Keywords
Haematoma - Triamcinolone - Free tissue flaps - Seroma
INTRODUCTION
Chronic expanding haematoma (CEH) is a rare type of haematoma that enlarges slowly
and continuously without coagulation. In general, it gradually decreases in size and
disappears naturally over time. Although the specific mechanism underlying this enlargement
is not completely understood, it is thought that CEH is caused by minor blunt trauma
or surgery [[1]]. In such cases, a small amount of shear stress-induced bleeding may occur in the
scar tissue between the subcutaneous fat and fascia [[2],[3]]. The bleeding then continues, and the haematoma enlarges because of the accumulation
of coagulation factors and degradation products of the fibrinolytic system [[1]]. Furthermore, because of irritation, blood and breakdown products could cause repeated
exudation or bleeding from capillaries in the granulation tissue [[4]].
CEH can occur at any location in the body [[5]], including the calf, thigh [[6]], knee [[7]], buttocks [[8]], abdomen, pelvis [[9]], and breast [[10]], and may often develop in simulated neoplasms. It occurs not only in soft tissues
but also in any type of cavity. It is presumed that shear force is easily generated
in the back region during daily activities such as turning over during sleep and twisting
at the waist while walking [[5]]. Therefore, reconstructive surgeons should be aware that CEH can develop in patients
who undergo surgery with a latissimus dorsi flap. Three such cases of CEH at the latissimus
dorsi flap site have been previously reported [[5],[11],[12]]. Although treatment for CEH has not yet been established, surgical excision or
aspiration is commonly performed. Here, we report three cases of CEH that developed
at the latissimus dorsi flap donor site between August 2012 and August 2014 at our
institute; these cases improved following a triamcinolone injection, without any severe
complications.
CASES
Three female patients were included in this study. Data on exposures and outcomes
were obtained using chart review after the patient provided informed consent. Although
the patients did not have any obvious complications immediately after the flap surgery,
CEH developed in the donor site at a mean of 47 months (range, 9 months-6 years) postoperatively.
This study was performed according to institutional ethical guidelines.
Treatment procedure
In the first two patients, the initial treatment consisted of multiple sessions of
aspiration of the CEH in the outpatient clinic. The haematoma was drained using an
indwelling needle and syringe, without the use of any anaesthesia, while the patients
were seated. Then, with the patients lying in the prone position, a piece of cotton
(5 cm thickness) was applied directly onto the site of CEH, a piece of gauze was laid
on top of the cotton, and an elastic bandage (width, 10 cm) was wrapped over the cotton
and gauze and around the body to compress the site to prevent recurrence. The patients
were carefully instructed on how to change the cotton and elastic bandage themselves
at home after washing. The compression dressing was basically applied 24 hours a day.
However, the CEH continued to enlarge. Therefore, after draining the haematoma, 40
mg of triamcinolone diluted in 4 mL of saline was immediately injected into the draining
space by using another syringe through the same indwelling needle. The same compression
dressing was tightly applied for at least 1 month to ensure appropriate spread of
triamcinolone and prevent recurrence. In the third patient, a 40-mg triamcinolone
injection was administered immediately after the initial drainage of the haematoma,
without first attempting multiple sessions of aspiration.
Case 1 (42-year-old woman)
The patient (height, 163 cm; weight, 54.0 kg) had undergone left mastectomy for breast
cancer (T1N0M0 stage 1) at 39 years of age, and reconstruction surgery using a latissimus
dorsi flap was performed after 4 months. The patient also suffered from systemic lupus
erythematosus and was taking aspirin for thromboprophylaxis. Although the postoperative
course was uneventful and no history of trauma was evident, a large mass on the back
measuring 100 mm×30 mm×230 mm suddenly developed 9 months after the breast reconstruction
surgery ([Fig. 1A]). The location corresponded with the previous latissimus dorsi flap donor site.
The mass was diagnosed with CEH, and the haematoma was aspirated using an indwelling
needle; the total aspiration volume was 130 mL. The CEH contents contained blood ([Fig. 1B]). Laboratory examination of the aspirated blood showed a haematocrit value of 30.6%
(red blood cell [RBC] count, 320×104/µL), while the haematocrit value in the blood on the same day was 34.1% (RBC count,
390×104/µL). Although the patient stopped taking aspirin and the haematoma was aspirated
three more times in 2 months, with aspirated volumes of 50 mL, 70 mL, and 200 mL,
respectively, the haematoma gradually increased in size. Because 520 mL was aspirated
at the fifth aspiration session, 40 mg of triamcinolone was injected into the draining
space followed by appropriate compression dressing for 8 weeks. The patient's condition
markedly improved without further enlargement of the CEH. Although the patient resumed
taking aspirin 6 months after the triamcinolone injection, there was no recurrence
or need for aspiration for 25 months ([Fig. 1C]).
Fig. 1 Case 1
(A) A 42-year-old woman suddenly developed a large mass on the back measuring 100
mm×30 mm×230 mm, 9 months after breast reconstruction surgery using a latissimus dorsi
flap. (B) The chronic expanding haematoma contents contained blood. (C) The chronic
expanding haematoma had disappeared. The image was taken 25 months after the triamcinolone
injection.
Case 2 (58-year-old woman)
The patient (height, 158.6 cm; weight, 70.3 kg) had undergone left mastectomy for
breast cancer (TisN0M0 stage 0) at 43 years of age and breast reconstruction using
a latissimus dorsi flap at 52 years of age with a good postoperative course. The patient
was taking sarpogrelate hydrochloride for lumbar canal stenosis. Six years after the
breast reconstruction, the patient noticed a large mass measuring 90 mm×75 mm×50 mm
on her back ([Fig. 2A]). The location corresponded with the previous latissimus dorsi donor site. The mass
was diagnosed as CEH, and the patient stopped taking sarpogrelate hydrochloride. The
haematoma was aspirated four times in 3 months, with aspirated volumes of 100 mL,
100 mL, 130 mL, and 190 mL (mean volume, 130 mL). The characteristics of the CEH contents
suggested the presence of blood. At the fourth aspiration, 40 mg of triamcinolone
was injected into the draining space followed by compression dressing for 6 weeks.
The haematoma size was reduced markedly; the aspirated fluid volume fell to 10 mL
at 10 days after the triamcinolone injection. However, a solid haematoma, which could
not be aspirated or injected with triamcinolone, remained. Hence, surgical excision
of the solid haematoma was performed 2 months after the triamcinolone injection. The
excised tissue consisted of a soft cystic mass with a thick fibrous capsule containing
an old blood clot and serous fluid ([Fig. 2B]). Although the patient resumed taking sarpogrelate hydrochloride 6 months after
the operation, there was no further CEH formation for 6 months ([Fig. 2C]).
Fig. 2 Case 2
(A) Magnetic resonance imaging showed a large mass measuring 90 mm×75 mm×50 mm on
the flap donor site. (B) The excised tissue consisted of a soft cystic mass with a
thick fibrous capsule containing a blood clot and serous fluid. (C) The chronic expanding
haematoma had disappeared. The image was taken 12 months after the surgery.
Case 3 (53-year-old woman)
The patient (height, 158.0 cm; weight, 44 kg) had undergone right mastectomy for bilateral
breast cancer (T1N0M0 stage 1) at the age of 48 years. Breast reconstruction using
bilateral latissimus dorsi flaps was performed at the age of 49 years. Although the
postoperative course was uneventful and there was no evident history of trauma, a
large mass on the right back measuring 110 mm×60 mm×85 mm suddenly developed 5 years
after the breast reconstruction surgery ([Fig. 3A]). The mass was diagnosed as CEH. The location corresponded with the right latissimus
dorsi donor site, and there was no sign of CEH on the left side. The first aspiration
resulted in an aspirated volume of 60 mL. Triamcinolone (40 mg) was injected immediately
after this first aspiration. Although the condition subsided for 4 months, a minor
recurrence of the CEH was noted. Therefore, the CEH was again aspirated, and another
40-mg triamcinolone injection was administered. There was no further CEH formation
for 10 months ([Fig. 3B]).
Fig. 3 Case 3
(A) A 53-year-old woman developed a large mass on the right back measuring 110 mm×60
mm×85 mm (surrounded by yellow arrows) 5 years after bilateral breast reconstruction
surgery using bilateral latissimus dorsi flaps. (B) The chronic expanding haematoma
had disappeared. The image was taken 10 months after the triamcinolone injection.
DISCUSSION
The latissimus dorsi is a major muscle of the back. A large space is created when
a portion of the latissimus dorsi muscle is harvested. In this space, a small amount
of bleeding might occur due to shear stress in the scar tissue between the subcutaneous
fat and fascia. Three cases of CEH in the latissimus dorsi flap donor site, with no
noted history of trauma, have been previously reported [[5],[11],[12]]. CEH developed 1 month, 5 years, and 13 years after the flap surgery in these three
cases. In our series, the haematoma developed 9 months, 5 years, and 6 years after
the flap surgery in the three cases. Based on the findings of these cases, surgeons
should consider that the duration between flap surgery and the development of CEH
may range from months to years.
In our first two cases, antiplatelet medication was administered before the operation.
Acetylsalicylic acid (Bayaspirin) was orally administered in case 1; this medication
is used primarily in the treatment of cardiovascular diseases, such as myocardial
infarction and cerebral infarction. It acts by inhibiting cyclooxygenase and plays
an important role in platelet aggregation; it acts as an antiplatelet agent by inhibiting
thromboxane A2 [[13]]. Sarpogrelate hydrochloride (Anplag) was orally administered in case 2. It inhibits
platelet aggregation and vessel constriction by selectively antagonising the serotonin
receptors 5-HT2 on the vessels and platelets [[14]]. This improves the ischemic symptoms of chronic arterial occlusive disease, such
as ulcers, pain, and cold sensation. The main side effect of these antiplatelet agents
is a bleeding tendency, which could increase the risk of a postoperative haematoma,
including CEH.
There are few reports regarding the treatment for CEH. However, because CEH is usually
encapsulated, surgical excision or aspiration is commonly used. As described here,
a triamcinolone injection could be the treatment of choice, particularly after failed
aspiration attempts. Triamcinolone has previously been used to improve seroma at the
latissimus dorsi flap donor site [[15]]. Despite a major difference in blood cell concentration, the clinical conditions
of CEH and seroma after latissimus dorsi flap harvesting are relatively similar; both
involve the accumulation of liquid between the skin and the underlying scar tissue
and occur because of inflammation caused by postoperative shear stress. In seroma,
inflammatory mediators are stimulated by tissue damage, and the exudate stagnates
in the dead space. Triamcinolone is an anti-inflammatory agent that is believed to
reduce the re-accumulation of a seroma. It suppresses the inflammatory process by
the formation of the phospholipase inhibitor lipocortin, which diminishes the supply
of arachidonic acid available for synthesis of prostaglandin and leukotrienes. As
a result, capillary permeability, oedema, migration of leucocytes, and the subsequent
signs of capillary proliferation and fibroblast and collagen deposition are inhibited.
In CEH, the pathogenesis is considered to involve inflammation that is induced by
the destructive products of hemocytes [[1]]. Therefore, we concluded that a localised triamcinolone injection might also be
effective for CEH.
Previous reports indicate that 40-80 mg of triamcinolone should be injected in cases
of seroma. On the basis of these reports, we injected 40 mg of triamcinolone at each
session. Consequently, the haematoma volumes were reduced after the initial injection.
Case 1 showed a marked improvement without the need for an additional triamcinolone
injection, even though this case involved the largest haematoma (520 mL) among the
three cases. The fluid volume of CEH also decreased in case 2, although a solid haematoma
remained. Surgical resection was required for the solid haematoma. The recurrence
experienced by case 3 after the first triamcinolone injection resolved with a second
40 mg triamcinolone injection. On the basis of these experiences, we recommend an
initial 40-mg triamcinolone injection at the first session irrespective of the haematoma
size. For recurrence, a second 40-mg triamcinolone injection is suggested. However,
the most appropriate triamcinolone dose for CEH treatment should be assessed further
with a larger number of cases.
In conclusion, in cases of CEH, a triamcinolone injection, rather than surgical excision
or aspiration, can be considered for treatment.
