No-drain Technique in Abdominal Closure for Breast Reconstruction: Lower Complication Rate, Shorter Hospitalization Stay

Abstract

Background: Progressive tension suture (PTS) technique in cosmetic abdominoplasty is safe in terms of seroma rates. This was extrapolated to deep inferior epigastric perforator (DIEP) flap donor site closure. No study to our knowledge has analyzed the PTS technique alone without drains in transverse rectus abdominis musculocutaneous (TRAM) flap donor sites. We aim to show that no-drain closure has similar complication rates and this may be applied to TRAM flaps safely even though they have higher drain output. Methods: A single-center, single-surgeon retrospective study was performed over 4 years. Patients undergoing breast reconstruction with an abdominal flap were included. Data collected included patient's demographics, type of flap, usage of drains or PTS technique, drain output, date of fitness for discharge, date of discharge, and seroma rates. The outcomes studied were drain volumes, seroma rates, and duration of hospital stay. Results: Fifty patients were recruited. The first 25 patients (13 DIEP and 12 TRAM) underwent conventional closure. The subsequent 25 patients (17 DIEP and 8 TRAM) underwent PTS technique. TRAM flaps had higher drain volume (785.6 mL) compared to DIEP flaps (366.2 mL) (P = 0.047). No patients developed a seroma. Patients who underwent the PTS technique had lower abdominal-specific complications (P = 0.021). Patients without drains were discharged faster at 5.4 versus 8.2 days (P ≤ 0.001). Conclusions: Patients who underwent the PTS technique had lower complication rates, faster time to fitness for discharge and shorter hospitalization stay. The PTS technique may be applied to TRAM flaps safely.

The Drain Dilemma: A Systematic Review and Meta-Analysis of Drain-Free Abdominal Closure With Progressive Tension Sutures Against Drain-Assisted Closure for Abdominal Flaps in Breast Reconstruction

“…In addition to preoperative optimization, the use of enhanced recovery after surgery (ERAS) programmes (ERP) throughout the patient pathway have been shown by a systematic review by Soterupulos et al to reduce both the length of stay and analgesia requirements [25]. In addition to patient education, multimodal analgesia, VTE and antibiotic prophylaxis, early drain removal by postoperative day 3 as advocated by many authors (Chan et al, Miranda et al) coupled with active mobilisation are important parts of the ERAS programmes [1,14]. Avoiding drain use in the first instance by utilising PTS can further contribute to patient progress in terms of time to first walk, reducing the length of hospital stay and minimising the complications reported above.…”

“…Chan et al: They performed a single-centre retrospective review of 50 patients undergoing DIEP and transverse rectus abdominis (TRAM) flap reconstructions [14]. The TRAM flap reconstructions included muscle-sparing free TRAM (3), free TRAM (17), and pedicled TRAM flap (4).…”

“… Figures based on reports by Chan et al, Mohan et al, Nagargkar et al, and Thacoor et al [ 4 - 5 , 13 - 14 ] …”

“…Furthermore, PTS is a useful closure technique when performing transverse rectus abdominis myocutaneous flap reconstruction. Rossetto et al reported a 50% reduction in drain output when PTS was used alongside drains while Chan et al reported that even when using PTS alone, it significantly lowered seroma rates and wound dehiscence and allowed for faster discharge and a more pleasing aesthetic outcome by strategic placement of PTS in recreating the linea alba and semiluminaris [ 14 , 19 ].…”

Postoperative Showering for Patients With Closed Suction Drainage: A Retrospective Cohort Study of Deep Inferior Epigastric Perforator Flap Breast Reconstructions

“…Thacoor et al have reported that drain-free abdominal closure in DIEP flap breast reconstruction could be safely achieved without increased postoperative complications [ 5 ]. No-drain techniques for DIEP flap donor site closure reportedly had a lower complication rate than the conventional abdominal drainage technique [ 6 , 7 ]. Meanwhile, a report has recommended the placement of CSD for breast reconstructions with a transverse rectus abdominis muscle (TRAM) flap [ 8 ].…”