Deep inferior epigastric perforator (DIEP) flap: Impact of drain free donor abdominal site on long term patient outcomes and duration of inpatient stay

Safety of Drainless Donor Closure in DIEP Flap-Based Breast Reconstruction: A Prospective Analysis Using Ultrasound

BACKGROUND

 Although drainless donor closure with progressive tension suture (PTS) technique has been attempted to further reduce donor morbidity in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, its clinical safety has not yet been fully elucidated. This study prospectively investigated donor morbidity after DIEP flap elevation and drain-free donor closure.

METHODS

 A prospective cohort study was performed on 125 patients who underwent DIEP flap-based breast reconstruction and drainless donor closure. Postoperatively, the donor site was evaluated repetitively using ultrasonography. Development of donor complications, including any fluid accumulation and seroma (defined as detection of fluid accumulation after postoperative one month), was prospectively noted, and independent predictors for the adverse events were evaluated.

RESULTS

 On ultrasound examination conducted within postoperative 2 weeks, 48 patients were detected to have fluid accumulation at the donor site, which were more frequently detected in cases of delayed reconstruction and those with lesser number of PTS conducted. The majority of those events (95.8%) were resolved with one- or two-times ultrasound-guided aspirations. Five patients (4.0%) showed persistent fluid accumulation after postoperative 1 month, which were successfully treated with repetitive aspiration without requiring reoperation. No other abdominal complications developed except for three of delayed wound healing. On multivariable analyses, harvesting larger-sized flap and conducting lesser number of PTS were independent predictors for the development of fluid accumulation.

CONCLUSION

 The results of this prospective study suggest that drainless donor closure of the DIEP flap with meticulous placement of PTS followed by postoperative ultrasound surveillance appears to be safe and effective.

Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis

Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.

Are Surgical Drains Needed in DIEP Flap Surgery? The Drain-Free DIEP Flap Concept

BACKGROUND

Studies support an inherent morbidity associated with the use of surgical drains-such as postoperative pain, infection, reduction in mobility, and delay in patient discharge-and they do not prevent seroma or hematoma. The authors' series aims to evaluate the feasibility, benefits, and safety of performing drainless deep inferior epigastric perforator (DIEP) flap surgery and to formulate an algorithm for when this can be used.

METHODS

A retrospective review of DIEP reconstruction outcomes of two surgeons was performed. Over the course of 24 months, consecutive DIEP flap patients were included from the Royal Marsden Hospital in London and Austin Hospital in Melbourne, and drain use, drain output, length of stay (LOS), and complications were analyzed.

RESULTS

A total of 107 DIEP flap reconstructions were performed by two surgeons. Thirty-five patients had abdominal drainless DIEP flaps, and 12 patients had totally drainless DIEP flaps. Mean age was 52 years (range, 34 to 73 years) and mean body mass index was 26.8 kg/m 2 (range, 19.0 to 41.3 kg/m 2 ). Abdominal drainless patients showed a potential trend toward shorter hospital stays as compared with the ones with drains (mean LOS, 3.74 days versus 4.05 days; P = 0.154). Totally drainless patients had an even shorter, statistically significant, mean LOS of 3.10 days, as compared with patients with drains (4.05 days, P = 0.002), with no increase in complications.

CONCLUSIONS

The avoidance of abdominal drains in DIEP flaps reduces hospital stay without increasing complications, and this has become our standard practice for patients with a body mass index of less than 30 kg/m 2 . It is our opinion that the totally drainless DIEP flap procedure is safe in selected patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Drain-free donor site in Deep Inferior Epigastric Perforator free flap: A single-surgeon experience

Donor-site seroma and wound dehiscence in Deep Inferior Epigastric Perforator (DIEP) free flaps can be problematic. The value of donor-site drains is debated, with alternative closure techniques demonstrating good outcomes. However, no literature exists on patient outcomes in which no drain or dead space reduction technique is used. The senior author of this paper has opted for a drain-free, simple layered closure without adjuncts since 2016. We evaluate the outcomes of this technique against the literature. A single-center, single-surgeon, prospective study of all DIEP flap breast reconstruction between January 2016 and March 2020, whereby the donor site was closed without drains or alternative dead space reduction measures. One hundred and thirty-eight patients with a mean age of 50.72±9.16 (range 26-73) underwent DIEP breast reconstruction (78% unilateral (n = 107), 22% bilateral (n = 31). The incidence of drain-free specific donor-site complications was 9.4%, with wound breakdown being the most common (9/138, 6.5%). However, only one patient required secondary closure. The average length of hospital stay was 4.2±1 days (range 2-9). Abdominal drains may serve as a psychological barrier for patients in expediting discharge and can be painful and cumbersome. This translates into significant cost implications. Evidence suggests that superior outcomes are achieved when dead space-reducing adjuncts rather than drains are used. However, our data suggest that DIEP donor sites can also be safely closed without these adjuncts, which may unnecessarily lengthen procedure time, consume more resources, and increase localized foreign body tissue reactions, without good indication.

"Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review

The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy.

Methods

MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al.

Results

There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin.

Conclusions

The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.

Outcomes of progressive tension donor-site closure in abdominal-based autologous breast reconstruction

BACKGROUND

The use of progressive tension sutures (PTSs) for drain-free abdominoplasty closure has been well published in the esthetic literature and found to be effective at reducing abdominal drainage without a worse complication profile. This research aims to evaluate the outcomes of incorporating PTS into donor-site closures for abdominal-based breast reconstruction.

METHODS

A retrospective chart review was performed evaluating patients at the University of Chicago Medicine, who underwent autologous breast reconstruction and either PTS closure or standard abdominal closure between 2018 and 2021.

RESULTS

A total of 100 patients were included with 50 patients receiving PTS closure and 50 with traditional abdominal closures. Patient demographics, including age (p = 0.82), body mass index (BMI; p = 0.17), diabetes (p = 1.00), tobacco use (p = 0.15), and chemotherapy (p = 1.00) did not significantly differ. Total drain output over the first 72 h was significantly lower in the PTS group compared with the standard closure (SC) group (p = 0.00005). Mean duration of drain placement was shorter by 2 days in the PTS group, but this did not reach significance (p = 0.08). Overall complication rates were lower in the PTS group (p = 0.03), however, no difference was appreciated when separately assessing for seromas (p = 1.00), hematomas (p = 1.00), wound dehiscence (p = 0.58), or surgical-site infections (p = 1.00). More abdominal revisions were observed in the SC group, however, this did not reach significance (p = 0.15) CONCLUSION: The use of PTS with placement of a single drain is a safe option for donor-site closure, and is a compelling technique for patients undergoing abdominal-based breast reconstruction.

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

Background

The deep inferior epigastric perforator (DIEP) flap has been widely used in breast reconstruction. During surgery, many surgeons use closed suction drainage for both the donor site and the reconstructed breast. However, the criteria for drainage removal depend on the surgeon’s preference and remain controversial. Moreover, it is well known that early postoperative showering is harmless to the surgical site and is recommended in many reports. However, it has not been discussed whether it is acceptable for patients with closed suction drainage to take a shower.

Methodology

We conducted a retrospective study of postoperative showering in 30 patients who underwent breast reconstruction with a DIEP flap. During the surgery, a total of three closed suction drains were connected to the patient’s body (one was connected to the reconstructed breast, and the other two were connected to the abdominal donor site). After the surgery, patients were allowed to shower when the number of connected drainage tubes was ≤2.

Results

The patients were divided into three groups according to the number of remaining drainage tubes connected to their bodies when they started postoperative showering. Group A included patients with no drainage tubes. Group B included patients with one remaining drainage tube. Group C included patients with two drainage tubes. No significant differences in the incidence of postoperative individual complications were observed among the three groups.

Conclusions

Postoperative showering for patients with closed suction drainage is safe and does not increase the incidence of postoperative complications, including surgical site infection.

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.

Predictors for Prolonged Drain Use Following Autologous Breast Reconstruction

BACKGROUND

 Surgical drains are routinely used following autologous reconstruction, but are often cited as the leading cause of peri-operative discomfort. This study defined routine drain use duration and assessed the risk factors for prolonged breast and abdominal drain use during microvascular breast reconstruction, measures which have never previously been defined.

METHODS

 Patients who underwent an abdominal microvascular free flap were included. Demographics, comorbidities, and operation-related characteristics were retrospectively collected in a prospectively maintained database. Statistical analysis utilized chi-square independent t-test, and linear regression analyses.

RESULTS

 One hundred forty-nine patients comprising 233 breast flaps were included. Average breast and abdominal drain duration were 12.9 ± 3.9 and 17.7 ± 8.2 days, respectively. Prolonged breast and abdominal drain duration were defined as drain use beyond the 75^th percentile at 14 and 19 days, respectively. Multivariable regression revealed hypertension was associated with an increased breast drain duration by 1.4 days (p = 0.024), axillary dissection with 1.7 days (p = 0.026), African-American race with 3.1 days (p < 0.001), Hispanic race with 1.6 days (p = 0.029), return to the OR with 3.2 days (p = 0.004), and each point increase in BMI with 0.1 days (p = 0.028). For abdominal drains, each point increase in BMI was associated with an increased abdominal drain duration by 0.3 days (p = 0.011), infection with 14.4 days (p < 0.001), and return to the OR with 5.7 days (p = 0.007).

CONCLUSION

 Elevated BMI, hypertension, and axillary dissection increase risk for prolonged breast drain requirement in autologous reconstruction. African-American and Hispanic populations experience prolonged breast drain requirement after controlling for other factors, warranting further study.

Incidence of Complications in Delayed Abdominal-Based Flap Breast Reconstruction Using a Drainless Recipient Site: A Case Series

BACKGROUND

Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site.

METHODS

A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications.

RESULTS

Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5).

CONCLUSIONS

In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.

Effects of hydrochlorothiazide on drainage volume and seroma formation in deep inferior epigastric perforator flap breast reconstruction: Randomized controlled trial

BACKGROUND

Seroma is a recognized complication encountered at the reconstructed breast and donor site after abdominal-based breast reconstruction. Seroma is caused by lymphatic channel disruption and the formation of a large space between the deep fascia during flap elevation. Surgical techniques to preserve the lymphatics and secure the closure of the donor site can reduce seroma formation. This study investigated the safety and effectiveness of the diuretic hydrochlorothiazide at reducing interstitial fluid accumulation and seroma formation during deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

Sixty patients with breast cancer who underwent skin- or nipple-sparing mastectomy and DIEP flap reconstruction were enrolled between August 2016 and June 2017. The patients were randomly assigned to receive either 25 mg per day of hydrochlorothiazide from the second to the twentieth day after surgery (treatment) or no diuretic (control). The clinicopathological characteristics, drainage time, and drainage volume were statistically compared between the two groups.

RESULTS

The average total drainage volume at the donor site was 291 mL in the treatment group and 434 mL in the control group (p = 0.003). The differences in body mass index and flap weight between the two groups were not statistically significant (p = 0.879 and p = 0.963, respectively). No hypotension or electrolyte imbalance was noted during the follow-up.

CONCLUSIONS

Intake of 25 mg per day of hydrochlorothiazide tablets effectively reduced the total abdominal drainage volume and removal time of indwelling drains. However, the adverse effects should be further investigated in a large population and multiracial cohort before using hydrochlorothiazide for seroma prevention.

The use of surgical site drains in breast reconstruction: A systematic review

BACKGROUND

Use of drains has been advocated in order to prevent seroma and hematoma; however, specific recommendations vary widely. The goal is to perform a systematic analysis of published literature on the use of drains for breast reconstruction.

METHODS

The literature search was performed according to the PRISMA guidelines. The search included the Cochrane Library, Embase, and Pubmed databases using the terms "breast reconstruction" and "breast flap" combined with "drain", "seroma," and "seroma prevention". The references were appraised in two rounds, by two independent reviewers; studies were included/excluded based on relevance of title and subsequently by the content of their abstracts/manuscripts. Outcomes regarding seroma, infection rate, length of stay (LOS), drainage, reconstruction type and complications were analyzed.

RESULTS

Of 2252 studies identified via search, 64 were relevant and 21 met inclusion criteria. Most of the study designs were case series or retrospective cohort studies (Level of Evidence III or IV), with the exception of one prospective randomized-controlled trial. Seroma rate was given in 18 studies, infection rate in 11, and criteria for drain removal in 19. Reoperation rate was available in 7 and LOS in 18 studies. The majority of studies (13) agreed to remove the drain when the output was less than 30 ml/24 h. Drain output was reported in 11, and 20 reported drain type used.

CONCLUSION

There is sparse literature available with which to make evidence-based guidelines. A standardized guideline for reporting drain use is crucial to providing a better understanding of complications in breast reconstruction related to surgical drains.

Intraoperative hypertonic saline irrigation preventing seroma formation and reducing drain secretion in extended endoscopic hernia and linea alba reconstruction glue

PURPOSE

Subcutaneous Seroma formation (SF) is commonly seen after abdominal wall Hernia surgeries and reconstructive surgeries due to large dissecting dead space and is associated with increased morbidity. SF is common particularly after big abdominal wall hernia repairs and its treatment can be challenging and long. Current prevention methods are not consistent and the treatment includes repeated aspirations and drains, both are associated with higher risk for infections. The purpose of this article is to present a novel and simple technique of Intraoperative Hypertonic Saline Irrigation (IHSI) to abdominal wall subcutaneous large dead space, which prevent postoperative SF and enables early drain removal due to reduced secretions.

METHODS

Eight patients undergone the Extended Endoscopic Hernia & Linea Alba Reconstruction Glue surgery (eEHLARglue), for Ventral Hernias (VH) and Rectus Muscles Separation (RMS). An extensive Endoscopic 450cm² dissection free surface of the anterior Rectus fascia, is performed prior to Hernia dissection and closing of the RMS. It is followed by onlay mesh placing over the repaired Rectus muscles and the mesh is fused into the muscles by Fibrin Glue. The novel preventive method is based on Intraoperative Irrigation of the vast cavity through the two 10 mm JP closed system drains with 20 cc of NaCl 12% left at site for 10 min.

RESULTS

Our early results with all our patients show seroma prevention, lower secretion rate of 20 cc in 10 h and drain removal within 20-24 h.

CONCLUSIONS

IHSI enhance adhesion formation and reduce secretion rate in wide subcutaneous dissection space like in eEHLARglue, therefore enables early drain removal and prevent SF. As a result, reducing overall morbidity and hospitalization period, decreasing inconveniency and cost saving of multiple outpatient visits or additional surgery. This simple technique could be used in other potential postoperative SF surgeries. Further larger study with a longer follow up is advised.