Urban Myths in Plastic Surgery: Postoperative Management of Surgical Drains

Background. Surgical patients are frequently discharged with surgical drains to assist in wound closure that could be disrupted by postoperative hematomas, lymphoceles, or seromas. In clinical practice, duration of drain use is typically dependent on daily output.Objective. The aim of this paper was to examine the origins and justifications of drain removal criteria. The authors considered factors that may influence recommendations such as duration, area of surgical site, and risk of infection. Methods. A literature review was performed regarding the indications for drain removal in patients undergoing reconstructive and breast surgeries. PubMed was queried for publications up to May 2015 with the following search terms: drain removal, hematomas, lymphoceles, seroma, volume, reconstruction, and mastectomy. Clinical trials, retrospective reviews, meta-analyses, and literature reviews were included. Results. Most plastic surgeons remove drains based on volume criteria; however, some evidence supports early, fixed-duration drain removal. Patients who produce large volumes of fluid from the surgical site are more likely to continue to do so after drain removal and may require increased duration of drain use. Surgical site surface area may also be a factor to consider when pulling a drain. Conclusion. Though drain-associated infection rates are low and appear unaffected by duration, poor outcomes such as implant loss and need for reoperation may be mitigated by antisepsis strategies.

Frequently, surgical patients are discharged home with surgical drains. The length of this self-care assignment is usually dependent on daily drain output. The most widely accepted standard for discontinuation is 30 mL/day for 24 hours. However, the purpose of drains is not to perplex patients with the responsibility of caring for them. Placement of a surgical drain assists in wound closure that could be disrupted by postoperative hematomas, lymphoceles, or seromas.

Although hemostasis is the ultimate preventive measure for hematomas, surgical drains are thought to help surgeons monitor such complications. Moreover, they may limit other associated sequelae such as pressure necrosis, overt incisional dehiscence, and reoperation in the case of small self-limiting postoperative hemorrhage. Ultimately, in the authors’ experience, surgical drains do little to prevent major hematoma formation.

While the terms lymphocele and seroma are often employed interchangeably, they are the result of different processes. Lymphoceles result from patent lymphatic channels resultive secondary to dissection. Surgical drains may control enlarging lymphoceles and eventually allow the closure of the channels responsible for their formation. But the resolution of lymphoceles relies on the closure of these channels, which drain placement cannot technically accomplish.

On the other hand, seroma composition most resembles an exudative process secondary to a concentration gradient created by the operative field.¹ This gradient is likely the product of inflammation as a result of bleeding, cauterization, and associated-tissue injury. Unlike hematomas and lymphoceles, seromas form from a translocation of fluid without a structural channel (vascular or lymphatic). Therefore, drains can prevent the development of a significant seroma as they are not obligated to close channels. By controlled drainage of a seroma, the dead space can be limited, allowing time for the inflammatory gradient to subside. Seromas are a common postoperative complication.² Prevention of seromas is likely the foremost consideration in the surgeon’s mind when deciding to place a drain. In fact, studies have shown that when drains are not utilized, a high rate of seroma formation after breast and axillary surgeries occurs.³

Low volume drainage output does not necessarily indicate resolution of the concentration gradient previously mentioned, nor does it signify the resolution of inflammation. Stages of wound healing have taught us that time is the most reliable predictor for resolution of inflammation in the absence of ongoing infection or presence of other sensitizing agents. Total time of drain placement may be an equally important parameter to consider when deciding to discontinue a surgical drain.

In a survey of 4,669 members of the American Society of Plastic Surgeons and the Canadian Society of Plastic Surgeons, more than 93% of participants cited volume criteria for drain removal—most commonly a drain output of less than 30 mL over 24 hours (86%).⁴ The purpose of this study is to examine the origins and justifications for this drain removal criteria and consider other factors that may influence recommendations, such as duration, area of surgical site, and risk of infection.

A literature review was performed regarding the indications for drain removal in patients undergoing reconstructive and breast surgeries. PubMed was queried for publications up to May 2015 with the following search terms: drain removal, seroma, lymphocele, hematoma, volume, reconstruction, and mastectomy using a combination of the binary search operators AND and OR. Reference lists of selected studies were reviewed for other appropriate publications. Prospective, randomized clinical trials, retrospective reviews, meta-analyses, and literature reviews were included. Animal studies, comments, letters, single case reports, and non-English publications were excluded.

Volume vs duration. The concept of removing drains based on daily volume parameters likely came from the widely cited work by Tadych et al,⁵ who reported the association of drain output with seroma formation and lymphedema in postmastectomy patients. The authors of that study found in 49 consecutive patients that no clinically significant seromas formed when the total 24-hour drainage prior to discontinuation was less than 20 mL. The resulting status quo was that patients were kept as inpatients between 7-14 days until their drain output met a volume requirement.

In an effort to limit lengthy hospital stays, subsequent studies focused on duration of drain use.⁶ Could a fixed period of time for drain removal be defined without affecting complication rates? In a randomized trial of 100 mastectomy patients, Parikh et al⁷ found no difference in either mean volumes, the number of seromas aspirated, or return visits for drain removal at 3 days vs 6 days postmastectomy. Similarly, in a prospective study, Yii et al⁸ found no significant difference in wound healing for patients who had drains removed when daily drainage was under 30 mL (mean postoperative stay: 4.5 days) compared to patients who had their drains removed at 48 hours.

Several studies^8-10 incidentally found that high output volume patients were more likely to form seromas or require follow-up aspirations. Barwell et al⁹ recorded daily suction drainage volumes in 63 patients who underwent mastectomy or wide local excision with axillary dissection with median drain removal at 4 days. The total volume drained was significantly higher in the group of patients who developed a seroma (480 mL vs 240 mL). Yii et al⁸ similarly noted that no seromas developed in either experimental group when the total drainage was < 150 mL. In a study of 90 patients with mastectomy and axillary dissection, Kopelman et al¹⁰ found the total amount of fluid aspirated during all 3 postoperative days before drain removal was significantly higher in those who developed a seroma. When the amount of fluid drained prior to removal was < 250 mL in 3 days, no seromas developed. Thus, some evidence supports early, fixed duration drain removal. However, patients who produce large volumes are more likely to continue to do so after drain removal and form seromas.

Volume vs area. Surface area may play an important role in the decision to pull drains based on volume. Surgical sites and dead space vary by area. This affects daily output and thus the threshold for drain removal. In a study by Miranda et al¹¹ regarding drain removal following deep inferior epigastric perforator breast reconstruction, the authors noted that though removal instructions are typically at 30 mL/24 hours, in cases where 2 drains are placed into the same cavity, the overall drainage goal from the site is actually 60 mL/24 hours. This challenges the rationale for a volume goal of 30 mL, and questions the consistency of findings across individual studies on drain removal.

Infections vs duration. Although there is a paucity of research on the relation between surgical drain duration and infection,^12-14 placement of surgical drains has been shown to be a risk factor for infection following reconstructive surgery. Therefore, it may be important to weigh the risk of infection when deciding duration of drain placement and to consider strategies for preventing infection. The authors found 2 primary studies in the literature addressing this topic.

Felippe et al¹⁵ conducted a prospective cohort study of 354 women who underwent surgical treatment for breast cancer to determine the incidence and factors associated with surgical site infection (SSI) among patients discharged with a drain. Bacterial colonization of the drain was found to be an independent predictor of SSI. Of those patients who developed infection, 83% were of the same bacterial species documented in the drainage fluid. The probability of bacterial colonization of the drain rose from 33% to 80.8% between postoperative days 7 and 14. Felippe and coauthors¹⁵ suggest a strategy of early drain removal by postoperative day 3 to prevent SSI. However, even with the rise of bacterial colonization following postoperative day 7, there was no significant difference in the incidence of infection when patients had drains removed prior to day 7 vs those who kept drains for up to 14 days.

Findings from Reiffel et al¹⁶ corroborate that early drain removal does not mitigate SSI in a plastic surgery practice. They conducted a medical record review of 54 patients with 101 drains in place for a mean of 13.5 days. All patients received perioperative antibiotics, and 39 patients received postoperative antibiotics. Although 63% of drains had positive cultures, the wound infection rate was low (5.6%). Almost two-thirds of all drains were colonized with bacteria. Yet there was no statistical correlation between the duration of drainage and SSI. Therefore, the notion that closed suction drains may be left in place for an extended period of time without increasing the risk of infection was supported.

While the risk of drain-associated infections is low and does not seem to be associated with duration of drain use, poor outcomes such as implant loss and the need for reoperation may be lessened with antisepsis strategies or antibiotic treatment. A survey of 917 breast surgeons (Degnim et al¹⁷) showed that in reconstruction cases, the majority (58%) reported routine antibiotic use beyond 24 hours. The primary driver of this decision was to use antibiotics at the individual desire of the plastic surgeon (83% of respondents). This consensus is further supported by Philip’s survey of plastic surgeons: preoperative antibiotic use was nearly universal (98%),⁴ and usually consisted of intravenous cefazolin (97%). Surgeons were divided on when to discontinue postoperative outpatient antibiotics: 46% preferred concomitant discontinuation with drains, whereas 52% preferred a specific postoperative day. Guidelines for use of antibiotics do not address whether antibiotic use should be altered in the context of drain placement. Reiffel and colleagues¹⁶ concluded that postoperative antibiotics to cover drains may not be necessary, given that approximately one-third of patients did not receive them. Infection rates still remained low. Current literature does not provide any evidence that postoperative antibiotics can lower the incidence of surgical site infections associated with drains.

Degnim et al¹⁷ randomized patients with bilateral mastectomy and reconstruction to a drain antisepsis protocol or standard drain care. Surgical site infection within 30 days occurred in 0 patients receiving drain antisepsis vs 3.8% of those in the control arm. After 1 year, 2.9% in the antisepsis arm had an infection vs 5.8% in the control side. Therefore, antisepsis with a chlorhexidine disc and hypochlorite solution reduced bacterial colonization of drains. This simple maneuver was associated with a lower rate of infections.

The practice of discontinuing drains when output reaches < 30 mL/day may be rooted less in dogma and more in evidenced-based findings from previous observational studies. The concept of discontinuing drains based on low outputs and/or extended set postoperative durations may allow the surgical site dead space to resolve inflammation and decrease exudative production. As a result, appropriate timing of drain removal lowers the chance of seroma formation.

A dilemma arises in regard to an infection associated with retained surgical drains: they often become the scapegoat when an unwelcome microbial infection occurs. Though research on the subject is limited, drain-associated infection rates seem low and do not appear to be related to duration of use. However, through simple aseptic drain care, surgeons may lessen drain-associated infection and poor outcomes such as implant loss and need for reoperation.

Surgeon preference ultimately dictates the use of surgical drains and their postoperative management. As a practitioner realizes his or her own technique, strengths, and weaknesses, the decision to pursue drain placement in postoperative care is tailored by experience. Proper timing of drain discontinuation may be different for each patient, procedure, and even for individual techniques. Perhaps this is why the debate endures.

Most plastic surgeons remove drains based on volume criteria. There is some evidence to suggest that earlier, fixed-duration drain removal is acceptable. However, it is important to consider other factors such as the existence of large volumes of fluid production and the surface area of the surgical site. Though infection rates attributable to drain use seem to be low, poor outcomes such as implant loss and reoperation may be mitigated by simple antisepsis strategies.

From the Division of Plastic Surgery, University of Miami, Miami, FL; and Miller School of Medicine, University of Miami, Miami, FL

Address correspondence to:
Emily A. Borsting, BS
Miller School of Medicine
University of Miami
eborsting@med.miami.edu

Disclosure: The authors disclose no financial or other conflicts of interest.