Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 810e814
The drain game: Abdominal drains for transverse rectus abdominis myocutaneous breast reconstruction B.H. Miranda*, R.B.L. Wilson, K. Amin, J.S. Chana Plastic & Reconstructive Surgery Department, Royal Free London NHS Foundation Trust, Royal Free Hospital, London NW3 2QG, UK Received 18 November 2014; accepted 9 February 2015
KEYWORDS Breast; TRAM; Flap; Drain; Complications; Seroma
Summary Introduction: We recently published data for the duration of donor site drain use in latissimus dorsi and deep inferior epigastric perforator breast reconstruction, due to a reported requirement in the literature; evidence is still required for transverse rectus abdominis myocutaneous (TRAM) reconstruction. Aim: To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), versus after POD 3 where instructions were by drainage volume/24 h output consistency (late group), in post-mastectomy TRAM breast reconstruction. Method: A retrospective review of TRAM breast reconstructions, between June 2008e2013, was undertaken with a minimum 1 year follow-up per patient. Results: Of 65 patients who underwent TRAM breast reconstruction, 56 hospital records contained complete documentation. Both the late (n Z 35) and early (n Z 21) drain removal group were matched for age and number of donor site drains (2 per patient). Mean drain removal day (5.34 0.20 days vs. 2.67 0.14 days; p < 0.0001), total drainage (797.86 77.15 mls vs. 295.71 29.72 mls; p < 0.0001) and hospital inpatient stay (7.46 0.29 days vs. 6.09 0.32 days; p Z 0.003) were greater for patients in the late versus early group. There were no differences in total complications (5.71% (2/35) vs. 14.29% (3/21); p Z 0.28), including seroma (2.86% (1/35) vs. 4.76% (1/21); p Z 0.71) rates between the late and early groups. Discussion: These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal by POD 3. ª 2015 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
* Corresponding author. Tel.: þ44 (0) 7961 996 229. E-mail address: [email protected]
(B.H. Miranda). http://dx.doi.org/10.1016/j.bjps.2015.02.025 1748-6815/ª 2015 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
The drain game: Abdominal drains for transverse rectus abdominis myocutaneous breast reconstruction
Introduction In the USA, around 93,083 women undergo breast reconstruction, with autologous flap reconstruction procedures being performed for over 18,500 patients.1 In the UK, free flaps are performed for 14% (476/3389) of patients who undergo immediate, and 32.7% (566/1731) who undergo delayed reconstruction.2 While some surgeons prefer to offer patients autologous reconstruction using the deep inferior epigastric perforator (DIEP) flap, the transverse rectus abdominis myocutaneous (TRAM) flap may be preferred in cases of inadequate perforators or surgeon preference due to a potentially lower rate of flap loss and less technically challenging operation.3e11 In contrast, a study of 200 consecutive free/muscle-sparing TRAM and DIEP flaps found complications to be identical in both groups; these included total/partial flap loss, infection, haematoma, minor wound healing problems, fat necrosis, mastectomy flap necrosis and systemic complications, with seroma rates reported as 7.5% and 4.9% in the TRAM and DIEP groups respectively (p Z 0.74).12 Of interest, reported clinically-detectable seroma rates during TRAM breast reconstruction range in the literature between 2.1% and 52.6%, with increased rates detectable on ultrasound.4,12e18 As seroma management is labour-intensive, often involving multiple outpatient visits for drainage compressive dressings, the lack of data pertaining to its development in TRAM flap breast reconstruction is surprising.2,19,20 Furthermore, even in the case of LD flap breast reconstruction, opinions vary with no clear evidence-based practice on the timing of donor site back drain removal and complications e.g. seroma; as such recommendations have been made in the literature for further investigation, particularly for breast augmentation and reconstruction.19,21e25
Aim We recently presented and published retrospective study data comparing post-operative outcomes of LD and DIEP breast reconstruction with donor site drain removal early by post-operative day (POD) 3 regardless of output, versus late after POD 3 where removal instructions were by volume output consistency (a change from fresh blood to serosanguinous fluid).26e29 The primary aim of this follow-on study was to compare donor-site complications associated with early closed suction abdominal drain removal (by POD 3), versus late removal (after POD 3), in post-mastectomy TRAM flap reconstruction donor sites. This cut-off was chosen due to the practice amongst several departmental Consultants of early drain removal. Secondary aims included analysis of drain output and inpatient hospital stay. The null hypothesis was that no differences would be found between these 2 groups (early vs. late).
Method After clinical governance registration, hospital database information was accessed using the clinical operative code ‘TRAM’ to generate a spreadsheet of procedures performed
between June 2008e2013, ensuring a minimum 1 year follow up for all patients. The inclusion criteria were all TRAM breast reconstructions, with donor site drains in situ, and the exclusion criteria were non-breast reconstructions or those procedures where full data were unavailable. Patient notes were retrospectively analysed for; age, date of birth, operation date, number of drains, drainage volume by day, day of hospital discharge, day of drain removal and donor site complications including seroma, flap-related or systemic complications. Complications were defined as per previous publication.27 When more than 1 abdominal drain was removed on the day of drain removal, output was cumulatively recorded. Statistics were analysed using SPSS with t-tests for parametric continuous data and Chi2 tests for discrete data.
Results There were 65 patients who underwent TRAM breast reconstructions (62 unilateral þ 3 bilateral), all of whom were followed up for 1 year. Operations were performed, in standard manner without use of donor site adjunct techniques e.g. quilting, by 9 Consultants, 5 of whom had patients with drain removal instructions by day 3. There were 56 sets of patient records with complete documentation. The average patient age was 51.23 1.17 years (Mean SEM), their hospital stay was 6.95 0.23 days and drains were removed at 4.34 0.22 days; only 3 patients had drains in situ prior to discharge. Subanalysis (Table 1) indicated that both the late (n Z 35) and early (n Z 21) groups were matched for age and number of drains. The mean drain removal day was greater for the late group (5.34 0.20 days) than the early group (2.67 0.14 days) (p < 0.0001) and patients in the late group were hospital inpatients for longer (7.46 0.29 days vs. 6.09 0.32 days; p Z 0.003) (Table 1). In all cases where drains were removed after day 3 (late group), drain removal instructions were by volume output consistency (a change from fresh blood to serosanguinous fluid); the most common removal instruction was 30 mls/24 h (82.86%, 29/35). There were no differences in total (5.71% (2/35) vs. 14.29% (3/21); p Z 0.28) or specific complications between patients in either group (Table 2).
Discussion Much debate exists in the literature regarding breast reconstruction and drain use; although definitive guidelines are still lacking and recommendations for further investigation have been made in current literature, our group has recently presented and published evidence-based recommendations for the day of LD and DIEP donor site drain removal in consideration of post-operative complications e.g. seroma.19,21,26e29 It has been shown that the use of 2 donor site closed suction drains significantly reduces the risk of abdominal seroma in TRAM breast reconstruction versus 1 drain.15 Furthermore, various abdominal closure techniques have been described to further reduce this risk e.g. double polypropylene mesh fold over, acellular dermal matrix insertion and the use of quilting sutures.12,13,16,17 As
B.H. Miranda et al.
Table 1 Drain removal group comparison. There were 35 patients in the late drain removal group (52.2 1.54 years) and 21 patients in the early group (49.62 1.79 years). Both groups were matched for age (p Z 0.28) and number of drains, with all patients having 2 abdominal drains in situ. The mean drain removal day was greater for the late group (5.34 0.20 days) than the early group (2.90 0.05 days) (p < 0.0001). Drain output on the day of removal was less for the late group (57.4 8.71 mls) than the early group (84.76 7.70 mls) (p Z 0.02), however the total drainage for the late group was greater (797.86 77.15 mls vs. 295.71 29.72 mls; p < 0.0001). Patients in the late group were hospital inpatients for longer than those in the early group (7.46 0.29 days vs. 6.09 0.32 days; p Z 0.003). Number of patients Age (years) Number of abdominal drains Drain removal (day) Drain removal output (mls) Total drain output (mls) Hospital stay (days)
Late group drain removal after day 3
Early group drain removal by day 3
35 52.2 1.54 20 4.32 0.10 57.4 8.71 797.86 77.15 7.46 0.29
21 49.62 1.79 20 2.67 0.14 84.76 7.70 mls 295.71 29.72 6.09 0.32
such, reported clinically-detectable seroma rates range between 2.1% and 52.6%, with increased rates detectable on ultrasound.4,12e17 Only a few studies have published figures for the duration of donor site drain use in patients undergoing TRAM breast reconstruction; approximately 8 days, reducible to around 4 days with additional quilting sutures.12,16,30 Although data are available for abdominoplasty, we feel that this cannot be transferred directly to DIEP/TRAM closure due to a more extensive dissection. In a survey of 4669 American Society and Canadian Society of Plastic Surgeons members, 98% used antibiotics, however preferences varied with 46% preferring discontinuation with drain removal and 52% preferring removal on a particular post-operative day.21 Of particular relevance, 90% used donor site drains in cases of autologous flap reconstructions, with 86.4% recommending removal with drainage 30 mls/24 h. However, in cases where more than one abdominal drain is placed, and drainage removal instructions are 30 mls/24 h, both drains could be removed on the same day with 30mls/24 h of drainage per drain. In this example, as both abdominal drains would be sited in the same cavity, the overall drainage would be 60 mls/24 h. This important consideration challenges the rationale for drain removal with 30 mls/24 h of drainage, the
Table 2 Complications between drain removal groups. There was no difference found in total complications (5.71% (2/35) vs. 14.29% (3/21); p Z 0.28), seroma (2.86% (1/35) vs. 4.76% (1/21); p Z 0.71), infection (2.86% (1/35) vs. 4.76% (1/21); p Z 0.71) or hernia (0% (0/ 35) vs. 4.76% (1/21); p Z 0.19) rates between patients in the late and early removal groups.
Total complications Seroma Infection Hernia
Late group drain removal after day 3
Early group drain removal by day 3
2.86% (1/35) 2.86% (1/35) 0% (0/35)
4.76% (1/21) 4.76% (1/21) 4.76% (1/21)
0.71 0.71 0.19