Breast augmentation and hematoma: are drains any useful?
Goals/Purpose:
Hematoma following a breast augmentation is diagnosed when a sudden enlargement of the breast appears within usually two-three hours (sometimes even more quickly). In such a condition, Breast is typically tense, tender and painful and may also present bruising. The diagnosis is mainly clinical.
Methods/Technique:
Two consecutive groups of patients which constituted 777 subjects were retrospectively analyzed (clinical audit). In the first group (466, Jan 2004-June 2005) drains were used for 12-24 hours. In the second group,No drains were used (311, July 2005-December 2006). The age ranged from 18 to 64, all females, 347 smokers. All procedures were performed by the same surgeon, under general anaesthesia. Only cohesive silicone textured implants were used. The breast implant pocket was created with a monopolar diathermy forceps minimizing the surgical trauma as advocated by Tebbetts. The incision was inframammary in 714 cases (92%) and inferior hemiperiareolar in 63 (8%). One hundred and seventy seven implants were placed subglandulary and 600 subpectorarly (dual plane I-III). The operating time ranged between 20 and 47 minutes. A soft, comfortable bra was used for the subglandular implant immediately after the procedure. When the implant was subpectoral, only an upper pole binder was applied for the first 10-14 days and a soft bra thereafter.
Results/Complications:
The data were analysed using odds which mainly shows how many times the probability of developing hematoma is higher than the probability of not developing hematoma. Compared to probability, odds are not constrained as they can take any value between 0 and infinity. For rare outcomes, i.e. P<0.1, odds and probability will be very close. Odds are more practical and in our study have similar interpretations as probability. 2.1% patients from the first group (drains) and 0.6% of the second group were diagnosed with a hematoma. Fisher's exact text did not reveal any significant evidence of the necessity of using drains for the prevention of hematoma (p>0.10). After controlling for smoking and pocket, the risk of developing hematoma is higher with drains than with no drains (p=0.06).
These
graphs below illustrate the odds for developing hematoma amongst smokers and non smokers. For group I the risk of hematoma seems to be higher when the patient smokes. For the purpose of
identifying the constituents involved in the development of such complication,
we have analysed three underlying factors; smoking,
the use of drains and pocket. With p=0.1 smoking and group have significant effect with the effect of
smoking having much larger magnitude. Analysing
smoking in both groups revealed that 2.3% of smokers developed hematoma in
comparison to only 0.9% of non smokers. Smoking
increases the odds of developing hematoma by 174%. 1.1%
patients from the first group (drains) developed seroma
against 0.6% in the second group. There is no significant evidence of the
necessity of using drains for the prevention of seroma
(p>0.05) The analysis of the odds ratio as illustrated in the graph signify
that smoking also plays a major role in the development of seroma,
more significantly than the position of the implants or the use of drains. A conservative treatment was never
considered once hematoma was clearly apparent. All patients with hematoma
underwent a surgical evacuation. A drain was subsequently re-applied on the
first group. The second group was
kept without drains even after the hematoma evacuation. Postoperative care was
the same as for the primary surgery. Conclusion: We did not observe any
hematoma recurrence; moreover, we did not notice any increased rate of implant
infection. Similarly, the rate of
capsular contraction did not increase after a 3-year follow-up. There is not a
general consensus as per using drain with a breast augmentation and the
relevant medical literature is limited. We do believe that a breast hematoma
has to be drained surgically. A conservative treatment is likely to increase
the chance of implant infection and capsular contraction. We did not find any
significant difference in the infection rate between the two groups. Therefore,
in this circumstance, we cannot support the theory that the drain could be a
potential entry port for microorganisms causing infection. As we all intuitively know,
smoking was proved to be conducive to the development of postoperative
complications such as hematoma and seroma. Our
hematoma rate after breast enlargement has significantly decreased since we
have stopped using drains. We think that the reason behind it might be
threefold: -The preconceived
effectiveness of drains could lead the surgeon to disparage a more careful hemostasis due to the widely held assumption of "false
security" given by the drains presence. -The lack of possible
internal tissue trauma secondary to drain displacement or removal. -Absence of continuous
intra-pocket negative pressure, which might possibly slow or impair the local
coagulation process. Based on our experience,
we strongly believe that the use of drains in breast augmentation is not only
unnecessary but even deleterious.
