Reevaluating the Need for Routine Drainage in Reduction Mammaplasty

Alan Matarasso, M.D., Steven G. Wallach, M.D., and Marlen Rankin, Ph.D.

Often surgeons do not challenge their established routines unless a need arises. For exam­ple, until the advent of concerns over blood transfusions, most reduction niammaplasiy pa­tients had a type and screen for blood prod­ucts. Similarly, the use of closed suction drain-ge after reduction mammaplasty has been the tradition in plastic surgery. Although many sur­geons use drains, Goldwyn1 pointed out that a proper randomized study to investigate the value of drainage after reduction mammaplasty pas lacking in the literature. Ostensibly, drains reduce fluid collection and its sequelae. Not­withstanding this, patients often complain about the discomfort associated with  drains; drain sites can leave conspicuous scars and may represent potential sources of tract formation or infection. Furthermore, with shorter hospi­tal stays, the outpatient management of drains can be a source of concern for patients

Early reports describing breast reduction techniques do not state whether drains were uscd.2-5 The reports that mention drains merely state that they were used; the reasons for their use are not discussed.6-14 Other authors sometimes use drains,15 but again, their criteria for doing so are absent. Nevertheless, some surgeons do not use them at all.16-17 Many authors who discuss the complications of breast reduction often do not mention the value of drainage or how its use may affect outcome.18-22 The purpose of this study was to determine the rate of complications in breast reduction surgery when no drains were used.

Patients and Methods

We analyzed a retrospective series of 50 consecutive female patients who underwent a bi­lateral reduction mammaplasty performed by one surgeon without the use of drains. All patients had general anesthesia. Patient ages ranged from 14 to 65 years, with a mean age of 28 years.

A Pitanguy or superior pedicle technique was used in 84 percent of the eases (42 patients), whereas the remainder were performed by either an inferior pedicle technique (14 percent, 7 patients) or an amputative tech­nique with free nipple grafts (2 percent, 1 pa­tient). The technique used was based on pro-operative patient assessment, as previously described.23 The volume reduction from each breast ranged from 112 to 1152 g from the right breast and 108 to 1200 g from the left breast, with an average reduction of 476 g from the right and 477 g from the left breast. The average total was a 953-g reduction bilaterally. Volume reduction was the weight recorded by the pathologist ("dry weight"), not the weight recorded intraoperatively ("wet weight"). Follow-up ranged from 1 to 7 years (Table I). An operating table that could he placed in a sit­ting; beach chair position was used. General anesthesia was administered by an anesthesiologist. Patients were prepared and marked in a sitting position, according to previous re­ports. The breasts were then injected with a local anesthetic solution containing epinephrine. During the procedure, normotensive blood pressure was maintained, and a warming blanket was used. Some patients underwent simultaneous aesthetic operations; those who did so had the reduction performed as the first procedure. Patients received broad-spectrum perioperativc antibiotic coverage and cortico-steroids. The right breast reduction was per­formed as indicated, and then initial hemostasis was obtained. The procedure was repeated on the opposite breast. The breasts were then reinspected, and final hemostasis was obtained in both breasts. The breasts were then mounted and compared for symmetry, shape, and volume. Finally, the breasts were closed. These steps did not differ from previous breast reductions performed with drains by the senior surgeon.

At the completion of surgery, a Telfa dressing was placed on the suture line; compression garments were not used. The nipple/areola complexes were left exposed and were periodically evaluated. Patients were given the option of wearing brassieres based on their comfort level. During hospitalization, routine postoperative instructions were given, i.e., maintain appropriate blood pressure and avoiding salva maneuvers. An anatomic data sheet filled out describing the procedure. Surgery was performed on an ambulatory or same-basis, and  patients were regularly examined within  the first 48 hours of surgery for ; abnormalities. Sutures were removed in stay over the first week, and patients progressed with normal activity over the ensuing weeks.

Results

All patients were satisfied with their outcomes. An occasional patient had post ions of her scars revised.
Complications occurred in 3 of the 50 tients. A Pitanguy technique was used in two these patients. Both had fat necrosis, and one had wound disruption. The first patient, where had a total of 500 g removed, presented with fat necrosis followed by wound disruption on postoperative day 10, and the second patient, who had a total of 907 g removed, presented with fat necrosis only on postoperative day 18. Both patients healed uneventfully. The third patient had three of the complications. She underwent an inferior pedicle technique, with a reduction of LOSS g on the right breast and 1200 g on the left. Although the nipple/areola complexes both were pink with good capillary refill at. the lime of surgery, the patient was noted to have a dusky right nipple/areola complex on postoperative day 2. When she failed to improve with release of the sutures and phar-macologic means, the breast was reexplored and a hematoma was evacuated from posterior to the pedicle. The pedicle was trimmed, and the nipple/areola complex was replaced as a free graft. The final result was a partial nipple loss with some wound disruption on the right side. This was subsequently revised, and long-term (greater than 7 years) follow-up revealed a satisfactory result.

There were no rases of infection, total loss of the nipple/areola complex, or seroma formation. The total complication rate of each cate­gory (Table II) compares favorably with previ­ous reports (Table III).18-22 Statistical analysis was   performed   using   the   chi-squared   test.

When comparing our data with earlier studies, the data suggest that our complication rates for all categories, except for wound disruption and complete nipple loss, arc: significantly lower statistically than in those procedures performed with drains. For wound disruption and partial nipple/areola loss, our complication rates were 4 percent (2 patients) and 2 percent (1 patient), respectively. Partial nipple/areola loss rate was significantly lower (p < 0.05). There was no significant difference in the wound disruption rate or in the complete nip­ple loss rate (Table IV). Skin slough rate, he-matoma rate, infection rate, and fat necrosis rale all were significantly lower (p < 0.01). A comparison of our data with those of the more recent studies (excluding Gupta's1-1 work) dem­onstrates no statistical difference in the com­plication rates.

Discussion

Breast reduction surgery is highly successful in improving functional, aesthetic, and psycho­logical problems.-' Mitigating any adverse as­pects of this elective procedure is advanta­geous. Drains have conventionally been used after reduction mammaplasty, perhaps because they are believed to reduce fluid collection. However, it is recognized that drains do not prevent hematomas, and there is nothing in the literature to support their use. Conse­quently, if drains are unnecessary, eliminating them might be beneficial.

There are a number of potential disadvan­tages in closed suction drains. An increased risk of wound infection has been reported.26-28 Drains may also require a separate stab incision or, when brought out through the mamma-plasty incision, may increase the risk of scar­ring. In addition, with ambulatory, nonhospital admissions  becoming  increasingly  common, the onus is placed on the patient to be responsible for managing the drains.

There are numerous potential advantages to not using drains in reduction mammaptasiy. Theoretically, the absence of a drain limits the risk of infection from migration of bacteria along the drain tract. Also, the drain has to exit the suture line or a separate stab incision, either one of which can result in additional scar­ring. Finally, the patient does not have the responsibility of caring for the drains. In the Pitanguy procedure, the embryologic relationship of the skin and the parenchyma is main­tained and dead space is avoided; therefore, drains for this technique in particular are most often unnecessary."

This study was not designed to determine whether the results would be the same if drains were used, but rather to determine the incidence of complications given (hat no drains were used. However, we did compare our re­sults with earlier studies on breast reduction surgery that used drains. It is probably unnec­essary to compare our data with those ol Gupta,19 because his data are based on proce­dures performed more than 30 years ago, using techniques that are no longer common1'1; how­ever, we included his work in our comparison because it was one of the only studies available in the literature. Modern studies using drains employ techniques similar to those used by us. When our data from reduction mammaplasty without drain use are compared with modern studies of the same surgery using drains, there is no statistically significant difference in com­plication rates. Stated differently, performing reduction mammaplasly without drains did not increase the risk of complications. Statistical analysis was performed using the chi-squared test and not a Fisher's exact test because the sample sizes were large. Comparison was made with each of the studies individually. Althoughit may be coincidental, we also did not see any infections, which have been estimated to occur in 3 to 7 percent of reduction mammaplasties.18-22

A randomized, prospective study with drain use as the only variable would represent the ideal way to investigate the value of drainage after reduction mammaplasty. This, however, would probably require a large, multicenter study with the collaboration of several surgeons at each institution.

Our study was designed to determine what the complication rate, of breast reduction surgery would be when drains were not used. We found that not using chains did not increase complications, nor is it likely that the compli­cations that did occur could have been avoided by using drains. However, we recognize that certain situations may warrant the use of drains, based on a surgeon's judgment of each individual case.

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