMATION	ARTICLE INFORMATION
Journal ID: ePlasty	Volume: 15
ISSN: 1937-5719	E-location ID: e7
Publisher: Open Science Company, LLC	Published: February 27, 2015