Recurring Seroma Formation After Tummy Tuck?

Thank you for your post. Seromas can be painful and cause a cosmetic deformity, as well as sometimes leak. The whole point of drains is to keep a seroma from happening in the first place. If a drainless procedure was performed, and you had a seroma, or you had drains that were pulled and you subsequently had a seroma, then you should be drained, otherwise a capsule builds around the fluid making it permanent. If a capsule builds around the seroma (pseudo bursa or encapsulated seroma) then the only way to remove the seroma is to surgically open the areas and excise the capsule, and close over drains to prevent another seroma from happening. If the seroma is encapsulated and is tight and painful, then it can be confused with just swelling or fat. An ultrasound is useful in distinguishing these and identifying the extent of the seroma. If the seroma is not yet encapsulated, then it is usually loose and has a 'fluid wave' or water bed type feel. Occasionally, a seroma can also become infected, especially if a permanent braided suture was used. This will have a hot, red appearance, and will eventually open up. I have never seen an infection from sterile aspiration of fluid.
Best wishes,
Pablo Prichard, MD

There is a delicate network of thin filamental lymphatic fibers on top of the rectus abdominis sheath. These lymphatic fibers drain into the lymph nodes down in the groin. The umbilical line divides the drainage of these fibers. Above the umbilicus, they drain upward to the axillary lymph nodes. Below the umbilicus, they drain down into the inguinal nodes.

It is my experience that traditional liposuction rarely goes down to these fibers, and therefore almost never causes a seroma. Scars left by traditional liposuction are intermittently placed, and therefore do not increase the chance of a seroma in a post liposuction abdominoplasty.

Unfortunately, the newer forms of liposuction, Vaser, Laser, Slim, Smooth, etc. create a much larger field-like destruction of these filmy lymphatics, and therefore abdominoplasties after these types of liposuctions very often are fraught with recurrent seromas.

Other forms of abdominal wall interventions such as C-sections and hysterectomies done from a bikini line incision (pfannenstiel incision) tend to increase the likelihood of a seroma. Surgeons performing these operations and assistants pulling on retractors are often more concerned with the intra-abdominal surgery than with protecting the lymphatics on the rectus sheath. Therefore, abdominoplasties after gynecologic bikini line incisions have a much greater chance of recurrent seromas due to the destruction of these necessary and delicate lymphatics.

Recurrent seromas in a situation where the channels to take up excess fluid have been destroyed are very difficult to resolve. I find recurrent drainage in this situation to be of minimal value. The seromacath left in for 3 or 4 days with intermitten installation of a sclerosing agent has a much better chance of obliterating these pockets of fluid since few, if any, lymph drainage channels remain.

Dear Salux in Luxembourg,

I visited your country many years ago and thoroughly enjoyed it. Moreover, while I am proud of the abilities of American Plastic surgeons, I would feel as confident about the quality of European trained and certified (ie ancien interne etc) Plastic surgeons.

Your abdomen was violated 4 separate times with C sections, once by liposuction and once with an abdominoplasty. Each time, new scar is laid down and the lymphatic circulation is further compromised prolonging both drainage and absorption of wound fluids. Recurrence of seromas after the last "re-do" validates the point that your abdominal wall does not behave the way a non-operated wall does.

After a tummy tuck cavity drains for more than 6-8 weeks a thin scar tissue begins to line the cavity and it becomes a bursa. If the drainage persists and cannot be effectively drained, the lining thickens and the bursa will not resolve with drainage. In these cases, I fully agree with the earlier post by Dr. Yates. Your surgeons should try putting a mixture of a local anesthetic and a sclerotic irritating solution in the remaining cavity to inflame the walls and get them to stick to one another closing the cavity. If this fails to work, you will require another operation in which the smooth lining of the bursa is removed and the wound is closed over drains. Again.

Hope it works for you this time.

If the ultrasound confirms a seroma, it will likely require drainage 9 weeks out. If it is small enough you may wait it out to see if it resolves. Drainage is usually successful with closed aspiration. Sometimes a sclerosing agent such as sodium tetradecyl can be infused in the pocket. These have a tendency to recur and it may require a couple of treatments. For a seroma that is large, tender, or has stretched the skin it would likely require open exploration and excision of the "wall" of the seroma. I have had to do this on a couple of occasions and am always surprised of the thickness of this wall and what a difference it makes in the contour after it is removed.