Surgical Drains After Plastic Surgery

Many surgeries include the placement of surgical drains. Why? Why do some procedures need drains and others don’t? Let’s look at what drains are designed to do, and just as importantly, what they are not designed to do. The whole concept of drains, and draining a surgical wound is confusing to many people, and not just patients. I find nurses and physicians often don’t fully understand drains either.

What is a drain? Although there are different types of surgical drains, most of the drains used tend to be silastic (silicone rubber) tubes, placed at the time of surgery through the wound or through a separate site through the skin, with a perforated end inside the patient, allowing fluid to go into the drain. At the other, external end of the drain, is a small silastic bulb that collects the fluid and is periodically emptied. After emptying, it is squeezed and closed, thus creating a gentle suction that helps pull more fluid into the bulb again. The drain is removed when the amount and/or color of the fluid reaches a certain point.

Let’s now define a couple other terms: Hematoma… A hematoma is a collection of blood within the surgical wound. The blood may remain liquid, or may be clotted, or more commonly, be a combination of liquid and clotted blood. A hematoma is a potential complication of virtually any surgical procedure. Seroma… Imagine you scrape your knee, and you put a bandaid on it. There may be some blood on the initial bandaid, but as you change the bandaids, there tends to be less blood and more of a straw colored fluid oozing from the wound. That is serous fluid, produced by any wound, whether traumatic or surgical. Imagine a big tummy tuck operation – there is a big dissection underneath that you don’t see, but that internal wound produces a lot of serous fluid. A seroma is a fluid collection of that serous fluid.

Both hematomas and seromas can cause problems and are best prevented, but if they occur, they need to be evacuated unless they are very small. Seromas, being liquid can be evacuated with a needle and syringe, but hematomas need to be evacuated surgically if they are large, clotted, or if there is ongoing bleeding that needs to be controlled.

So back to drains… A drain will drain out the serous fluid, along with some blood, thus allowing the wound to heal together. If fluid accumulates and doesn’t get drained, you can imagine how that fluid will prevent the space from healing together. A little bit of blood, typically diminishing on a daily basis, commonly comes out of the drain along with the serous fluid, so we call that serosanguinous (serous and blood). So do drains prevent seromas? Generally, yes. Occasionally after the drain comes out, the body doesn’t have the capacity to resorb the fluid the wound is still creating and a seroma will form. This is usually a minor complication, and the fluid is easily removed with needle and syringe in the office. Rarely does a new drain need to be placed. So do drains prevent hematomas? Generally, NO! (This is what many people, including doctors and nurses, don’t understand about drains – they think drains are placed to prevent or treat hematomas – wrong!). When there is continued bleeding from inside the wound, or when a blood vessel opens up inside the wound, the drains will typically clog up with clot, and the blood inside the wound clots as well. The drain in this circumstance is now doing nothing. Surgery is then needed to evacuate the hematoma, stop any ongoing bleeding, and replace the drain.

Procedures which have a big dissection, like a tummy tuck, need drains. Some techniques like quilting techniques that you may read about try to prevent the need for drains or minimize their time in place, but I have seen seromas after these too. Placement of fibrin glue (Tisseel, others) may help, but adds other issues including significant added cost. The drains stay for up to 2 weeks in a tummy tuck, and are commonly what patients complain about most, more than pain. Dealing with drains is annoying, especially when trying to shower and wear clothes. For a mini-tummy tuck, I typically keep the drain 1 week, while for facelifts, they come out in 2 days. Breast reductions, no more than 3 days. Some surgeons drain breast augmentations, but I have an extremely low rate of capsular contracture, and never had issues with seroma formation after breast augmentations, so I don’t drain them.

Patients often ask whether or not leaving the drain in will increase the risk of infection. Not for the usual lengths of time mentioned above, but if the drain is left in for a long time, the risk is likely to rise, so we don’t keep them any longer than necessary. Drains help minimize infection by allowing the wound space to heal quicker and by removing the fluid that could essentially become a Petri dish for an infection. Generally the pros of using surgical drains far outweigh the cons, but they do have their limits.

Author
Douglas J. Mackenzie, MD

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