The impact of surgical drains on postoperative complications following DIEP flap breast reconstruction: a multicentre cohort study
This multicentre cohort study of 1,739 patients undergoing DIEP flap breast reconstruction found that surgical drain placement was not associated with a reduced risk of seroma or hematoma at either the donor or recipient sites, challenging the routine use of drains in this procedure.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
When a woman undergoes breast reconstruction using her own tissue, surgeons often perform a delicate operation known as the DIEP flap procedure. This technique involves carefully harvesting skin and fat from the lower abdomen to rebuild a breast, while leaving the underlying abdominal muscles untouched to preserve strength and movement. However, once the tissue is moved and the abdominal wall is closed, a small pocket of empty space remains between the layers of skin and muscle. In the days following surgery, the body's natural response to this disruption can be the accumulation of fluid in these pockets, much like water collecting in a hollow after a heavy rain. This fluid, known as a seroma, or blood, known as a hematoma, can lead to infection, pain, and the need for further medical intervention. To prevent this, surgeons have long placed thin plastic tubes, called drains, into the surgical sites. These tubes act as a safety valve, sucking out the fluid and allowing the tissues to heal together without a gap. For decades, this has been the standard of care, with most surgeons placing these tubes at both the new breast and the donor site on the abdomen, sometimes using as many as six tubes for a single patient.
Despite their widespread use, the necessity of these drains has never been definitively proven. They are not without their own drawbacks; they can cause discomfort, limit a patient's ability to move freely, increase the risk of infection, and prolong the time spent in the hospital. As surgeons began exploring alternative methods to seal these empty spaces, such as using special stitches to hold tissue layers together tightly, a question arose: are these tubes actually doing what they are supposed to do? A large team of researchers across three medical centers in the Netherlands set out to answer this by looking back at over a decade of surgical records. They examined the outcomes of nearly 1,740 patients who underwent this specific type of breast reconstruction between 2010 and 2024, comparing those who had drains placed against the small group who did not.
The study revealed a striking reality about current surgical habits. The vast majority of patients, more than 95 percent, received drains, while only a tiny fraction, less than 5 percent, underwent the procedure without them. This imbalance made it difficult to draw a perfect comparison, yet the data told a clear story. When the researchers looked at the rates of fluid and blood collection at the breast site, they found that patients with drains did not have fewer complications than those without. In fact, the rate of blood collection was slightly higher in the group with drains, though the difference was not statistically significant enough to prove a direct cause. At the abdominal donor site, the results were equally telling. The presence of a drain did not lower the odds of a seroma or a hematoma forming. Whether a tube was inserted or not, the likelihood of these fluid collections occurring remained the same.
The researchers also noted that patients with drains stayed in the hospital for a slightly longer time, averaging six days compared to five days for those without. While the study design could not prove that the drains caused this delay, it suggested that the tubes might be keeping patients in the hospital longer than necessary, perhaps because surgeons feel compelled to monitor the output of the tubes before sending patients home. The study authors emphasized that their findings do not prove that drains are harmful, nor do they declare that a drain-free approach is superior. Instead, the results suggest that the routine placement of these tubes may not be providing the protection surgeons have long assumed. The key to preventing fluid buildup, the data implies, may lie less in the tubes themselves and more in the surgical technique used to close the empty spaces, such as the use of specific sutures to eliminate gaps where fluid could gather.
This large review of over a decade of practice challenges a long-held routine in reconstructive surgery. The authors conclude that while drains have been the standard for preventing fluid accumulation, there is no evidence from this massive dataset that they actually reduce the risk of these complications at either the breast or the abdomen. The study suggests that surgeons should reconsider the automatic use of drains, particularly as other techniques for managing dead space have become available. However, because this was a look back at past records rather than a new experiment where patients were randomly assigned to groups, the authors caution that their findings are a strong suggestion rather than a final verdict. They call for future studies to confirm whether removing these tubes entirely is safe and effective, but for now, the data indicates that the tubes may be an unnecessary addition to a complex and delicate recovery process.
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