Taking a Whole-Person Care Approach to Seroma Prevention in Breast Reconstruction

This Clinician’s View is written by AdventHealth Plastic & Reconstructive Surgeon Quintessa Miller, MD, FACS, who specializes in implant-based breast reconstruction at AdventHealth East Orlando and Kissimmee.

In breast reconstruction, a seroma is more than a postoperative complication. Depending on its size and severity, that pocket of fluid which can develop after tissue removal can trigger a cascade of new challenges for a breast cancer patient, including infection, implant loss, a return to the operating room, and delays in radiation or chemotherapy.

For patients, it can also feel like an emotional setback during an already long and demanding cancer journey.

That is why I think about seroma prevention long before I make my first incision. The process begins with primary care optimization and continues through multidisciplinary planning, meticulous reconstruction technique, thoughtful radiation sequencing, tailored postoperative care, and most importantly, patient engagement. Preventing complications isn't solely the responsibility of the reconstructive surgeon; it requires a coordinated team committed to whole-person care.

The journey often starts in a place many don’t immediately associate with breast reconstruction: the primary care office.

Preoperative Optimization and Collaboration Across the Care Continuum

Although they never step foot in the operating room, primary care physicians (PCPs) play an essential role in reducing postoperative complications, including seromas. Optimizing a patient’s health before surgery can have just as much impact on outcomes as the surgical technique itself.

In my practice, this means focusing on several key areas:

• Improving body mass index (BMI). Elevated BMI is associated with seroma development, wound dehiscence, infection, fat necrosis and delayed healing. We individualize decisions based on overall health, comorbidities and oncologic timeline, generally striving for a BMI below 38 kg/m² while recognizing that lower BMIs are associated with the most favorable reconstructive outcomes.
• Controlling diabetes (A1C). Elevated HbA1c impairs wound healing and tissue adherence, leaving a larger potential space for serous fluid to accumulate. Our goal is an A1C below 7.5% before surgery.
• Stopping all forms of nicotine. Cigarettes, vaping and nicotine replacement products can compromise blood flow through vasoconstriction and significantly impair wound healing. That is why we recommend stopping all nicotine products at least four weeks before surgery.

These conversations aren't always easy, and sometimes the safest decision is to delay reconstruction until modifiable risk factors are better controlled. While patients are understandably eager to move forward, appropriate optimization can give them the best chance for a successful reconstruction and smoother recovery.

Of course, patient optimization is only one part of the equation. Reducing complications also depends on coordination across the care continuum, including PCPs, breast and reconstructive surgeons, radiation oncologists, APPs, nurses and the patient.

Close collaboration with the breast surgeon is foundational. Our shared priority is eliminating the cancer, and that goal drives every decision about the surgical and reconstructive plan, including nipple- versus skin-sparing mastectomy and incision placement. Planning together before surgery helps minimize tissue trauma, streamline the operation and reduce anesthesia time.

Coordination with the radiation oncologist is equally important. Timing reconstruction appropriately and, when necessary, temporarily deflating tissue expanders to facilitate radiation therapy, can help patients stay on track with their cancer treatment.

After surgery, APPs and nurses manage drains, reinforce recovery protocols and provide ongoing education, and patients are active members of the team as well. Early mobilization and regular walking promote lymphatic drainage, support fluid reabsorption and may reduce fluid accumulation.

Every member of the care team contributes to achieving better outcomes.

Integrating Surgical Technique into Seroma Prevention

Collaboration with my medical colleagues and patients has also shaped how I approach implant-based reconstruction. Surgical technique is an important component of seroma prevention, but no technique exists in isolation. The best outcomes depend on selecting the right operation for the patient and pairing it with protocols that anticipate and mitigate known risks.

The discussion surrounding prepectoral versus submuscular implant-based reconstruction continues, and both techniques have well-established advantages. In my practice, I most often favor the prepectoral approach because, in appropriately selected patients, its long-term benefits frequently outweigh its potential drawbacks.

Although prepectoral reconstruction has historically been associated with a higher risk of seroma, I believe that risk can be substantially reduced through careful patient selection and a disciplined surgical protocol. Benefits can include less postoperative pain, preservation of pectoralis muscle function, elimination of animation deformity, easier tissue expansion, shorter operative times, improved radiation tolerance and reduced opioid requirements.

My perspective evolved while caring for veterans, many of whom were already living with chronic pain. Reconstructing the breast without disturbing the pectoralis muscle often translated into a more comfortable recovery, and in many cases, eliminated the need for narcotic pain medication. That experience reinforced an important lesson: rather than avoiding a surgical technique because of its risks, we should understand those risks and develop consistent strategies to reduce them.

Refining Surgical Technique to Reduce Seroma Risk

In the operating room, my focus is clear: minimize dead space while maximizing tissue perfusion.

I routinely use intraoperative fluorescence angiography to confirm flap perfusion, fill tissue expanders sufficiently to create a hand-in-glove fit without compromising skin viability, place two drains to manage fluid associated with the larger amount of acellular dermal matrix (ADM) often required for prepectoral reconstruction, apply fibrin sealants to promote tissue adherence and use closed-incision negative pressure therapy with the Prevena™ system.

Each intervention contributes incrementally, creating an environment that supports healing and reduces fluid accumulation.

Like many surgeons, my approach has evolved with experience. Early in my career, I intentionally underfilled tissue expanders because I was concerned about flap perfusion. Over time, I realized that excessive dead space carries its own consequences. Routine perfusion imaging has given me greater confidence to increase expander fill while confirming tissue viability, and I've seen fewer seromas as a result.

Adding closed-incision negative pressure therapy has further strengthened my protocol by improving soft tissue support, managing postoperative fluid and reducing wound complications.

These refinements have helped reduce complications while improving the overall patient experience. However, my seroma prevention strategies don’t end in the operating room.

Managing Surgical Recovery

Even the best operation can be undermined by inadequate postoperative care.

Our evidence-based enhanced recovery after surgery (ERAS) pathway emphasizes conservative drain management, early ambulation and progressive mobilization. We generally wait until drain output is less than 20 mL per day for three consecutive days before removal. Throughout recovery, our APPs and nursing team reinforce these expectations and encourage frequent walking.

These seemingly small details make a meaningful difference in reducing seroma formation, supporting functional recovery and allowing patients to resume their lives more quickly.

Treating the Whole Person

When I perform breast reconstruction, I know I’m treating far more than a breast.

A desire to alleviate human suffering drew me to medicine. I initially planned to become an internist, but a general surgery rotation during my third year of medical school changed my trajectory. After observing a breast reconstruction, I realized I could help a woman move from one of the hardest moments of her life toward healing. I had found my calling. That perspective continues to shape my practice today.

Seroma is more than just a postoperative complication, and every decision we make to prevent it -- from optimizing health before surgery to coordinating care, refining surgical technique and supporting recovery – is an opportunity to help patients heal more completely, stay on track with cancer treatment and move forward with greater confidence to reclaim their lives. That is the essence of whole-person care.