Review articles

By Dr. Jedidiah S Prakash , Dr. Anil Luther , Dr. Michael Deodhar
Corresponding Author Dr. Jedidiah S Prakash
General Surgery , CMC & Hospital ,Ludhiana, CMC & Hospital, Ludhiana - India 141008
Submitting Author Dr. Jedidiah S Prakash
Other Authors Dr. Anil Luther
CMC , Deptt. General Surgery , CMC - India 141008

Dr. Michael Deodhar
CMC , Deptt. General Surgery , CMC - India 141008


Breast cancer , MRM , suction drains , vacuum suction

Prakash JS, Luther A, Deodhar M. Modified Radical Mastectomy and Wound Drainage. WebmedCentral GENERAL SURGERY 2015;6(3):WMC004822
doi: 10.9754/journal.wmc.2015.004822

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 28 Feb 2015 01:59:50 PM GMT
Published on: 02 Mar 2015 01:31:33 PM GMT


Modified Radical Mastectomy [MRM] is a commonly practised surgical procedure for management of operable breast cancer. Necrosis of skin flaps , wound dehiscence , hematoma, seroma , venous thromboembolism and infection are early complications . Late complications include lymphedema , sensory loss, shoulder dysfunction etc. Suction drains are employed to minimize incidence of fluid collection , seroma , hematoma and lymphedema .  Paucity  of  Indian studies comparing   outcome of  different vacuum suction drains  is an indication  to undertake topical  prospective comparative  studies .


Radical mastectomy was first carried out in 1882 and described in 1894 by William Stewart Halstead .For a number of decades it remained standard operation for early breast cancer . Modified radical mastectomy combines removal of all breast tissue from the affected breast with lymph node removal from the armpit from the affected side of body . MRM typically includes removal of both the nipple and areola but the surgery can be performed using  skin and nipple sparing technique . The purpose of MRM is removal of breast cancer. MRM may be combined with total breast reconstruction at the same time in accordance with patient’s preference [15 ,11] .


Breast cancer is the most common cancer among women worldwide with an incidence of 120.9 per 100,000 new cancer cases with a mortality of 21.9 per 100,000 women . In India the age standardized incidence rate of breast cancer varies from 9 to 32 per 100,000 women [10] . Around  130,000 fresh cases of breast cancer are reported annually in India. Of every  2 women diagnosed with breast cancer one dies because of it . Ca breast has remained the second leading cause of cancer death among  women  worldwide for the last 3 decades. Breast cancer is a disease of the developed world .It is commoner in West in  nulliparous women or in women who refuse breast feeding [09] .

Two main types of management options are : local and systemic. These include lumpectomy , mastectomy , ±  radiation therapy . Chemotherapy , hormone therapy , targeted therapies are systemic because they affect the whole body . Beside these , neoadjuvant and adjuvant therapies are utilized pre & post surgery to help shrink the size of tumor or to kill cancer cells .Treatment of breast cancer varies with the TNM staging of disease which is usually carried out during detailed diagnostic stage following examination and investigations   [05 ,12] .

In general, complications following breast surgeries include wound infection , wound dehiscence , seroma , hematoma, chronic pain , venous thromboembolism VTE , surgical dog ear ; late sequel -  breast fibrosis , sensory loss , shoulder dysfunction, lymphedema ,and chronic / recurrent breast cellulitis . Of these, seroma poses a major threat [01,18 ,16] .


In any surgery which entails creation of a dead space , the body has  a natural tendency to fill the space with fluid or air . Earlier , usage of a drain was not routinely recommended after clean surgical procedures . However ,  studies claim that use  of drains results in seroma or  hematoma reduction [13 ,08] .


Use of drains has been a common surgical practice to obliterate the dead space created during surgery .Drains are used both prophylactically and therapeutically .Common use is prophylactic post surgery to prevent accumulation of fluid e.g. blood or pus . Various types of surgical drains are used after procedures  on the thyroid , breast , axillary and abdominal areas , joint replacements , amputations , external fixations  etc  [04, 07,14] .

 Drains may be classified as active or passive drains. Passive drains depend on the higher pressure inside wound in conjunction with capillary action and gravity [ postural] to draw fluid out of a wound [i.e. the difference in pressures between the inside and outside of the wound forces the fluid out from wound ] .Passive drains like penrose or corrugated  rubber  drains  do not require special attention. When saturated , the dressing is changed.

Active drains require special maintenance and offer certain advantages . The end of drainage tube inserted inside the wound has multiple openings on the inner side through which fluid is evacuated from the wound .The wound should be closed before the clamps on the drain are opened ,otherwise the vacuum will be lost as the tube sucks in atmospheric air . Collection reservoir of an active drain [e.g. Romovac Romsons – an Indian brand ] expands as it collects fluid drainage  by exchanging negative pressure for fluid . The drain becomes ineffective if the vacuum is lost .  If the drain is attached to a reservoir then the reservoir is emptied  or changed when it is full  . Once every 24 hours the Resident / nurse marks the volume of drainage collected before charging / clamping /  emptying the container  .

 Active drains utilizing negative pressure therapy are safe and feasible in low resource settings . Vacuum drains are classified according to the degree of pressure used . Typical bottled vacuum drains [e.g. Redivac ] use high negative pressure . Bulb shaped suction devices [e.g. Jackson Pratt ] and collapsible 4 channel vacuum drains [ e.g. J Vac ,Blake ] use low negative pressure .

Suction drainage in the management of mastectomy patients was used first in 1947 . It has been accepted as effective in reducing morbidity .Studies comparing the intensity of negative  drain suction as well as early or late removal of drains have shown mixed results  . High vacuum drains had a higher incidence of vacuum loss but a lower incidence of leakage around the drain .No suction or high suction drainage both may contribute to higher incidence of seroma formation and longer hospital stay [02, 04, 16 ] .


Knowledge  about whether no suction or low negative suction or high negative suction drain provides greater benefit to the patient in terms of wound healing and hospital stay  assumes importance for the treating surgeon .During our search we could find very few studies globally comparing effects of different drainage systems in  mastectomy patients [04,17 ,03,02 ] . One Indian study was found comparing full vacuum suction drain versus half vacuum suction in mastectomy  patients [06] . More  comparative / prospective topical  studies should  be undertaken and are the need of the hour .


01. Aitken DR , Minton JP : Complications associated with mastectomy : Surg Clin North Am : 1983 :63: 1331- 52

02. Barton A , Blitz M , Callahan D , Yakimets W , Adams D , Dabbs K : Early removal of post mastectomy drains is not beneficial : results from a halted randomized controlled trial : Am J  Surg : 2006 : 191: 652-56

03. Bonnema J, van Geel AN, Ligtenstein DA, Schmitz PI, Wiggers T : A prospective randomized trial of high versus low vacuum drainage after axillary dissection for breast cancer : Am J Surg : 1997 : 173: 76-9.

04. Bourke JB  , Balfour TW ,Hardcastle JD , Wilkins JL : Comparison between suction and corrugated drainage after simple mastectomy : a report of a controlled  trial : Brit J Surg : 1976 :63: 67 – 9

05. Charfare H , Limongelli S , Purushotham AD : Neoadjuvant chemotherapy in breast cancer : Brit J Surg : 2005 : 92 : 14 – 23

06. Chintamani  , Singhal V , Singh JP , Bansal A , Saxena S : Half versus full vacuum suction after modified radical mastectomy  for breast cancer – a prospective randomized clinical trial : BMC Cancer : 2005 : 5 - 11

07. Dwyer AJ ,  Paul R , Mam MK , Prakash JS , Gosselin RA : Modified skew flap below knee amputation : Am J  Ortho : 2007 : 36 :3 : 123 - 26

08. Ismail M , Garg M , Rajagopal M , Garg P : Impact of closed suction drain in preperitoneal space on the incidence of seroma formation after laparoscopic  total extraperitoneal inguinal hernia repair : Surg Lap Endos Percut Tech : 2009 : 19: 263 -66

09. Jemal A , Siegel R , Ward E , Hao Y , Xu J , Murray T ,Thun  MJ  : Cancer statistics : CA Cancer J Clin : 2008 : 58: [2] : 71-96

10. Kamath R , Mahajan KS , Lena A , Sanal TS : A study on risk factors of breast cancer among patients attending tertiary care hospital in Udupi district : Ind J Comm Med : 2013 :38 : 95 -99

11. Lynch JB , Madden JJ Jr, Franklin JD : Breast reconstruction following mastectomy for cancer : Ann Surg : 1978 : 187 : 490 - 501

12. Palmer BV , Walsh GA , McKinna JA , Greening WP : Adjuvant chemotherapy for breast cancer : side effects and quality of life : Brit Med J : 1980 : 281 :1594 – 7

13. Pogson CJ , Adwani A , Ebbs SR : Seroma following breast cancer surgery : Euro J  Surg  Onco : 2003 : 29 : 711 – 17

14. Prakash JS , David VK , Bhatty SM , Deane A : Across wrist external fixation for distal radius fractures in adults : WMCPLS00500 : 2015 :

15. Simmons RM , Adamovich TL : Skin sparing mastectomy : Surg Clin North  Am : 2003 : 83 :885 - 99

16. Srivastava V , Basu S , Shukla VK : Seroma formation after breast cancer surgery : what we have learned in the last two decades : J Breast Cancer : 2012 : 15 :373 – 80

17. vanHeurn LW, Brink PR : Prospective randomized trial of high versus low vacuum drainage after axillary lymphadenectomy : Br J Surg : 1995 : 82: 931-2.

18. Vitug AF , Newman LA : Complications in breast surgery : Surg Clin North Am : 2007 : 87: 431 - 51  .

Source(s) of Funding

Self funded

Competing Interests


4 reviews posted so far

Modified Radical Mastectomy and Wound Drainage
Posted by Dr. Prasan K Hota on 08 Jul 2015 08:54:26 AM GMT Reviewed by Author Invited Reviewers

Modified radical mastectomy - To drain or not to drain
Posted by Prof. Sanjeev K Gupta on 23 Mar 2015 08:44:14 AM GMT Reviewed by WMC Editors

Modified Radical Mastectomy and Wound Drainage
Posted by Anonymous Reviewer on 04 Mar 2015 01:37:31 PM GMT Reviewed by Author Invited Reviewers
This review will not be counted towards final review score for this article and for its inclusion into WebmedCentral Peer Reviewer articles because review was posted by an anonymous reviewer.

Modified Radical Mastectomy and Wound Drainage
Posted by Dr. KETAN R VAGHOLKAR on 02 Mar 2015 04:18:28 PM GMT Reviewed by WMC Editors

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