Drains....and why I don't use them.
December 20, 2022
May 16, 2023
By Dr. Andrew Campbell-Lloyd

Drains....and why I don't use them.

Surgical drains are completely unnecessary after most breast surgery.

Possibly contentious, but in my practice that is a simple statement of fact. I haven't used drains for routine breast surgery for about 8 years. But many surgeons would take serious issue with that statement, so let's debunk some of the persistent dogma about needing drains, and in particular, let me offer some reassurance that if you are considering explant surgery, breast reduction, or implant revision surgery, you DO NOT NEED DRAINS (at least, not with me).

There is one major exception to the "no drain" rule and that is implant-based immediate breast reconstruction. Whilst we have modified our technique over the years to reduce the duration that drains remain in for ladies after a mastectomy, it simply isn't possible to perform this surgery without drains. That is another interesting topic and if anyone is interested, please let me know and I can write more about it another time.

The use of drains remains the norm for most surgeons, and most patients expect that they will have to have them after any breast operation. They are a feared aspect of surgery due to anticipated pain, and the general "ick" factor of having things hanging out of your body with stuff leaking out and collecting in bags or bottles.

So let's look at three things:

1) what do drains do, and why would you need them?

2) why do most surgeons use them for operations like explant procedures?

3) and what makes me so bloody special that I don't need to use drains for my patients?

What do drains do, and why would they be necessary?

Ok, so first off some basic concepts.

Drains do not prevent a haematoma (or a collection of blood) after surgery. If your surgeon has failed to control bleeding during surgery, drains won't do a damn thing about it.

Drains ARE designed to prevent seromas (fluid collections) after surgery. Lovely.

What the hell is a seroma?

Good question, and one that is surprisingly poorly answered by science. The simple version though is that a seroma is a collection of "inflammatory fluid" within a space that has been created during surgery. Pretty much any breast operation involves more than just what is seen on the surface. The deeper aspects of surgery normally involve separating various tissue layers and making pockets or spaces within the breast. The creation of spaces is an essential factor in whether a seroma can form.

No space. No seroma.

There is one other major reason for seromas to form beyond just having a space. In the normal course of healing, if there is a space created by a surgeon, then the tissue layers that have been separated are really quite keen to stick back down and seal that space off. The major impediment to that happening is excessive movement. You can think of excessive movement as an "irritant". It will result in those layers (which are trying to stick together) rubbing on each other (sort of) - as a general rule your body doesn't like that, and so it can trigger fluid secretion as a "lubricant" to minimise the irritation that comes from all of that movement.

Space = seroma. You either need to fill the space, or obliterate the space to prevent seroma.

Excessive movement = seroma. Movement is the most significant, modifiable risk factor which is determined by post-operative patient behaviour. Quite simply, this is why resting and limiting activity is so important in the post-op period.

One way of managing these problems is to use a drain. The drain will allow any fluid build-up to escape, and the drain also applies suction which will collapse any pockets or spaces. Righto. But (obviously) that isn't the only answer.

Why do most surgeons persist in using drains?

Most surgeons are just doing what they have been taught, and as I have just mentioned above, using drains is one way to limit the formation of seromas. But let's consider that critically - it should be apparent that using a drain is reactive. It is not actually managing the root cause of why a seroma would form in the first place. But never let logic get in the way of a surgeon doing what has always been done.

So, drains go in. And they have to stay in until such time as the fluid output from the operation site has reduced to a level that means there isn't going to be a progressive accumulation of that fluid. That can mean drains staying in anywhere from overnight to 2 weeks, depending on the surgeon and the operation. When drains are used, if they are removed too early then the seroma will just form after the drain removal, rendering the whole thing pointless. Alas.

Preventing seromas is vital.

Seromas, if allowed to accumulate and persist, don't just go away. This is a really important point. Seromas (of a certain volume) will not be absorbed by your body and they will not magically get better. There is a process that takes place (relatively quickly) once a seroma has been present for longer than about a week. This process is called "encapsulation" of the seroma, and it is a little bit similar to the encapsulation of a breast implant. The encapsulation process is interesting because it creates two problems.

Firstly, the capsule that forms has a smooth, slippery lining which prevents tissues sticking down (the way we would have wanted them to) and which also doesn't lend itself to absorbing any fluid that is present. The capsule basically creates a permanent pocket within which the seroma fluid can persist.

The second problem (which is a bigger issue) is that the seroma capsule is a scar, and more importantly, it is a scar that the surgeon has no control over. When we make incisions and then carefully close them up during surgery we have some degree of control over the nature of the scar that will form. The scar tissue that forms a seroma capsule is out of our control, and it is reactive. The scar within that capsule has a tendency to be stiff, and to thicken, which will potentially create distortion of the overlying tissues - which is to say, it will create distortion of the breast that you can see.

Another (massive!) problem associated with seromas is that the seroma fluid, which is full of dead inflammatory cells is basically an ideal growth medium for bacteria (ie. it's bug food). Which is to say that a seroma is a common cause of infections. And an infected seroma is mess.

So all that being said, most surgeons persist in using drains to prevent seromas. But I think there is a better solution.

Why don't I need to use drains when everyone else does?

Fair question. It's pretty simple though at the end of the day: it comes down to technique.

I said above that drains manage seromas, but drains fail to address the root cause of why seromas occur.

My surgical techniques address the root cause of seroma formation. I don't allow a seroma to form, hence, no drains required.

Let me explain: if the drivers for seromas to form are movement and space, then we need to think about ways to modify those two issues. Whilst there is some variation amongst different breast procedures, there are also common themes, but for the purposes of this discussion, I think it is best to focus on the procedure I perform with the highest risk of seroma, which is explant surgery.

99% of surgeons performing explant surgery with capsulectomy will use drains. There are plenty of surgeons who DON'T PERFORM A CAPSULECTOMY when removing breast implants, and they may argue that they don't need drains in that context, but that becomes a bit of a straw-man argument - my opinion (which I have written about quite a bit) is that failure to perform a capsulectomy is a failure to perform explant surgery correctly. But that is a different topic.

So, assuming that an explant is performed with a capsulectomy, then the space that results from removing a breast implant is quite extensive. The basic argument for most surgeons is that therefore, a drain is require to "suck down" the muscle (if the implant was under the muscle) and close off that space to prevent seroma. My argument is that you can close that space off whilst also restoring natural anatomy by simply repairing the Pectoralis major muscle to its original insertion onto the ribs and sternum. This actually serves two purposes - the space that results from removing the breast implant is obliterated, and just as importantly, the muscle is fixed in position which then prevents movement of the muscle, thus also addressing our second cause for seroma formation.

So with one step, we have managed both of the main causes for seroma, whilst offering our patients the benefit of significantly improved breast aesthetics, better function, and avoiding the potential distortion and breast deformity that can arise from poorly performed explant procedures where the muscle hasn't been repaired. Lovely.

If implants are on top of the muscle (rare in Australia to be honest), we have to consider a few other approaches. Firstly, we often perform explant procedures in conjunction with a mastopexy. The mastopexy technique we use involves an "auto-augmentation" which repositions the breast tissue in such a way as to nicely fill the space resulting from the capsulectomy. If we don't do mastopexy, then we spend a bit of time really carefully closing off the space with sutures, partly in conjunction with our internal bra techniques, to achieve the same goal.

Now that is all well and good for explant patients, but what about other procedures?

Well, to be honest the need for drains in things like breast reduction and mastopexy has never really been clear to me - I mean, when we do a breast reduction, there is no unfilled space in the breast with modern techniques. We reorganise the internal breast tissue in such a way as to fill the breast quite firmly (which is one of the goals of the procedure), so there is no drive for seromas to form. Sure, older fashioned techniques for breast reduction fail to manage this issue (I find it hard to believe surgeons are still using an "inferior pedicle" technique for breast reduction, but they are, and that technique certainly increases the risk of seroma due to the way in which the internal spaces are underfilled), but with superior and superomedial pedicles (which most surgeons these days would use), there is no need for drains. It isn't because of anything fancy that I do....it's just becuase a lot of surgeons are still stuck doing the things they were taught and haven't bothered to change.

The other common one where patients seem to expect that they will need drains is when I perform breast implant correction/revision surgery. This is an interesting one because in a sense, it is an operation halfway between an explant and a mastopexy (typically) and it warrants slightly different consideration. Again, this comes down to my techniques though.

Somewhat like an explant, the issue with implant revision procedures involving a capsulectomy is that we create a space which may not be filled. So many surgeons (rather unwisely) advise patients to INCREASE their implant size to manage this issue. I take an opposite approach in some respects. I nearly always advise revision patients to downsize. That has the advantage of reducing the weight of the implant (which increases long-term stability), and more importantly, we perform a "plane change" which allows us to firstly close off the space from the old implant, and then create a new space for the new implant which is precisely controlled, which ensures that there is no excess space into which fluid could collect. Closing off the old space after capsulectomy involves a muscle repair (given that most implants in Australia are "dual-plane" or under the muscle, just like an explant), and the new pocket is then developed on top of the muscle where we can control the space. Where the old implant was on top of the muscle, we have to carefully modify the pocket using "internal bra" techniques to ensure that we can use a smaller implant without a problem. The other thing that we frequently do with implant revision cases is perform a mastopexy, so that also allows us to tighten things up which again prevents any excess space, especially where the implant was pre-pectoral.

No drains = more comfortable.

So, at the end of the day, there is no need for me to use drains for most breast surgery. Drains are often a source of discomfort and inconvenience, so that is a good thing for my patients. Drains are also a common reason that patients stay overnight in hospital which can add to costs substantially.

I hope this helps explain why drains are simply unnecessary in my opinion.

Having said all of that, please remember that all surgery involves risk. My job to is to do what I can to minimise that risk to my patients. Whilst I can happily tell my patients that I think the risk of seroma is low with my techniques for surgery, it isn't zero. And perhaps more importantly, none of what i have discussed negates the importance of care in the post-operative period. A misbehaving patient is always at higher risk of complications (including seroma) than a patient who follows their instructions and limits their activity.

Any questions, as always, let me know via our contacts.