Do You Really Need Drains After Explant Surgery?

May 11, 2026

One of the topics I’d like to weigh in on is the use of drains in surgery, particularly in explant surgery and capsulectomy.

In the teaching of plastic surgery, drains have traditionally been used routinely in operative spaces. Depending on the size of the surgical pocket or degree of tissue disruption, a surgeon may place one drain or multiple drains. The rationale is straightforward: surgery creates inflammation, inflammation creates fluid, and drains are intended to evacuate that fluid while tissues heal.

But not every breast surgery routinely requires drains.

For example, in standard lumpectomy surgery, drains historically were not used. It was common for patients to develop a seroma afterward, which could later be identified on ultrasound or mammogram. In more extensive breast cancer procedures, especially when lymph nodes in the axilla are removed, drains are commonly placed because lymphatic drainage pathways have been disrupted. Those patients can produce fluid for extended periods of time because the lymphatic system itself has been altered.

Explant surgery with capsulectomy is different.

The decision to use drains after explant surgery depends on multiple variables:

The size of the implant
The extent of the capsulectomy
Whether the muscle is repaired completely
Whether a simultaneous lift or reshaping procedure is performed
Whether fat transfer is done
Whether liposuction or pocket modification is performed

Ultimately, the decision is made by the surgeon based on surgical judgment and patient-specific factors.

But I believe the more important discussion is understanding why the body produces fluid after surgery in the first place.

Fluid production after surgery is driven by inflammation, disruption of tissue planes, changes in vascular permeability, activation of the sympathetic nervous system, and the cortisol surge associated with surgery itself. Following surgery, the body enters what many describe as a “capillary leak phase,” where blood vessels become more permeable and fluid shifts into tissues.

The question then becomes:
How do we reduce that physiologic overreaction?

That is where preparation matters.

In our patient population, we’ve consistently observed that many patients arrive with significant inflammatory burdens. In an audit of our genetic testing results, approximately 83% of patients demonstrated single nucleotide polymorphisms, commonly including MTHFR variants. But even more importantly, many patients demonstrated elevated toxic burdens.

In an audit of more than 500 patients:

BPA was the most common toxin identified
Glyphosate followed closely behind
Mycotoxins were also extremely common

Some patients had very unique toxicity profiles. Lauryn Bosstick, for example, demonstrated extremely elevated heavy metals. More recently, one of our patients, Ashley Kurtz, had profoundly elevated organophosphates after years as a competitive golfer with chronic pesticide exposure.

Patients bring different physiologic burdens into surgery, and those burdens influence inflammatory response, recovery, swelling, fluid production, sleep disruption, autonomic nervous system activation, and pain perception.

That is why preparation matters.

Within the SHARP Method, our focus is reducing inflammation and reducing sympathetic overactivation before surgery ever occurs.

That preparation begins preoperatively with:

Sleep optimization
Higher protein nutrition
Supplementation support
Reduction of inflammatory foods
Hydration optimization
Circadian stabilization

We emphasize the “3-2-1 Rule” before sleep:

Stop eating 3 hours before bed
Stop drinking fluids 2 hours before bed
Stop screens 1 hour before bed
Aim for 7–9 hours of restorative sleep

The goal is to place patients into surgery in the best physiologic state possible.

Our ERAS protocol — Enhanced Recovery After Surgery — actually begins the night before surgery.

Patients begin:

Anti-inflammatory support
Anti-nausea therapy
Nerve pain modulation
Sleep optimization

On the day of surgery, we continue reducing cortisol surge and sympathetic activation through multimodal anesthesia techniques.

This includes:

Preoperative ultrasound-guided nerve blocks by anesthesia
Long-acting local anesthetic blocks using Exparel
Careful fluid management
Normothermia maintenance during surgery
Muscle repair when indicated
Multimodal pain control designed to minimize narcotic use

In our cases we perform pocket modification extending toward the flank, we frequently and do not use drains.(older ruptured silicone implants that are more like syrup inside are the exception)

Instead, the focus becomes controlling the physiologic drivers of capillary leak and fluid production.

Postoperatively:

Patients are encouraged to walk the evening of surgery
Protein intake is maintained at approximately 100–150 grams daily
Sleep hygiene continues to be prioritized
Narcotic exposure is minimized whenever possible

The following day in clinic, our goal is helping patients transition from a sympathetic-dominant stress response into a more parasympathetic healing state.

Because ultimately, the less inflammatory overreaction the body experiences, the less swelling, fluid production, capillary leak, and prolonged recovery we tend to see.

Drains are not inherently good or bad.

They are a surgical tool.

But understanding the physiology behind why fluid develops — and how to reduce the body’s inflammatory response to surgery itself — is, in my opinion, the more important discussion.

In our clinic, patients return the following day accompanied by their caregiver. Importantly, they are already walking into the clinic under their own power, which reflects one of the core goals of our recovery philosophy: early mobilization and restoration of physiologic balance.

At that visit, patients participate in a series of recovery modalities specifically designed to reduce cortisol, calm sympathetic overactivation, and support a more parasympathetic healing state.

We begin with the Human Regenerator to support relaxation and autonomic recovery. We then focus on lymphatic support using the Flowpresso lymphatic compression system from New Zealand, combined with NanoVi support. This is followed by treatment in our vertical hyperbaric chamber and concluded with red light therapy.

The overall objective is to reduce the physiologic stress response associated with surgery and help the body transition out of the acute inflammatory phase as efficiently as possible.

To summarize:
Capillary leak — which is responsible for the fluid production surgeons are attempting to manage with drains — is most significant during approximately the first 72 hours after surgery. The cortisol surge associated with surgery, which we intentionally work to reduce through multimodal preparation and recovery strategies, meaningfully declines between approximately day three and day five postoperatively.

While the acute inflammatory response improves during that period, full inflammatory normalization can take weeks after surgery.

That longer-term recovery process in our clinic is managed by two teams:

Our functional medicine team, which oversees detoxification and inflammatory optimization programs
Our postoperative surgical care team, which guides patients through recovery and healing protocols

As a result of this comprehensive approach, we have not routinely used drains in explant surgery outside of very specific circumstances for more than five years in our clinic.

Our position is that drains are simply a tool. They do not prevent bleeding, they do not prevent infection, and they do not prevent seroma formation. The more important objective is controlling the physiologic conditions that contribute to excessive fluid production in the first place: