Quilting sutures versus conventional closure after modified radical mastectomy with axillary dissection: a GRADE-assessed systematic review and meta-analysis of randomized controlled trials with pre-specified subgroups by quilting extent

Abstract Background Postoperative seroma is the most frequent complication of modified radical mastectomy (MRM) with axillary lymph node dissection (ALND). Quilting sutures mechanically obliterate the dead space between the mastectomy flaps and chest wall; however, prior syntheses included heterogeneous breast procedures. We evaluated quilting versus conventional closure after MRM with ALND using only randomized evidence. Methods The protocol was registered with PROSPERO (CRD420251237379). We searched MEDLINE (PubMed), Embase, Scopus, Web of Science, CENTRAL, ClinicalTrials.gov, WHO ICTRP, and Google Scholar from inception to June 1, 2025, using reference list screening. Eligibility: Parallel-group RCTs enrolling adult women undergoing MRM (or equivalent total mastectomy) with level I–II ALND, comparing quilting/flap fixation versus conventional non-quilting closure; studies of breast-conserving surgery, immediate reconstruction/oncoplastic procedures, sentinel node-only surgery, and non-randomized designs were excluded. Two reviewers independently screened/extracted data and assessed the risk of bias using the Cochrane RoB 2. Random-effects meta-analysis (REML with Hartung–Knapp–Sidik–Jonkman adjustments) was used to synthesize risk ratios (RR) and mean differences (MD). A prespecified subgroup analysis compared aggressive dead space obliteration (pectoral-plus-axillary quilting and/or drain reduction) with standard pectoral quilting. The certainty of evidence was assessed using GRADE. Results Seven randomized controlled trials (1,412 patients) were included. Quilting significantly reduced seroma incidence (RR 0.36, 95% CI 0.23–0.55; moderate-certainty evidence; ≈200 fewer seromas per 1,000 patients [95% CI 141–241 fewer]) and the need for aspiration (RR 0.29, 95% CI 0.20–0.42; moderate-certainty evidence; ≈192 fewer patients requiring aspiration per 1,000 [95% CI 157–216 fewer]), and also reduced the number of aspirations (MD − 1.03, 95% CI − 1.58 to − 0.47) and total drainage volume (MD − 214 mL, 95% CI − 402 to − 27 mL). Quilting did not significantly affect drain removal duration, surgical site infection (RR 0.71, 95% CI 0.39–1.32; ≈10 fewer SSIs per 1,000 [95% CI 10 more to 20 fewer]), or flap necrosis (RR 0.65, 95% CI 0.32–1.32; ≈22 fewer flap necroses per 1,000 [95% CI 20 more to 43 fewer]). Subgroup analysis showed that both aggressive dead space obliteration (RR 0.31, 95% CI 0.22–0.51) and standard pectoral quilting (RR 0.57, 95% CI 0.36–0.80) significantly reduced seroma without significant differences between the techniques (p = 0.89). Leave-one-out sensitivity analyses confirmed the robustness of these findings. Conclusions Quilting sutures provide a clinically meaningful reduction in postoperative seroma following modified radical mastectomy with axillary dissection and may help support smoother postoperative recovery pathways without compromising wound healing.