DIEP flap breast reconstruction most often requires surgical drains for post operative care. Patients often mention to me they are awkward, can become infected at the suture site where they are attached, and are cumbersome to hide under clothing after surgery when going out in public. This is a summary of Episode 43: The Drain-Free DIEP flap Concept as it relates specifically to this type of autologous breast reconstruction.
My guest on this episode of the DiepCJourney podcast has been in communication with me over the past year in anticipation of his published paper, Are Surgical Drains Needed in DIEP Flap Surgery? The Drain-Free DIEP Flap Concept.
Dr. Nanidis and the Motivation for the Drain-Free DIEP
Mr. Theo Nanidis, is a Consultant Plastic and Reconstructive surgeon with the NHS and private practice at The Royal Marsden. He graduated with distinctions from University College London Medical School in 2003 and completed his general surgical and higher plastic surgery training in London. Mr. Nanidis was awarded specialist fellowships at the Royal Marden and Queen Victoria Hospitals, where he spent two years specializing in microsurgery with a focus on breast reconstruction.
His research interests include meta-analytical outcomes research, volumetric analysis of flaps and patient enhanced recovery pathways. He has published and presented his work nationally and internationally. We reference a paper by Ms. Anita Mohan, Modified aesthetic abdominoplasty approach in perforator free-flap breast reconstruction: Impact of drain free donor site on patient outcomes. This was the impetus for further work and the recently published paper by Mr. Nanidis.
A Leap of Faith in Microsurgery
Theo tells us the drain-free DIEP flap concept and publishing the paper has been a very long journey for him. He acknowledges the other big-name mentors he was inspired by and what motivated him to take his own leap of faith to try this method. It was in his training he observed patients were being delayed in their discharge because of their drains. Theo explains there is an idea in microsurgery with DIEP that drains must be less than thirty cc’s for twenty-four hours for patient drains to be removed.
He explored this further by conducting an audit in the unit he was working in. In the UK, because many patients travel for their surgery, the requirement is to go home drain-free. Theo found this to be the biggest contributor to patients’ delay in release from hospital. He states, “For us, removal of drains was synonymous with discharge.”
Quicker Release with the Drain-Free DIEP Flap Concept Improves Patient Recovery
Mr. Nanidis wanted to increase their use of ERAS (Enhanced Recovery After Surgery) protocol. At home, he says patients sleep better, use of toilet at home is easier (opening the bowels), eating properly, shower situation is better, and they can be with their families. This was a strong motivation to begin the process of trying the drainless DIEP flap.
He looked to literature in the aesthetic world of plastic surgery studying tummy tucks. He began by convincing others in his field to narrow it down to one drain. Measuring nearly two hundred plus patients daily and their drain output he found it was linearly correlated with BMI (body mass index). Theo points out the “golden BMI” is around thirty-three. Most patients will find, even in the U.S. that the BMI cutoff varies from facility to facility. He tells us that a BMI higher than thirty-eight resulted in a nearly one hundred percent complication regardless of other factors. He describes them not as “massive complications but manageable complications”.
The Enlightening Moment to Begin the Drain-Free DIEP Flap Concept Study
He goes on to talk about the safety of the flap and ideal time of release. Theo also mentions the type of suturing used for his DIEP flaps and how this had overall benefits to the healing of the abdominal area. Part of his “leap of faith” was realized when he sent one of his first patients’ home on day two. He shares with us the trepidation of his colleagues witnessing this. They were used to the five-day hospital stay with drains. He persisted despite the criticism of colleagues. That enlightening moment was the impetus for his study highlighting the fact that patient safety for him is a priority.
It’s not guessed work. It was a very educated move.
Theo Nanidis, Plastic Surgeon
I am grateful to have met Mr. Nanidis while visiting London in September of 2023 at the London Breast Meeting. Our hope today is to inform patients about the drain-free DIEP flap. Additionally, our intention is to inspire other microsurgeons to consider this procedure in your own practice with appropriate patient selection. Enjoy the entirety Episode 43: The Drain-Free DIEP Flap Concept podcast here.