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

The use of abdominal drains in donor site closure following breast reconstruction with abdominal flaps is widespread. Our review aimed to compare the outcomes of donor site closure with and without the use of abdominal drains following breast reconstruction with abdominal flaps. Randomized, non-randomized, and observational studies that compared the use of drains vs. no drain in breast reconstruction were included by searching MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). Four studies enrolling 327 participants were identified. A statistically significant difference was found in terms of duration of hospital stay favouring abdominal closure without the use of drains (MD = -1.15, 95% CI = -1.88 tom-0.42, P=0.002), with a similar difference found in terms of overall complication rate (OR = 0.44, 95% CI = 0.23 to 0.83, p=0.01). Likewise, a statistically significant difference was found favouring abdominal closure without the use of drains for the secondary outcome of operative time (MD = -55.95, 95% CI = -107.19 to -4.74, p=0.03). Abdominal closure without drains following breast reconstructions with abdominal flaps is superior to closure with drains.


Introduction And Background
Free flap breast reconstruction is utilised for 14% of patients undergoing immediate breast reconstruction and 33% undergoing delayed reconstruction [1]. The use of the deep inferior epigastric perforator (DIEP) free flap for breast reconstruction is popular due to its supple aesthetically similar tissue, minimal donor site impact, and cost-effective nature [2][3].
Although used by 90% of plastic surgeons, the use of abdominal drains during donor site closure in breast reconstruction with abdominal flaps is widely debated across the surgical literature [1]. Inserting a drain is based on the premise that it has a role in reducing dead space by preventing fluid accumulation, thereby minimising subsequent complications such as seroma formation and wound dehiscence [4]. Drain use, however, does carry caveats to patient care, including an increased risk of infection, pain, reduced mobility, greater nursing requirements, as well as prolonged hospital admission [5].
Taking this into account, alternative techniques have been used to circumvent the drawbacks associated with abdominal drains, including tissue sealants, progressive tension sutures (PTS), as well as barbed sutures [6]. PTS have been adapted as a reliable technique for dead space reduction post abdominal closure by evenly distributing tension across the surgical site and minimising shearing force [7]. Initially described by Pollock, and shown in Figure 1 below, PTS have demonstrated encouraging results with comparable complication rates to standard closure with drains [8][9][10][11]. Several recent reports in the literature have compared the two modalities, yet there is no study to amalgamate outcomes and provide the best available evidence to guide surgeons [4][5]. The authors, therefore, report the first systematic review and meta-analysis assessing the outcomes of drain-free closure of abdominal wounds in breast reconstruction.

Review Methodology
A systematic review and meta-analysis were performed as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessment of Multiple Systematic Reviews (AMSTAR) guidelines [12]. This study is registered with the Research Registry and the unique identifying number is reviewregistry1030.

Eligibility criteria
All randomised and non-randomised trials, as well as observational studies that compared the use of drains versus no drains in abdominal closure in the setting of breast reconstruction, were included. Patients were included regardless of age, sex, or comorbidity status. Articles not reported in English were excluded from the review.

Data synthesis
Review Manager 5.4 software ([Computer program], Version 5.4, The Cochrane Collaboration, 2020) was used to conduct the data analysis using a random-effects model, and results were reported in forest plots with 95% confidence intervals (CIs). For continuous outcome data, the mean difference (MD) was used to assess both groups, and dichotomous outcomes were analysed with an odds ratio.

Assessment of heterogeneity
Heterogeneity among the studies was assessed using the Cochran Q test (χ2) as well as the I 2 score, which was interpreted using the following reference: 0% to 25% was representative of low heterogeneity; 25% to 75% (moderate heterogeneity); and 75% to 100% (high heterogeneity).

Literature search
Our search strategy retrieved 19 studies and, after thorough screening, we identified four studies that met the eligibility criteria ( Figure 2).  [14]. The TRAM flap reconstructions included muscle-sparing free TRAM (3), free TRAM (17), and pedicled TRAM flap (4). All patients were divided into groups depending on the method of closure. Twenty-five (25) patients underwent abdominal closure with barbed progressive tension sutures without an abdominal drain, and 25 patients underwent abdominal closure with a drain. There was no external source of funding reported.
The characteristics of the included studies are summarised in Table 1  In Figure 3, length of hospital stay was reported in 102 patients from the above three studies. There was a statistically significant difference seen in the mean difference analysis, showing a shorter duration of stay in the drain-free group (MD = -1.15, CI = -1.88 to -0.42, p<0.002). Heterogeneity proved to be moderate with an I² value of 68% and P = 0.04. The overall complication rate was calculated by summating events across all types of complications from each study. It is not clear from the reports whether each complication occurred in unique patients or if several of the reported complications occurred in one patient. We have not sought further information to clarify this. Figure 4 shows the overall complication rate reported in 327 participants from all four studies. There was a statistically significant difference between the closure with abdominal drain group and the drain-free closure group, with complications less likely to occur in the latter (OR = 0.44, CI = 0.23 to 0.83, P = 0.01). A low level of heterogeneity was found (I² = 2%, P = 0.38).

Methodological quality assessment
The quality of the included studies was assessed using the Newcastle-Ottawa scale. The summary is included in Table 2 below.

Discussion
The analysis showed that abdominal closure following breast reconstruction using abdominal flaps without the use of a drain was superior to drain-assisted closure in terms of both primary and secondary outcome measures. Avoiding a drain has been found to significantly reduce both the duration of hospital stay (p= 0.002) and overall complication rates (p = 0.01). Furthermore, the operative time for abdominal closure was significantly shorter, with a mean difference of -55.96 minutes when compared to wound closure with a drain (p = 0.03).
Drain use remains common practice across the surgical field. There is, however, as seen in other surgical specialities, such as head and neck surgery, a scarcity of evidence to support or negate drain use post abdominal closure following breast reconstruction [15][16]. Furthermore, there is a paucity of evidence to guide drain management, time of removal, and antibiotic use [13]. This study has demonstrated that based on the currently available evidence, a drain does not significantly reduce complication rates of seroma, haematoma, or wound dehiscence when used in abdominal closure post-free-flap breast reconstruction; questioning the widely quoted reasoning for drain insertion in the first instance.
The results of this study are mirrored somewhat by a recent meta-analysis and systematic review by Li et al.
(2020) who found that PTS without a drain has been shown to significantly reduce seroma rates in patients undergoing abdominoplasty [17]. Jabbour et al. (2016) further reported from a meta-analysis and systematic review that the use of a drain in addition to PTS did not affect seroma formation when compared to PTS alone thus again deliberating the need for surgical drains [7]. Like Miranda et al. (2014), the authors recognise that DIEP free-flap reconstruction does require further dissection and thus outcomes from abdominoplasty may not be directly transferable [1]. The general principles, however, of shearing and generalised inflammation will occur in DIEP surgery and thus the results from both Li et al. and Jabbour et al. do outline the positive outcomes achievable without drain use [7,17].
Progressive tension sutures that plicate the abdominoplasty flap to the abdominal wall have provided positive outcomes in breast reconstructive surgery since they were first adopted by Pollock and Pollock in 2000 [8]. With variations on the original technique, a variety of authors have demonstrated a reduction in postoperative complications. Nagarkar et al. found that the use of PTS when compared to PTS and drain yielded no significant difference in seroma formation while Liang et al. highlighted a reduced drain output when PTS was used and a shorter length of stay in a group closed with PTS only [5,18].
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].
Mohan et al. advocate the use of barbed self-anchoring sutures and minimal lateral dissection of the abdominoplasty flap to optimise speed and minimise infection [13]. They also demonstrated that when compared to standard drain closure following DIEP breast reconstruction, barbed PTS offers a faster time to discharge, lower analgesic requirements and comparable seroma rates. Lower seroma rates have also been reflected by Landis et al. when using PTS as an adjunct in the closure of latissimus dorsi flaps for breast reconstruction, and if used in conjunction with a drain can expedite its postoperative removal [20]. This has furthered previous evidence from a review by Sajad et al. who showed the importance of quilting the latissimus dorsi donor site in minimizing complications [21]. Griner et al. have also demonstrated the effectiveness of PTS when applied in implant-based breast reconstruction following mastectomy with a reduction in seroma rates and less reliance on suction drains [22].
Preoperative optimisation before breast reconstruction cannot be overemphasised as highlighted by Cheng et al. 2015 [23]. Based on a 10-year retrospective review of 758 DIEP procedures, complications of fat necrosis were seen in 12.9%, seroma in 4.6%, haematoma in 1.8%, wound infection in 2.8%, partial flap loss in 2.5%, and total flap loss in 0.5%, with 5.9% of patients returning to the theatre for associated complications, with Gill et al. (2003) highlighting smoking, hypertension, and radiotherapy to be significantly associated with such complications [24]. Ensuring smoking cessation and blood pressure control before surgery, as well as a meticulous surgical technique minimising tissue trauma and advocating pressure garments may be a more effective tool than a postoperative drain [7].
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.
There are several limitations to this review, with there only being four studies available in the literature meeting the criteria for analysis. In addition, all are retrospective in design with no defined variables by which patients were stratified into receiving either PTS or drain-assisted abdominal closure. Moreover, Nagarkar et al. included, in their data, patients who underwent abdominal closure with progressive tension sutures with the concomitant use of abdominal drains [5]. This has implications for our study in that it introduces progressive tension sutures as a confounding variable. The authors suggest inferring the results of this meta-analysis accounting for the inherent limitations of the study designs. High-quality, randomised trials are, therefore, recommended to further the current evidence base.

Conclusions
The authors report the first meta-analysis within the literature comparing the use of drains in abdominalbased free-flap surgery for breast reconstruction with PTS closure and no drains. Alternative techniques, such as progressive tension sutures to assist in dead space reduction, can decrease the length of hospital stay, complication rate, and operative time. A limitation of this review includes the small number of studies as well as not all outcomes being reported homogeneously, with operative time being depicted by only two authors. Based on the current evidence, however, closure of the abdominal wounds in autologous breast reconstruction using abdominal flaps with PTS and no surgical drains appears to reduce the duration of hospital stay, reduce the incidence of complications, and result in a shorter operative time. The authors, however, suggest high-quality randomized control to add to the current evidence base.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.