Superomedial pedicle reduction mammaplasty with and without drains: a comparative analysis

Section: Breast Abstract Background: Postoperative suction drainage has historically been a routine part of care following reduction mammaplasty surgery. Purported benefits are a reduction in complications such as haematoma, seroma, delayed wound healing and loss of nipple or areola. The aim of this study is to compare the complication profile of breast reduction surgery patients who had received postoperative drains and those who had not.


Introduction
Postoperative suction drainage has been a routine part of care following reduction mammaplasty surgery. Purported benefits are a reduction in complications such as haematoma, seroma, delayed wound healing and loss of nipple or areola as a result of minimising dead space. However, the use of suction drains is not without inherent issues and potential risk. Drainage tubes are a source of patient concern, discomfort and inconvenience, are prone to migration and occlusion, and may be a potential source of infection through a stab incision if brought out separately. They can also produce an additional scar on the patient's chest and, from an economic perspective, patients discharged with drains in situ require an increased level of care in the community.
Several randomised studies have suggested that the use of surgical drains following breast reduction does not result in any significant difference in wound healing or haematoma rates. [1][2][3] Two systematic reviews also concluded that there was no significant benefit to using postoperative wound drains in reduction mammoplasty. 4,5 Despite this, most surgeons in the United States and United Kingdom routinely use drains. [6][7][8] At present, there is no data from the Asia-Pacific or other regions regarding trends or practices with regards to reduction mammaplasty.
The advantages of the superomedial pedicle with various skin resection patterns in reduction mammaplasty are well-known. 9 They relate primarily to its safety profile, reproducibility and adaptability and superior aesthetic results as compared to alternative pedicle designs.
However, one prospective observational study found a significantly higher risk associated with postoperative wound drainage in superiorly-based pedicles (superior and superomedial) compared to inferior pedicle breast reduction, perhaps due to the larger dead space created by dissection within the central aspect of the breast. 10 This led Anzarut et al to recommend the routine use of drains to avoid complications in patients undergoing superiorlybased pedicles. 10 Only one previous study, however, has directly compared complications between superomedial pedicle breast reduction with and without drains and found no significant difference in complication profile. 2 In light of this conflicting data, we sought to compare the complication profile of superomedial breast reductions with and without drains using a sizeable sample of consecutive patients operated on by a single experienced surgeon, co-author Dr Merten.

Results
The 172 patients in the study were equally divided between the drained (n=86) and drainless (n=86) cohorts. Patient characteristics of the two groups are set out in Table 1.
There was no significant difference in age, history of smoking and diabetic status between the two groups. The mean BMI, however, was significantly higher in the drained group (29.0 compared to 25.7, with p<0.05). Patients in the drained group had a significantly higher breast reduction weight (660g compared to 536g, with p<0.05). Skin resection pattern difference between the two groups was  Table 2.
Complications were stratified into 'major' and 'minor', depending on the need for reoperation.
There were eight major complications in total (Table 3), with five occurring in the drained group and three in the drainless group.

Discussion
The use of closed suction drainage has become routine following reduction mammaplasty. We therefore do not believe that routine drain insertion following bilateral breast reduction is warranted and our data adds to a growing body of evidence suggesting that drain insertion offers no demonstrable clinical benefit.
As far as we are aware, our study of 172 patients is the largest so far to compare the complication profile of drained and drainless breast reduction surgery. Our results are in agreement with all previous retrospective [11][12][13] and randomised studies The rate of complications in this study was 27 per cent, which is broadly consistent with reported rates in the literature of 3-45 per cent. [14][15][16][17] Our multivariate analysis confirmed BMI as an independent factor for increased risk of postoperative complications following breast reduction (p<0.05), but failed to reveal any association between the breast reduction volume and complication rates. These findings replicate those reported by Chun et al. 18 We would contend that this apparent discordancy may reflect significant variability in the aesthetic goals of patients, as well as a lack of correlation between reduction volume and degree of obesity.
Our study provides further support for the need to counsel patients with higher BMI regarding the potential increased risk of complications.
There are certain limitations of the present study, primarily its retrospective cohort design. Bias may also be present due to the study being based on a single surgeon's experience and on an evolution in that practice from drained to drainless breast reduction. Note should also be made of the significantly higher BMI in the drained cohort.
While this was adjusted for in the multivariate analysis, it may represent a confounding variable.
Additionally, mean tissue reduction volumes in our study were 660g in the drained group and 536g in the drainless group and so our conclusions cannot necessarily be extrapolated to significantly larger breast reductions (which can exceed 1500g).