Open Access

Aurelia Taubner

• Bei der Reduktionsmammaplastik entstehen weitgehend unabhängig vom Operationsverfahren große Wundflächen. Diese führen in 1,8 - 6% zur Ausbildung von behandlungspflichtigen Hämatomen [1, 2, 3, 4, 5, 6, 7]. In bis zu 6,3% entstehen anhaltende Serome [1, 2, 4, 5, 6, 7]. Flüssigkeitsansammlungen verursachen durch größere Spannungen der Haut und Infektionen Komplikationen im Heilungsverlauf. Bei 7,5 - 24% der Brustverkleinerungen kommt es zu einer verzögerten Wundheilung [1, 2, 3, 4]. Davon werden das Wohlbefinden der Patientinnen und die Dauer des stationären Aufenthalts nachhaltig beeinträchtigt. Der Nutzen von Drainagen zur Vermeidung von Hämatomen und Seromen ist nicht abschließend geklärt [8, 9, 10, 11, 12, 13]. Die Anlage von Nähten zur Verkleinerung der Wundfläche kompromittiert die Perfusion. Dabei ist besonders die Mamille gefährdet, eine Nekrose zu entwickeln. Eine moderne Technik zur Verkleinerung der Wundfläche und folglich auch zur Verringerung der Sekretionsmenge stellt die Versiegelung mit Fibrinklebung dar, die sich seit 1975 für zahlreiche Indikationen etabliert hat [14, 15, 16, 17]. Bisher wurde die spezielle Wirkung der homologen Fibrinklebung auf den Wundheilungsprozess nach Reduktionsmammaplastik nicht untersucht. Das Ziel dieser Studie ist es festzustellen, ob und inwieweit durch das Aufsprühen von Fibrinkleber ein positiver Effekt auf die Wundsekretion, d.h. auf deren korpuskulären bzw. serösen Anteil im einzelnen und auf die Wundheilung insgesamt besteht. Letztendlich geht es darum, Verbesserungen im Sinne der Fast-Track-Chirurgie zu erzielen. Im Rahmen einer prospektiven Studie sollten deshalb die Daten von einhundert konsekutiv rekrutierten Patientinnen ausgewertet werden, die sich zwischen Juli 2004 und August 2006 einer bilateralen Brustverkleinerung in der Klinik für Plastische Chirurgie, Wiederherstellungsund Handchirurgie des Markus-Krankenhauses, Frankfurt am Main unterzogen.
• Background: Reduction mammaplasty causes large wound surfaces. Major haematomas and seromas are frequent complications. Their formation increases skin tension, compromises skin viability and wound healing and slows ambulatory care. The effect of postoperative drainage is still beeing discussed. Sutures may effect the perfusion negatively. Investigations into homologous fibrin sealant have shown it to be effective in a broad range of clinical applications since 1975. But there have been no studies of its effects on reduction mammaplasty up to now. So this study was undertaken to evaluate whether fibrin is effective in reducing drainage volume at all and corpuscular and serous components in their particular cases to speed recovery and minimise hospitalisation. Methods: 100 patients were registered, who were due to undergo bilateral reduction mammaplasty, according to the Pitanguy-Höhler technique with inverted T-incision, a proximal pedicle and one drain per breast. 50 patients (100 breasts) were treated with fibrin sealant (Tissucol® Kit 2 Immuno, Baxter). The others were assigned to the control group. Baseline comparability of the two groups was evaluated to ensure adequate patient distribution. Patients were treated between 2004 and 2006 at the Department of Plastic and Reconstructive Surgery, Markus-Krankenhaus in Frankfurt, Germany. The quantity and composition of the drainage (haematocrit and total haemoglobin) was examined each day postoperatively and related to the individual serological measures independently as well as dependently. The wound condition, the swelling, the skin tension, the extent of eccymosis and any complications were documented daily by the same member of the team. The data collection included medical and drug history, smoking status, operative details and at least two ultrasound examinations. If no further follow-up visits were necessary the final review took place at least 3 months after surgery and included another ultrasound examination. For statistical evaluation following programs were used: SAS® and SPSS®, regression analysis, unpaired t-test (least squares), OLS (Ordinary Least Square) and Probit Model. Results: All of the 100 patients conformed to a predefined set of variables and had a similar distribution of all relevant clinical parameters. In using fibrin sealant the quantity of the mean cumulative seroanguinous drainage (80.1 ml vs. 100.6 ml, p < 0.05) was significantly reduced especially on the first postoperative day (34.6 ml vs. 54.5 ml, p < 0.05). The difference in corpuscular volume was significant on day one, too (12.9 ml vs. 29.1 ml, p < 0.05). The serous component was almost equal in both groups over the entire time of observation. The incidence of haematoma was 0% in the treatment group vs. 4% in the control group (p < 0.05). There was no statistically significant difference in the incidence of any other clinical event (seroma, sonographically assessed retentions, ecchymosis and necrosis) between the two groups. On day 3 a significantly larger proportion of patients in the treatment group (p < 0.05) had no skin tension. The differences in the incidence of superficial and deep dehiscence, minor epitheliolysis and hypertrophy scars were not significant. Age, a high BMI and a high resection weight were identified as significant independent risk factors for complications after breast reduction surgery. Conclusions: The application of fibrin in reduction mammaplasty significantly decreases the total volume of seroanguinous drainage. The major effect is achieved on day one. The corpuscular component of the content reacts the most intensely. The incidence of haematoma is significantly reduced. This shows that fibrin sealant mainly works by efficiently promoting haemostasis. The postoperative drainage of one day would be sufficient for the corpuscular secretion. The effect of fibrin on serous secretion and seroma formation is marginal. The effect of postoperative drainage on the serous secretion must be studied in more depth to find out whether it is possible to do without it. Older patients and those with a high BMI and breast resection weight have an increased risk of complications and are not eligible for fast ambulatory care.