DIEP flap, spitting stitches, hematomas -- what should I do? (Photos)

Question

I had a DIEP flap procedure 6 weeks ago, and my breast was very bruised. After about 2 weeks, I noticed that I was spitting stitches and white plastic staples, but I also had drainage of old blood that I informed my wound RN about. PS wasn't worried, even though it was a considerable amount. Yesterday, I drained more than 40ml from the site, and went to the ER where they confirmed that I had a hematoma. I don't trust the PS any more but I have an appointment tomorrow, what should I do?

Christopher Pannucci, MD, MS · Answer

Hi bunnymade,
At 6 weeks from surgery, your plastic surgeon would manage any immediate postoperative complications. Based on the photos, your flap which came from the abdomen appears completely alive, as evidenced by the normal-looking ellipse of the abdominal skin which is visible. However, at multiple locations the native breast skin has separatedfrom the flap, and fluid which accumulated the underlying appears to be draining. 
I would 100% suggest that you keep working with your plastic surgeon, as he or she knows what occurred on the inside, and is uniquely qualified to manage any immediate postoperative complications.
Hope this helps.
Sincerely,Christopher Pannucci MDBoard Certified Plastic SurgeonPlastic Surgery NorthwestSpokane, Washington

Ryan Rebowe, MD · Answer

In these situations, the best course of action is to have an open discussion with your plastic surgeon regarding your concerns. Spitting sutures are common following surgery, especially DIEP flap surgery, as is bruising. It would be normal to be relatively unconcerned about these findings in the absence of other information. The hematoma is certainly an unfortunate consequence and will likely need to be taken care of either at the bedside or surgically. I am sure your surgeon would like to be the person to help you through this if he or she understands your concerns. While there is often fear from patients that this will turn into a confrontational experience, most surgeons are happy to address any issues that come up so that there is no rift in the physician-patient relationship.

Michael Orseck, MD · Answer

At this point, meticulous wound care is indicated.  It would be best to stick with the current PS to help you get healed.  If you still have concerns about him/her performing the second stage, then by all means, seek the opinion of another MD.

Stephanie Peng, MD · Answer

Hi there, thank you for sharing your photos.  I'm so sorry you're having a hard time with your breast reconstruction.  As difficult as it may be, I strongly encourage you to keep your appointment with your plastic surgeon so you guys can work through these complications together.  Good luck!

Robert Whitfield, MD · Answer

If there is retained fluid of blood and the drain is already out then it will continue to drain from the spaces in and around the flap.  I typically return patients that have had a hematoma to the operating to get the residual blood out of the tissues.

DIEP flap, spitting stitches, hematomas -- what should I do? (Photos)

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