Q: I am a healthy 55 yo female. Over the past year, I have lost 40lbs in an attempt to become healthier. After the weight loss, I had a bilateral breast reduction perfomed. The surgeon removed approximately 3lbs from each breast. The original surgery went very well, the drains were removed on post op day 3, and I thought I was on my way to complete healing. By day 10, the wounds started to separate and open, and subsequently, all the suture lines were involved. The surgeon treated my with prophylactic ATBs with no resolution. I was never sick and never ran a fever. I saw an Infectious Disease specialist who treated with with IV antibiotics but the cultures were negative. I was then referred to an allergist who patch tested me for the two types of suture material (Monocryl and Vicry) and the chemical coating (Triclosan); all of which were negative. I am going on 5 months post op and still have some areas of non-healing and draining. The drainage is sometimes a creamy, bloody fluid and is mainly from the areolar areas and the horizontal area. Could you please offer any insight into what may be causing this delay and how long this may last. The breast surgeon claims he has never seen a case like this and offers no answers to my questions. I will get hard nodules under the suture lines, which then pustule up, opens, and then drains.This has been an extremely frustrating experience, expecially since not one of the specialists can tell me exactly what caused this and how long to expect it to continue.
A: Your postoperative breast reduction course has been complicated, and is not a common experience, but it is not rare or unheard of. While I have never seen your wounds, your exact course and the time sequence by which it occurred is something that I have seen more than once from breast reduction surgery. It is not the result of an infection nor is it a reaction to the suture material. The origin lies in the nature and skin perfusion of how a breast reduction is done.
A breast reduction, and even a full breast lift, raises skin flaps whose blood supply is separated from the underlying breast tissue. Its perfusion largely relies on coming in through the skin along the sides. In addition to this vascular compromise, it is then put togther under considerable tension in the inverted T or anchor area on the lower pole of the breast. All of this stresses how well the incisions heal. While the vast majority of time healing is uneventful, the balance can occasionally tip and the wound comes apart. And it never comes apart until between 10 to 21 days after surgery when inflammation and healing really start. Before then the incisions are not really healing but just held together by the sutures. This begins by opening of the invert T and stop in that area for most patients. But rarely it will extend up the vertical incision to the nipple area and open up the whole way. When this occurs, one has to wait for secondary healing which can take several months if not longer until the wounds fill with granulation, contract, and then re-epitheliaze. As the wound is largely open in this process, suture spitting and extrusions become common even in those areas of the incisions that have remain closed.
This is a skin perfusion/vascular injury, not an infection or allergy. I assume you have closed downk considerably and are getting closer to closed wounds. It may take another month or so for the healing to be complete.
Dr. Barry Eppley