Breast cancer is a socially relevant group of malignant conditions of the mammary gland, affecting both males and females. Most commonly the surgical approach of choice is a modified radical mastectomy (MRM), due to it allowing for both the removal of the main tumor mass and adjacent glandular tissue, which are suspected of infiltration and multifocality of the process, and a sentinel axillary lymph node removal. Most common post-surgical complications following MRM are the formation of a hematoma, the infection of the surgical wound and the formation of a seroma. These post-surgical complications can, at least in part, be attributed to the drainage of the surgical wound. However, the lack of modern and official guidelines provides an ample scope for innovation, but also leads to a need for a randomized comparison of the results. We compared different approaches to wound drainage after MRM, reviewed based on the armamentarium, number of drains, location, type of drainage system, timing of drain removal and no drainage alternatives. Currently, based on the general results, scientific and comparative discussions, seemingly the most affordable methodology with the best patient outcome, with regards to hospital stay and post-operative complications, is the placement of one medial to lateral (pectoro-axillary) drain with low negative pressure. Ideally, the drain should be removed on the second or third postoperative day or when the amount of drained fluid in the last 24 hours reaches below 50 milliliters.
Introduction & Background
Breast cancer is a socially relevant group of malignant conditions of the mammary gland, affecting both males and females, showing a tendency for development after the third decade and increasing its incidence with age, peaking in the fourth and fifth decade [1-5]. Worldwide it is the most commonly diagnosed malignant condition in females and one of the leading causes for metastatic disease and cancer-related deaths affecting women [1-2, 6-8].
The approach of choice for the treatment of breast cancer is based on its clinical staging. Most commonly the approach of choice is a modified radical mastectomy (MRM), due to it allowing for both the removal of the main tumor mass and adjacent glandular tissue, which are suspected of infiltration and multifocality of the process, and a sentinel axillary lymph node removal [9-10]. This procedure has been shown to have the same long-term effects on survival in breast cancer patients when compared to tissue-sparing techniques in the same stage and grade of the cancer. However, when it comes to local recurrence of the condition MRM has a statistically significant lower incidence of local recurrence of the disease [11-12].
The most common direct post-surgical complications following MRM are the formation of a hematoma, the infection of the surgical wound and the formation of a seroma. These direct post-surgical complications can, at least in part, be attributed to the drainage of the surgical wound .
However, the lack of modern and official guidelines and recommendations for drainage of the surgical wound from leading organizations and unions provides a wide opportunity for personalization of the already approved methods and introduction of new techniques and approaches. This provides an ample scope for innovation and customizations, but also leads to a need for a randomized comparison of the results with the aim of promoting the drainage method with the most favorable patient outcomes – optimal drainage, low levels of post-surgical complications, limited physical and mental traumatism. Institution wise, methods must be financially sound and must not interfere with the deontological aspects of medical servicing.
Approach to wound drainage after MRM was reviewed based on the approach to the armamentarium of the procedure itself, the number of drains used, drain location, type of drainage system, the timing of drain removal and no drainage alternatives.
The armamentarium, although not connected to the drainage technique per say, has a high impact on the postoperative period and the amount of tissue agitation, predisposing to wound drainage complications. Overall, the consensus is that the best results are achieved using a harmonic scalpel, when compared to standard electrocautery, which lessens the drainage needs. However, electrocautery also achieves a higher percentage of complications associated to postoperative drainage, when compared to those of cold steel MRM [14-20]. These results may be explained by tissue agitation and the physiological effects of electricity when compared to standard physical aggravation and ultrasound [21-22]. Harmonic scalpel was also associated with a lower rate of skin flap necrosis and decreased patient hospital stay .
Number of drains used
The running consensus is that the performance of a single drainage system has the same overall effect as compared to the placement of either two or three separate drains [23-24]. Placing a single drain significantly reduces traumatism and patient discomfort, together with the possibility of postoperative complications. This also allows for an earlier hospital discharge without increasing patient discomfort and emotional trauma.
There are multiple options for drainage placement following MRM due to the great volume of surgically created free space. However, drainage placement plays a greater role. Placement in the vector of the gravitational gradient gives a greater performance when compared to the placement of either two or three separate drains against it. Therefore, a pectoro-axillary drainage system is superior to placement in other vectors, be it even placement of more than one drain. The choice of either conventional or vacuum drains has not demonstrated a significant role in the location of drainage placement .
Type of drainage system used
When classical and vacuum drainage systems are compared, the consensus is that vacuum drainage systems limit trauma and discomfort for the patient, but they may increase the frequency and volume of seromas [9, 25-28]. However, vacuum systems give considerably better results in terms of incidence of postoperative infections and hematoma formation and thereby allow for an earlier hospital discharge of the patient .
When compared to one another vacuum drainage systems with low and high negative pressure, the results showed that systems with low negative pressure gave a lower incidence of seroma and infections of the surgical wound, while also limiting hospital stays [9, 29].
Time of drain removal
Opinions that early removal of the drainage systems limits injuries, infections and time of hospital stay, but increased the incidence of seromas seem to be the reigning ones while considering the time of drainage removal [30-33]. However, there is no unanimous opinion on the optimal time for the removal of the drainage system after surgery. Based on the general results, seemingly the best patient outcome with the least complications occurs when the drains are removed on the second or third postoperative day, or preferably when the amount of drained fluid in the last 24 hours reaches below 50 milliliters
Drainage and tissue sealant combination
Some authors recommend a combination of a drainage system and a tissue sealant to further try and decrease the possibility of postoperative complications and hospital stay for patients [34-37]. However, based on the limited report and their discouraging reported figures, it seems that the combination of tissue sealant and a drainage system does not further decrease the duration of hospital stay and the percentage of postoperative complications, mainly seroma [34-37].
No drainage option
Wound closure following the classical and well-known methodologies, without drains has reported a higher frequency of occurrence and greater volumes of clinically recognizable seroma, formed in the postoperative period [38-41]. However, fibrin-based and other type of tissue sealants in the process of closing the surgical wound in some of the procedures have resulted in significantly lower incidence of seroma in those patients compared to other drained and undrained patients .
The views that a no drains policy combined with a tissue sealant or quilting flap sutures in MRM, decreases hospital stay, have been expressed by some clinical trials, which have confirmed these encouraging statements in some respects [35-39, 42-46]. The lack of drainage discomfort and pain for the patient, as well as the risk of postoperative infections, have given further commercial rise to these claims. These types of procedures generally allow for an earlier hospital discharge and limit the emotional traumatism for the patient.
Although encouraging, these results are reported only in a small case series, when compared to other options. However, these results seem more encouraging when compared to the drainage and tissue sealant option [32, 35-37]. This approach seems to be the most promising as of the current trends of breast cancer surgery, as it completely excludes the tissue irritation caused by the drainage systems, however, more trials are needed for it to be widely implemented and standardized for this type of procedure.
Compatibility of methods
Despite the accumulated data from various clinical studies, the number and type of drainage systems used after MRM, the drainage approach continues to be determined primarily by the clinical experience and personal preferences of the operating team and the financial capabilities of both the patient and the institution in which the intervention is being carried out. New drainage methods significantly limit the frequency and risk of complications as well as total length of hospital stay, however with significant rise in the total cost due to the high market value of the materials needed and the need for frequent hospital monitoring and outpatient postoperative examinations.
Similar trials and results have also been reported in other fields of surgical medicine, where early removal of drains, when applicable, reduced the hospital stay and postoperative complications in patients [47-50]. However, an individual approach to each patient is highly recommended as there are no standardized drainage protocols, necessitating high surgeon intuition, adaptive to individual cases .
While the short-term effects on hospital stay and postoperative complication between all drainage options have been compared, albeit in small cohorts for some methodologies, the long-term effects of drainage on subsequent formation of deep scar tissue and long-term restoration of mobility in these areas have not been compared on a wider scale.
Currently, based on the general results, scientific and comparative discussions, seemingly the most affordable methodology with the best patient outcome, with regards to hospital stay and postoperative complications, is the placement of one medial to lateral (pectoro-axillary) drain under low negative pressure. The characteristics of the selected method limit postoperative complications such as hematoma formation and wound infection, the discomfort for the patient and period of hospital stay, but however paradoxically may also increase the frequency and volume of clinically recognizable seromas, compared to other methodologies. Ideally, the drain should be removed on the second or third postoperative day or when the amount of drained fluid in the last 24 hours reaches below 50 milliliters. In cases when this drain volume is not achieved, the drain should still be removed prior to the fifth postoperative day.
- Althuis MD, Dozier JM, Anderson WF, et al.: Global trends in breast cancer incidence and mortality 1973–1997. Int J Epidemiol. 2005, 34:405–412. 10.1093/ije/dyh414
- Bray F, McCarron P, Parkin DM: The changing global patterns of female breast cancer incidence and mortality. Breast Cancer Res. 2004, 6:229–239. 10.1186/bcr932
- Giunta G, Rossi M, Toia F, et al.: Male breast cancer: modified radical mastectomy or breast conservation surgery? A case report and review of the literature. Int J Surg Case Rep. 2017, 30:89–92. 10.1016/j.ijscr.2016.11.030
- Guinee VF, Olsson H, Moller T, et al.: The prognosis of breast cancer in males: a report of 335 cases. Cancer. 1993, 71:154–161.
- Tallón-Aguilar L, Serrano-Borrero I, López-Porras M, et al.: Breast cancer in males. Cir Cir. 2011, 79:296–298.
- McPherson K, Steel CM, Dixon JM: Breast cancer—epidemiology, risk factors, and genetics. BMJ. 2000, 321:624–628. 10.1136/bmj.321.7261.624
- Schouten LJ, Rutten J, Huveneers HA, et al.: Incidence of brain metastases in a cohort of patients with carcinoma of the breast, colon, kidney, and lung and melanoma. Cancer. 2002, 94:2698–2705. 10.1002/cncr.10541
- Tsukada Y, Fouad A, Pickren JW, et al.: Central nervous system metastasis from breast carcinoma autopsy study. Cancer. 1983, 52:2349–2354. 10.1002/1097-0142(19831215)52:12<2349::AID-CNCR2820521231>3.0.CO;2-B
- Prakash JS, Luther A, Deodhar M: Modified radical mastectomy and wound drainage. Web Med Centr. 2015, 6:WMC004822. 10.9754/journal.wmc.2015.004822
- Maddox WA, Carpenter JT Jr, Laws HL, et al.: A randomized prospective trial of radical (halsted) mastectomy versus modified radical mastectomy in 311 breast cancer patients. Ann Surg. 1983, 198:207–212. 10.1097/00000658-198308000-00016
- Turner L, Swindell R, Bell WG, et al.: Radical versus modified radical mastectomy for breast cancer. Ann R Coll Surg Engl. 1981, 63:239–243.
- Veronesi U, Cascinelli N, Mariani L, et al.: Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002, 347:1227–1232. 10.1056/NEJMoa020989
- Woodworth PA, McBoyle MF, Helmer SD, et al.: Seroma formation after breast cancer surgery: incidence and predicting factors. Am Surg. 2000, 66:444–450.
- Adwani A, Ebbs SR: Ultracision reduces acute blood loss but not seroma formation after mastectomy and axillary dissection: a pilot study. Int J Clin Pract. 2006, 60:562–564. 10.1111/j.1742-1241.2006.00689.x
- Damani SR, Haider S, Shah SSH: Comparison of modified radical mastectomy using harmonic scalpel and electrocautery. J Surg Pakist (Internat). 2013, 18:2–6.
- Deo SV, Shukla NK, Asthana S, et al.: A comparative study of modified radical mastectomy using harmonic scalpel and electrocautery. Singapore Med J. 2002, 43:226–228.
- Deo SV, Shukla NK: Modified radical mastectomy using harmonic scalpel. J Surg Oncol. 2000, 74:204–207. 10.1002/1096-9098(200007)74:3<204::AID-JSO9>3.0.CO;2-U
- Galatius H, Okholm M, Hoffmann J: Mastectomy using ultrasonic dissection: effect on seroma formation. Breast. 2003, 12:338–341. 10.1016/S0960-9776(03)00110-3
- Khan S, Khan S, Chawla T, et al.: Harmonic scalpel versus electrocautery dissection in modified radical mastectomy: a randomized controlled trial. Ann Surg Oncol. 2014, 21:808–814. 10.1245/s10434-013-3369-8
- Anandaravi BN, Nair PP, Aslam MA: A study showing efficacy of harmonic scalpel over electrocautery in modified radical mastectomy. Int Surg J. 2017, 4:1422–1425. 10.18203/2349-2902.isj20171154
- Porter KA, O'Connor S, Rimm E, et al.: Electrocautery as a factor in seroma formation following mastectomy. Am J Surg. 1998, 176:8–11. 10.1016/S0002-9610(98)00093-2
- Ribeiro GH, Kerr LM, Haikel RL, et al.: Modified radical mastectomy: a pilot clinical trial comparing the use of conventional electric scalpel and harmonic scalpel. Int J Surg. 2013, 11:496–500. 10.1016/j.ijsu.2013.03.013
- Saratzis A, Soumian S, Willetts R, et al.: Use of multiple drains after mastectomy is associated with more patient discomfort and longer postoperative stay. Clin Breast Cancer. 2009, 9:243–246. 10.3816/CBC.2009.n.041
- Terrell GS, Singer JA: Axillary versus combined axillary and pectoral drainage after modified radical mastectomy. Surg Gynecol Obstet. 1992, 175:437–440.
- Ezeome ER, Adebamowo CA: Closed suction drainage versus closed simple drainage in the management of modified radical mastectomy wounds. S Afr Med J. 2008, 98:712–715.
- Yii M, Murphy C, Orr N: Early removal of drains and discharge of breast cancer surgery patients: a controlled prospective clinical trial. Ann R Coll Surg Engl. 1995, 77:377–379.
- Parikh HK, Badwe RA, Ash CM, et al.: Early drain removal following modified radical mastectomy: a randomized trial. J Surg Oncol. 1992, 51:266–269. 10.1002/jso.2930510413
- Andeweg CS, Schriek MJ, Heisterkamp J, et al.: Seroma formation in two cohorts after axillary lymph node dissection in breast cancer surgery: does timing of drain removal matter?. Breast J. 2011, 17:359–364. 10.1111/j.1524-4741.2011.01099.x
- Chintamani, Singhal V, Singh J, et al.: Half versus full vacuum suction drainage after modified radical mastectomy for breast cancer- a prospective randomized clinical trial [isrctn24484328]. BMC Cancer. 2005, 5:11. 10.1186/1471-2407-5-11
- Barton A, Blitz M, Callahan D, et al.: Early removal of postmastectomy drains is not beneficial: results from a halted randomized controlled trial. Am J Surg. 2006, 191:652–656. 10.1016/j.amjsurg.2006.01.037
- Dalberg K, Johansson H, Signomklao T, et al.: A randomised study of axillary drainage and pectoral fascia preservation after mastectomy for breast cancer. Eur J Surg Oncol. 2004, 30:602–609. 10.1016/j.ejso.2004.03.020
- Gupta R, Pate K, Varshney S, et al.: A comparison of 5-day and 8-day drainage following mastectomy and axillary clearance. Eur J Surg Oncol. 2001, 27:26–30. 10.1053/ejso.2000.1054
- Barwell J, Campbell L, Watkins RM, et al.: How long should suction drains stay in after breast surgery with axillary dissection?. Ann R Coll Surg Engl. 1997, 79:435–437.
- Ulusoy AN, Polat C, Alvur M, et al.: Effect of fibrin glue on lymphatic drainage and on drain removal time after modified radical mastectomy: a prospective randomized study. Breast J. 2003, 9:393–396. 10.1046/j.1524-4741.2003.09506.x
- Vasileiadou K, Kosmidis C, Anthimidis G, et al.: Cyanoacrylate adhesive reduces seroma production after modified radical mastectomy or quadrantectomy with lymph node dissection – a prospective randomized clinical trial. Clin Breast Cancer. 2017, 10.1016/j.clbc.2017.04.004
- Jain PK, Sowdi R, Anderson AD, et al.: Randomized clinical trial investigating the use of drains and fibrin sealant following surgery for breast cancer. Br J Surg. 2004, 91:54–60. 10.1002/bjs.4435
- Carless PA, Henry DA: Systematic review and meta-analysis of the use of fibrin sealant to prevent seroma formation after breast cancer surgery. Br J Surg. 2006, 93:810–819. 10.1002/bjs.5432
- Taylor JC, Rai S, Hoar F, et al.: Breast cancer surgery without suction drainage: the impact of adopting a ‘no drains’ policy on symptomatic seroma formation rates. Eur J Surg Oncol. 2013, 39:334–338. 10.1016/j.ejso.2012.12.022
- Soon PS, Clark J, Magarey CJ: Seroma formation after axillary lymphadenectomy with and without the use of drains. Breast. 2005, 14:103–107. 10.1016/j.breast.2004.09.011
- Baker E, Piper J: Drainless mastectomy: is it safe and effective?. Surgeon. 2016, 10.1016/j.surge.2015.12.007
- Zaidi S, Hinton C: Breast cancer surgery without suction drainage and impact of mastectomy flap fixation in reducing seroma formation. Eur J Surg Oncol. 2017, 43:S32. 10.1016/j.ejso.2017.01.129
- Eichler C, Dahdouh F, Fischer P, et al.: No-drain mastectomy – preventing seroma using TissuGlu®: a small case series. Ann Med Surg. 2014, 3:82–84. 10.1016/j.amsu.2014.07.003
- Ouldamer L, Bonastre J, Brunet-Houdard S, et al.: Dead space closure with quilting suture versus conventional closure with drainage for the prevention of seroma after mastectomy for breast cancer (QUISERMAS): protocol for a multicentre randomised controlled trial. BMJ Open. 2016, 6:e009903. 10.1136/bmjopen-2015-009903
- Ouldamer L, Caille A, Giraudeau B, et al.: Quilting suture of mastectomy dead space compared with conventional closure with drain. Ann Surg Oncol. 2015, 22:4233–4240. 10.1245/s10434-015-4511-6
- Puttawibul P, Sangthong B, Maipang T, et al.: Mastectomy without drain at pectoral area: a randomized controlled trial. J Med Assoc Thai. 2003, 86:325–331.
- Purushotham AD, McLatchie E, Young D, et al.: Randomized clinical trial of no wound drains and early discharge in the treatment of women with breast cancer. Br J Surg. 2002, 89:286–292. 10.1046/j.0007-1323.2001.02031.x
- Merad F, Yahchouchi E, Hay JM, et al.: Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. Arch Surg. 1998, 133:309–314. 10.1001/archsurg.133.3.309
- Allemann P, Probst H, Demartines N, et al.: Prevention of infectious complications after laparoscopic appendectomy for complicated acute appendicitis—the role of routine abdominal drainage. Langenbecks Arch Surg. 2011, 396:63–68. 10.1007/s00423-010-0709-z
- Sun HC, Qin LX, Lu L, et al.: Randomized clinical trial of the effects of abdominal drainage after elective hepatectomy using the crushing clamp method. Br J Surg. 2006, 93:422–426. 10.1002/bjs.5260
- Franco D, Karaa A, Meakins JL, et al.: Hepatectomy without abdominal drainage. Results of a prospective study in 61 patients. Ann Surg. 1989, 210:748–750.
Drainage after Modified Radical Mastectomy – A Methodological Mini-Review
Ethics Statement and Conflict of Interest Disclosures
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.
Cite this article as:
Stoyanov G S, Tsocheva D, Marinova K, et al. (July 10, 2017) Drainage after Modified Radical Mastectomy – A Methodological Mini-Review. Cureus 9(7): e1454. doi:10.7759/cureus.1454
Received by Cureus: June 22, 2017
Peer review began: June 27, 2017
Peer review concluded: June 30, 2017
Published: July 10, 2017
© Copyright 2017
Stoyanov et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.