Hematoma

A hematoma (also spelt haematoma) is a pocket of blood that collects under the skin after surgery, when a small vessel keeps bleeding after the wound is closed. In FTM surgery a hematoma is the classic early complication of top surgery, appearing in the first day or two, and it can follow most bottom surgery procedures too.

A hematoma is a pocket of blood under the skin, caused by a vessel that keeps bleeding after the wound is closed. It is not a seroma, which is clear fluid collecting in the same space a week or more later and is treated far more casually.

Where does a hematoma happen?

A hematoma is most likely after top surgery. Double incision lifts a large area of skin off the chest wall, and that raw surface holds many small vessels that can bleed again once you are awake and moving. Peri-areolar and keyhole carry the same risk at a lower rate, and a major revision that reopens the chest brings it back.

A hematoma can also follow bottom surgery; the metoidioplasty, scrotoplasty and vaginectomy pages name it.

What does a hematoma look like?

A hematoma shows as one side swelling noticeably more than the other, usually within the first 24 to 48 hours. The swollen side feels tight, firm and painful, and the skin over it may go dark purple. If you have drains, one may fill with fresh red blood or clot and stop. Symmetrical bruising that settles over a week or two is normal healing, not a hematoma.

How common is a hematoma?

A hematoma affects a small minority of patients. Published series for top surgery put it in the low single digits as a percentage, higher for double incision than for the small-scar techniques, and higher again in people on blood thinners, with poorly controlled blood pressure, or who do too much too early. Drainless closure does not seem to raise the rate, though without tubes a hematoma is spotted by swelling alone.

What is done about a hematoma?

A small hematoma is usually left alone; the body breaks the blood down over a few weeks. A large or expanding hematoma is treated as urgent, because blood under tension presses on the skin above it and, after double incision, on the nipple grafts, and skin or graft starved of blood supply for long enough dies.

A sizeable hematoma therefore usually means a return to theatre, typically the same day or the next, to open the incision, wash out the clot, tie off the vessel and close again. The operation is shorter than the original and most people go home that day. The final result is usually unaffected if the hematoma is dealt with promptly; delay is what causes trouble.

What does a hematoma mean for you?

The first-week rules exist largely to prevent a hematoma, so follow them to the letter: nothing above shoulder height, no lifting, no straining, vest on. Tell your surgeon about every medication and supplement, including aspirin, ibuprofen, fish oil and anything herbal, because several thin the blood. Stop nicotine as instructed; the eligibility section explains why.

Sudden one-sided swelling and pain in the first few days means phoning the surgical team straight away, not waiting for your follow-up. They would rather see you for nothing than two days late.

What to ask the surgeon

Ask for the surgeon's own hematoma rate, whether a return to theatre is covered by the original fee, and how to reach the team out of hours in the first week. If you are travelling for surgery, ask how long to stay nearby; the answer is shaped by exactly this risk.

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