What is a drain in breast surgery?
Drains are used in surgery to drain fluid and blood which may accumulate in the space around the breast implant created during surgery. We want to prevent fluid collection to aid in healing and avoid infection.
Do you need a drain when doing a breast implant exchange?
This is an area where you will find differing opinions from different plastic surgeons. I used to frequently use drains when doing implant exchanges. The thought was fluid collections around the new implant could lead to inflammation and increase capsular contracture rates.
But then I became familiar with biofilm, and the drain took on another dimension. The drain connects the dirty, bacteria laden outer world with a new sterile implant. It is like a highway to bring bacteria and biofilm to the implant. So I avoid them if at all possible. What do studies show?
Study: “Prophylactic Drain Use is Expander to Implant Exchange?”
This was a study in the Plastic Reconstructive Surgery Journal November 2025,”Prophylactic Drain Use in Breast Expander to Implant Exchange; Necessity or Nuisance?”
In this study the authors discuss how drains are widely use in breast implant reconstruction when going from tissue expanders to the final implant. Should drains be used? They looked at surgeries (343 patients, with 502 breast surgeries) from 2018 to 2023 and compared complication rates of those with and without drains. They looked at detailed patient profiles- demographics, health issues, breast cancer characteristics, chemo/radiation, operative details. They did a modified frailty index score on each patient, which included diabetes, high blood pressure, and heart failure within a month of surgery.
Findings?
- 24% had used drains, 76% did not.
- Median follow up 20 months.
- In unmatched cohorts, drain use did not provide significant advantage and “should be avoided in routine practice”.
- Significantly higher rates of overall complications, implant exposure, and implant removal in t hose with drains.
- In unmatched comparisons, drains caused higher complication rates whether in front of or behind the pectoral muscle. When matched, the comparison was harder. They think that the shorter drain tract in pre-pectoral recon and the thinner tissue may be more susceptible to contamination.
- They do think that some higher risk groups for seroma- high BMI, large implant size, smokers- may need drains.
- There may be bias- the surgeons may only use drains in the patients who are higher risk, so they are higher risk for having complications period.
- There may be different rates based on how thick the mastectomy flaps are- which is determined by the operating general surgeon. Thinner flaps have higher complications.
They conclude, “Surgical drains do not appear to provide a protective benefit against adverse outcomes in second stage breast reconstruction… Drains may be warranted in selected cases… Drain use should not be routine.”
Dr. Greenberg’s thoughts
I try to avoid drain use. I do a meticulous dissection, focusing on stopping all bleeding so the surgical area is “dry.” I use TXA in the IV and irrigation to help reduce bruising and fluid. I use gentle compression after surgery. I have my patients really rest to allow the area to heal.
This is not news to me, and it makes sense. I believe in the issues of biofilm leading to capsular contracture, implant infection, and breast implant illness. I do so many things to avoid biofilm. Avoiding drains is one of them.
Prior studies have looked at drains in breast augmentation. One prospective randomized trial found drains in breast augmentations had high costs and time consumption without demonstrating benefits.
I have never used a drain in first time primary breast augmentation patients.
Another study, a retrospective, showed drains were linked to higher risk of infections in breast augmentation implant exchange procedures.
Medical citation
Prophylactic Drain Use in Breast Expander-to-Implant Exchange: Necessity or Nuisance?, Plastic & Reconstructive Surgery Journal, Nov 2025
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