Closed-Suction Drains After Subcutaneous Mastectomy for Gynecomastia: Do they Reduce Complications?

Dear Sir, We read with great interest the article titled: ‘‘Comment on ‘‘Closed-suction drains after subcutaneous mastectomy for gynecomastia: do they reduce complications?’’ by Chao et al. [1]. The authors investigate the effects of drain placement on preventing or reducing seroma and hematoma after subcutaneous mastectomy for gynecomastia, evaluating the occurrence of complications 30 days postoperatively. We appreciate this interesting authors’ retrospective study, and we fully agree with the efficacy of closed-suction drains after male breast surgery in reducing the occurrence of hematoma complications in the early postoperative period, but we have some elements to discuss. Certainly, we believe that drain placement is useful in reducing fluid accumulation, such as hematomas, in the early postoperative time, but we have some doubts about its efficacy in 30-day postoperative seroma prevention. In gynecomastia surgical correction, seroma is a collection of fluid under the surface of the adipocutaneous flap, usually collecting in the late post-op period. Typically, it is related to the amount of adipose tissue damage during the surgical procedure. It occurs more frequently in extensive procedures compared to minor surgical procedures. Because the risk of seroma depends mainly on the amount of disrupted tissue, the type and the entity of gynecomastia play a main role in the occurrence of seroma. Based on our experience, severe gynecomastia in overweight patients showed a higher risk of seroma than the glandular disorder in the athletic population [2]. Consequently, we maintain that in high-risk seroma patients, surgical dissection with scissors rather than electrocautery is recommended [3]. Besides the amount of excised tissue and the patient’s body type, the dimension of the undermined surgical area also heavily influences the risk of seroma, especially if liposuction is performed. Therefore, in cases of widely undermined surgical surfaces, the use of ‘‘Baroudi’’ stitches reducing the dead spaces and improving the adherence of the adipocutaneous flap to the thorax can dramatically decrease the incidence of seroma [4]. However, the vacuum used in closed-suction drains as well the postoperative compressive medical dressings can support successfully the efficacy of quilting stitches [5]. On the other hand, as the authors reported in their paper, the risk of hematoma occurrence strictly depends on the surgeon’s accuracy during hemostasis and last but not the least, on the correct patient postoperative attitude and lifestyle.