No superiority of double drains over single drainage after tissue expander–based breast reconstruction: A systematic review and meta-analysis
7 affiliations
- 1Department of Medicine, Universidade Federal de Minas Gerais, Minas Gerais, Belo Horizonte, Brazil
- 2Department of Plastic, Reconstructive and Aesthetic Surgery, Imperial Hospital, Trabzon, Türkiye
- 3Department of Plastic Surgery, Cleveland Clinic, Ohio, United States
- 4Independent Scholar, Boston, Massachusetts, USA
- 5Department of Medicine, Centro Universitário de Belo Horizonte (UniBH), Belo Horizonte, Brazil
- 6Department of Surgery, Universidade Federal de Minas Gerais, Minas Gerais, Belo Horizonte, Brazil
- 7Santa Maria di Leuca Clinic, Via Tiberina 173, Rome, 00188, Italy
Abstract
Background: The optimal number of drains after postmastectomy tissue expander (TE)-based breast reconstruction remains uncertain. Although double-drain placement may theoretically improve fluid clearance and reduce seroma formation, it may also increase patient discomfort, prolong drain-related morbidity, and potentially increase contamination risk. This systematic review and meta-analysis compared postoperative outcomes between single- and double-drain strategies following TE-based breast reconstruction.
Methods: PubMed, Embase, and Cochrane Library were searched from inception to May 16, 2026. Comparative studies evaluating single versus double drains after postmastectomy TE-based reconstruction were included. Outcomes of interest included seroma formation, surgical site infection (SSI), hematoma, return to the operating room, skin flap necrosis, drain duration, and TE/implant-related complications. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models. Risk of bias was assessed with ROBINS-I and certainty of evidence with the GRADE approach.
Results: Three retrospective observational studies comprising 1350 reconstructions were included, with 660 reconstructions in the single-drain group and 690 in the double-drain group. There were no significant differences between single- and double-drain strategies in seroma formation (RR 0.84, 95% CI 0.47 to 1.49; p = 0.54; I² = 63%), SSI (RR 1.01, 95% CI 0.75 to 1.37; p = 0.93; I² = 39%), hematoma (RR 0.84, 95% CI 0.44 to 1.63; p = 0.61; I² = 0%), return to the operating room (RR 0.66, 95% CI 0.30 to 1.43; p = 0.29; I² = 12%), skin flap necrosis (RR 0.74, 95% CI 0.46 to 1.19; p = 0.22; I² = 0%), or drain duration (MD −3.90 days, 95% CI −12.42 to 4.63; p = 0.37; I² = 97%). Leave-one-out analyses did not materially alter the findings for seroma formation or SSI. Certainty of evidence was low for seroma, SSI, and skin flap necrosis, and very low for hematoma, return to the operating room, and drain duration.
Conclusion: Current evidence does not demonstrate a benefit of routine double-drain placement after TE-based breast reconstruction. The certainty of evidence was low, and these findings indicate a lack of demonstrated benefit rather than equivalence between the two strategies. Selective second-drain placement based on intraoperative findings remains reasonable, and adequately powered prospective studies are needed.
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BibTeX
@article{delgado2026superiority,
title = {{No superiority of double drains over single drainage after tissue expander–based breast reconstruction: A systematic review and meta-analysis}},
author = {Lucas Monteiro Delgado and Enes Agah Kodalak and Guilherme Franceschini Machado and Deepti Sreepathi and Rafaela Xavier de Almeida Amaral and Alexandre Catojo Poggi and Gabriel Bráulio Xavier de Sena and Leandro Ricardo de Aquino Santos and Agostino Bruno},
journal = {JPRAS open},
year = {2026},
month = oct,
doi = {10.1016/j.jpra.2026.10.010},
url = {https://europepmc.org/article/PMC/PMC13721860},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - No superiority of double drains over single drainage after tissue expander–based breast reconstruction: A systematic review and meta-analysis
AU - Lucas Monteiro Delgado
AU - Enes Agah Kodalak
AU - Guilherme Franceschini Machado
AU - Deepti Sreepathi
AU - Rafaela Xavier de Almeida Amaral
AU - Alexandre Catojo Poggi
AU - Gabriel Bráulio Xavier de Sena
AU - Leandro Ricardo de Aquino Santos
AU - Agostino Bruno
PY - 2026
DA - 2026/10/21
JO - JPRAS open
DO - 10.1016/j.jpra.2026.10.010
UR - https://europepmc.org/article/PMC/PMC13721860
AB - Background: The optimal number of drains after postmastectomy tissue expander (TE)-based breast reconstruction remains uncertain. Although double-drain placement may theoretically improve fluid clearance and reduce seroma formation, it may also increase patient discomfort, prolong drain-related morbidity, and potentially increase contamination risk. This systematic review and meta-analysis compared postoperative outcomes between single- and double-drain strategies following TE-based breast reconstruction. Methods: PubMed, Embase, and Cochrane Library were searched from inception to May 16, 2026. Comparative studies evaluating single versus double drains after postmastectomy TE-based reconstruction were included. Outcomes of interest included seroma formation, surgical site infection (SSI), hematoma, return to the operating room, skin flap necrosis, drain duration, and TE/implant-related complications. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models. Risk of bias was assessed with ROBINS-I and certainty of evidence with the GRADE approach. Results: Three retrospective observational studies comprising 1350 reconstructions were included, with 660 reconstructions in the single-drain group and 690 in the double-drain group. There were no significant differences between single- and double-drain strategies in seroma formation (RR 0.84, 95% CI 0.47 to 1.49; p = 0.54; I² = 63%), SSI (RR 1.01, 95% CI 0.75 to 1.37; p = 0.93; I² = 39%), hematoma (RR 0.84, 95% CI 0.44 to 1.63; p = 0.61; I² = 0%), return to the operating room (RR 0.66, 95% CI 0.30 to 1.43; p = 0.29; I² = 12%), skin flap necrosis (RR 0.74, 95% CI 0.46 to 1.19; p = 0.22; I² = 0%), or drain duration (MD −3.90 days, 95% CI −12.42 to 4.63; p = 0.37; I² = 97%). Leave-one-out analyses did not materially alter the findings for seroma formation or SSI. Certainty of evidence was low for seroma, SSI, and skin flap necrosis, and very low for hematoma, return to the operating room, and drain duration. Conclusion: Current evidence does not demonstrate a benefit of routine double-drain placement after TE-based breast reconstruction. The certainty of evidence was low, and these findings indicate a lack of demonstrated benefit rather than equivalence between the two strategies. Selective second-drain placement based on intraoperative findings remains reasonable, and adequately powered prospective studies are needed.
SN - 2352-5878
ER -