Strategies to prevent seroma formation after mastectomy surgery: A systematic review and meta-analysis.

Background: Seroma formation is a frequent and challenging complication after mastectomy surgery, with incidence rates ranging from 3 % to over 85 % (1). Despite numerous proposed interventions, no universally accepted standard for prevention exists. Methods: A systematic review and meta-analysis was conducted following PRISMA guidelines. PubMed was searched for randomized controlled trials, cohort studies, and systematic reviews published in the past 10 years that evaluated interventions to prevent seroma after mastectomy surgery. Thirty-four studies met inclusion criteria. Data were extracted on study design, intervention, comparator, seroma incidence, seroma volume, and statistical outcomes. Pooled odds ratios (OR) and 95 % confidence intervals (CI) were calculated for each intervention group using a random-effects model. Heterogeneity was assessed with the I² statistic. Results: Quilting sutures demonstrated the greatest efficacy, reducing seroma incidence by 76 % compared to standard closure (pooled OR 0.24, 95 % CI: 0.11-0.52, I² = 0 %). Flap fixation also significantly reduced seroma rates (pooled OR 0.43, 95 % CI: 0.26-0.70, I² = 0 %). Steroids and selected adjuncts (OK-432, hemostatic powders, diuretics) were associated with a 59 % reduction in seroma incidence (pooled OR 0.41, 95 % CI: 0.26-0.64, I² = 36 %). Drain management strategies showed that early or no drain removal may increase seroma risk (pooled OR 1.99, 95 % CI: 0.96-4.14, I² = 54 %), though not statistically significant. Tissue adhesives (TissuGlu®, fibrin glue, cyanoacrylate) and harmonic scalpel showed modest or inconsistent benefits (adhesives pooled OR 0.63, 95 % CI: 0.35-1.14, I² = 57 %; harmonic scalpel pooled OR 0.59, 95 % CI: 0.36-0.96, I² = 0 %). Nitroglycerin ointment did not significantly reduce seroma formation (pooled OR 0.78, 95 % CI: 0.31-1.96, I² = 0 %). Conclusions: Quilting sutures and flap fixation are the most effective interventions for preventing seroma after mastectomy surgery, with strong supporting evidence and minimal heterogeneity. Output-based drain management and selective use of steroids or adjuncts may further reduce risk in high-risk patients. Routine use of tissue adhesives, harmonic scalpel, or nitroglycerin ointment is not supported by current evidence. Future research should focus on standardized outcome reporting and direct comparisons of effective strategies, particularly in the setting of mastectomy reconstruction.