KEY WORDS
Drainless abdominoplasty - seroma - toilet liposuction - no drains abdominoplasty
INTRODUCTION
It is routine practice to use drains in lipoabdominoplasty operations. It can be safely
assumed that only closed; suction drains are being used. Open drains are obsolete
due to inconvenience, soakage, soiling of surrounding skin and inability to calculate
exact amount of effluent. Closed drains are less messy and facilitate measurement
of the drainage fluid. Active drains are preferred over passive.
The function of negative suction drain is purported to be evacuation of accumulated
fluids - blood, serum and pus if any. Suction is expected to improve approximation
of raw areas by better apposition of the surfaces. However, problematic issues with
drains are ineffectiveness, discomfort, difficulty in mobilisation, breakage or premature
extrusion, bacterial colonisation and increased the duration of hospitalisation.[[1]]
Our earlier experience with liposuction patients showed that seromas could be avoided
by uninterrupted use of elastic garment for initial 4 days post-operatively. This
prompted us to adopt the same protocol for our lipoabdominoplasty patients. Once drains
were done away with, we could implement uninterrupted garment support for initial
4 days with early mobilisation after abdominoplasty.
The objective of our retrospective study is to evaluate the results of lipoabdominoplasty,
wherein drains were avoided and to define a protocol to avoid seromas after drainless
abdominoplasty.
SUBJECTS AND METHODS
Clinical records of 204 consecutive abdominoplasty patients operated in the last 11
years (2006–2017) by a single surgeon were reviewed retrospectively. Parameters observed
were (1) method of abdominal closure (2) occurrence of seroma, haematoma, pus collection,
skin necrosis and wound discharge or dehiscence till the time of suture removal. (3)
Whether drains had to be inserted and time of removal if inserted.
All patients underwent abdominoplasty depending on type of deformity they had, without
any compromise on extent of dissection as shown in [Figure 1]. Infiltration was done with standard Toledo's formula in wet technique proportion,
1:2. Waiting time was a minimum of 10 min. Extensive liposuction was done in all required
areas including upper abdomen, flanks, back and trochanters. Thighs and buttocks were
treated if indicated. Superficial liposculpture as depicted in [Figure 2] was used, especially around bony prominences such as iliac crests, flanks, back
and trochanters. The liposuction was done using MicroAire power assisted device, using
three, four and five calibre, single or double Mercedes cannulae in all patients done
after 2008. Traditional liposuction was done for patients operated between 2006 and
2008 (27 in number). The abdominoplasty flap was raised taking care to leave a layer
of loose areolar tissue and fat behind on the rectus sheath as shown in [Figure 3]. Dissection was done with diathermy and scissors as needed. Perfect haemostasis
was achieved using diathermy and ligatures.
Figure 1: Extent of dissection in typical abdominoplasty. It cannot be compromised in drainless
procedure
Figure 2: Concept of superficial liposculpture – diagrammatic representation. Subdermal liposuction
helps retraction of skin as well as better draping
Figure 3: Flap in abdominoplasty with rectus sheath tightening. Note the amount of flap left
on the sheath which prevents formation of gliding surfaces leading to seroma formation
‘Toilet liposuction’ was done by holding the cannulae in the tunnels of liposuction
– without to-and-fro movement – and sucking out the fluid from time to time throughout
the procedure and during closure. Particular care was taken to rest the cannulae in
flanks and over trochanters to wring out as much fluid as possible. The deep fat at
the lower end of abdominoplasty flap was excised, taking care to preserve superficial
layer of the fascia. Closure was done in multiple layers using Vicryl, PDS, Ethilon
or staplers as required; rolling out accumulated fluid intermittently. Three patients
underwent closure with barbed suture as shown in [Figure 4]. The deepest layer of closure incorporated the loose areolar layer and the rectus
sheath below. Neither Baroudi's sutures/progressive tension sutures nor fibrin glue
were used. All liposuction ports were sutured with 6-0 ethilon. The surgical wound
was dressed with compressive dressing.
Figure 4: Barbed suture for closure used in three patients. Note absence of drains
A thick gumjee sheet, secured with elastic tapes, was used as padding. After shifting
the patient to the room, a custom-made, pre-stitched one in four stretchable lycra
pressure garment was put on, with help of the patient, ensuring a proper fit.
All patients had suturing done in the position of flexion at the hips and the same
was maintained for 18 h that is up to next morning. After that, the flexion was slowly
released and patients were mobilised by late afternoon. Deep vein thrombosis pump
was used during this period to prevent leg vein thrombosis.
The patients were mobilised after 24 h and discharged after 36–48 h after surgery.
They were instructed not to remove garment till 96 h after operation. Follow-ups were
done at 96 h, 10th post-operative day and 14–18th post-operative day to check for following:
(a) The comfort level, (b) incidence of seroma by palpation, (c) wound dehiscence
and (d) discharge.
The usual time of suture removal was 14–18 days after surgery.
RESULTS
The total number of abdominoplasty patients was 204; females – 203, male – 1. No drains
were used in 201 patients (200 females and 1 male).
Drains had to be used only in three female patients, as below:
-
A. Patient underwent Buck's procedure for urinary incontinence. A pelvic drain as
well as subcutaneous drain were used
-
B. Patient had total hysterosalpingo-oophorectomy for dysplasia in large ovarian cyst
found in frozen section. Pelvic and subcutaneous drains were kept. Subcutaneous drain
was removed on 3rd day after effluent dropped to 20 cc. Pelvic drain left in situ for 12 days as advised by the oncosurgeon
-
C. Patient had general oozing despite adequate haemostasis. Hence, the decision was
taken to keep drain.
Amount of lipoaspirate – 5–22 L.
Number of seromas-two, one each in the DRAIN and NON-DRAIN groups.
Wound dehiscence with serous discharge – one.
Patient A in the drains group developed a seroma despite the drain, and it responded
to serial aspiration performed three times. This was the patient who had simultaneous
pelvic procedure done for urinary incontinence by gynaecologist.
The other seroma occurred in non-drain group. The seroma was tapped twice and the
patient asked to wear garment continuously. She presented with inflamed suprapubic
skin and an area of fat necrosis on the 6th day as shown in [Figure 5]. This was managed with excision of the fat and packing the wound with collagen particles
and intrasite gel. The wound healed by 24th day after surgery.
Figure 5: Wound dehiscence in drainless abdominoplasty seen in one patient secondary to seroma
formation. Patient responded to conservative management without surgical intervention
The results of abdominoplasty in certain patients, with respect to age, body mass
index (BMI), type of deformity are shown in [Figures 6]
[7]
[8]
[9]. The post-operative contours are satisfactory, indicating that there is no compromise
in the extent of dissection and liposuction.
Figure 6: Pre- and post-operative pictures of patient shown in [Figures 1]
[3]
[4]
Figure 7: Results of drainless method in mild deformity patients. Patient 1 had umbilical hernia.
Three had only skin excess
Figure 8: Results of drainless method in moderate deformities. Patient 3 had visceral fat deposits
which were responsible for the residual bulge after abdominoplasty. Pre-op counselling
was done
Figure 9: Results in severe deformity patients. Patient-1 had more subcutaneous fat whereas
patient-2 had debulking apronectomy only as this patient had large visceral fat deposits.
Apronectomy was planned for purpose of hygiene and mobility
DISCUSSION
The primary purpose of inserting drain after any operation is to avoid accumulation
of collecting fluid. The collected fluid gets lined by a pseudo capsule and is termed
seroma. The fluid also increases tissue tension and prevents wound healing. The source
of seroma in abdominoplasty is residual infiltrate as well as damaged fat and fluid
secreted in the third space. The third space fluid continues to form in post-operative
period also.
The disadvantages of drains have been widely documented as discomfort, pain, difficulty
in mobilisation and blockage (which defeats their purpose). Drains may cause irritation
of tissues and add to seroma formation, as noted by Koller and Hintringer.[[1]]
Issues we had faced with drains before 2006 were as follows:
-
a. Ineffective – the drains have tendency to get blocked as shown in [Figure 10] – due to clotting of blood inside or due to tissue particles. Attempts to reduce
blockage involved use of powerful floor suction three times daily to charge drains,
removal of tissue using a stillette or by attaching a 50 cc syringe to create powerful
negative force. This would convert a safe closed system to open system with substantial
risk of iatrogenic infection; though none occurred in our patients. Beer and Wallner[[2]] reported reduction of seroma by immobilising the patient for 48 h in a retrospective
study of 60 patients. All these patients had drains, but those who were mobilised
within 24 h had seroma rate of 13%, whereas among those mobilised after 48 h had drop
in the seromas to 0%. They recommended thromboprophylaxis in all patients. This illustrates
inefficacy of drains
-
b. Discomfort – every patient who had drain (before or after 2006 when this series
began); complained of pain ranging from discomfort to pricking sensation or local
pain. The relief after removal of drain was remarkable, only the dull pain of liposuction
remained
-
c. Difficulty in mobilisation – with drains in place, mobilisation of the patients
was cumbersome. The staff had to manage the drains while the patient turned to one
side in bed to get up in post-operative period. Patients were scared of drains getting
pulled out and either declined mobilisation or complained of severe pain
-
d. Breakage and premature extrusion caused concern
-
e. Theoretically, bacterial colonisation could occur, though there is no concrete
evidence that drains cause necrotising fasciitis in post-operative patients. We did
not face infections in any of our abdominoplasty patients
-
f. Increased duration of hospitalisation. However, this by itself is not a major reason
to try to avoid drains.
Figure 10: Drains get blocked with blood clots and tissue particles
Evidence in favour of use of drains is insufficient. Available studies exist, some
in favour and some against use of drains to avoid seromas. Same is true for the question
of drains as source of infection; with or without necrotising fasciitis.
The timing of drain removal is arbitrary. It may depend on drop in the output to a
certain level or change in colour of fluid from reddish to amber to pale yellow. According
to Chim et al.[[3]] removal at a pre-decided fixed time has some supporting evidence.
Rangaswamy[[4]] advocates initial synchronous liposuction, flap elevation at Scarpa's fascia level,
discontinuous incremental flap dissection, vascular preservation and obliteration
of sub-flap suture by multiple sutures for avoiding complications in abdominoplasty.
We had started operating on similar lines from the beginning of our series in 2006.
We considered following aspects while deciding to do away with drains: (This was,
in general, our protocol in liposuction patients from the year 2004 onwards – when
the incidence of seroma had become nil in our practice).
-
a. Incidence of seromas and wound dehiscence has been shown to have reduced, per se, over the years and reduced further with incorporation of thorough liposuction in
abdominoplasty.[[4]]
Najera et al.[[5]] described increase in the incidence of seroma if combined with flank liposuction
and in high BMI patients between 2004 and 2007. Later, the reports clearly show reduction
in average occurrence of seromas across the globe. Heller et al.[[6]] reported that modified transverse abdominoplasty with extensive liposuction was
associated with least complications, including seroma formation, in a retrospective
review in 2008. They compared four groups of patients, namely, liposuction alone,
modified transverse abdominoplasty with and without liposuction and W-pattern abdominoplasty
Stewart et al.[[7]] studied complications in a series of 278 consecutive abdominoplasties and reported
5% seromas, 3% haematoma and infection and 2.5% fat necrosis despite use of drains
in 2006 – probably before the techniques were refined to use small cannulas
-
b. Tumescence is not essential for liposuction.[[8]] If adequate time out is observed after infiltration, one can get bloodless aspirate
and surgical field. Thus, the input fluid was restricted to wet technique. Basically,
tumescence was used for office procedures done under local anaesthesia. Abdominoplasty
is invariably conducted under regional or general anaesthesia where the purpose of
infiltration is mainly to increase turgidity of tissues thus facilitating suction,
rather than providing analgesia for the procedure as in office suctions. In fact,
lower-volume infiltrate is preferred to allow removal of larger volumes without causing
fluid overload. This is everyday experience of any plastic surgeon. We feel wet technique
reduces the amount of fluid that stays in the raw area post-operatively compared to
tumescence
-
c. Smaller cannulas have been documented to avert tissue damage and ensuing complications,
as shown by Teimourian and Rogers[[9]]
-
d. Superficial liposculpturing has been shown to create thin flaps that conform to
bony contours giving better apposition of raw surfaces by Gasperoni et al.[[10]
[11]] Najera et al.[[5]] has shown increased incidence of seroma when flank liposuction is done in abdominoplasty.
We think this happens because of thick flaps resulting from lack of suction of the
superficial layers that do not conform to bony contours. The resultant space due to
rigidity of the flap fills up with seroma. Zhang et al.[[12]] mention difference between stiff and areolar superficial layer and deep lamellar
layer of fat separated by superficial fascial system
-
e. Full dissection as needed for the type of abdomen was done to produce best possible
contour. Flaps were elevated at level of Scarpa's fascia leaving a significant amount
of loose areolar tissue and some fat on rectus sheath. Najera et al.[[5]] as well as Koller and Hintringer[[1]] mention similar technique and omitting use of drains. Antonetti and Antonetti[[13]] postulated that seromas form when there is no adhesion between flap and the underlying
tissues with shearing movements between them, especially when both surfaces are gliding.
Our experience is commensurate with this. Baroudi and Ferreira[[14]] in their original article indicate that fat-to-fat apposition along with progressive
quilting has a role in the prevention of seroma
-
f. Progressive quilting, to relieve tension on the incision and to improve apposition
of raw areas, averts seromas – as reported by several authors. However, we found quilting
to be time-consuming and tedious. Before the current series, a few cases were indeed
done with quilting, but those are not included here. Number of studies show efficacy
of barbed sutures in the prevention of seroma in controlled trials with and without
drains. Mohan et al.,[[15]] Drury Phillippa,[[16]] Nahas et al.,[[17]] Arantes et al.,[[18]] Pollock and Pollock,[[19]] Marsh et al.[[20]] and Mohan as well as Liang et al.[[21]] have shown usefulness of quilting barbed sutures in avoiding drains in abdominal
donor areas of flap used in radical mastectomy reconstructions
-
g. Another option to reduce the need for drains is fibrin sealant,[[22]] but it is clearly shown to have higher incidence of seroma compared to drains and
quilting sutures groups as shown by Bercial al.[[23]] in a triple arm study. Even in the original prospective study by Hunstad et al.,[[22]] 27.3% of the patients in whom urethane-based sealant was used, needed needle aspiration
of fluid. We had similar experience while trying fibrin glue in skin grafting cases
where excess sealant was found to form seromas, lifting the graft
-
h. Finally, we decided to reduce the quantity of fluid left behind at the end of procedure
by undertaking ‘toilet liposuction’ in addition to rolling the fluid out. The concept
of toilet liposuction was born because of observation that if one restarts liposuction
in an area that was treated a little while back, a lot of thinner lipo-aspirate can
be removed. So to remove the residual fluid, cannula is left in one of the tunnels
with suction on. As there is no to-and-fro movement, more fat is not damaged but third
space fluid keeps coming. The interlobular septae being semi-permeable, it is possible
to empty a large area by this method.
Toilet liposuction in the dependent areas like flanks and non-retractile areas like
trochanter is done intermittently all through the procedure, and especially towards
end when the suturing starts; for removal of residual and secreted fluid as well as
broken fat. The author recommends use of this new term and technique.
After closure is completed in multiple layers, with deepest layer incorporating the
aponeurosis, the residual fluid is encouraged to be reabsorbed by the use of a well-fitting
pressure garment.
Klein[[24]] has described fluid shifts and post-operative fluid balance and mechanism of absorption
of the residual volume. We also close all suction ports with single 6-0 ethilon stitch.
Teimourian[[8]] found 6% incidence of seroma in his own cases despite use of drains. A national
survey of complications associated with suction lipectomy reported 1.2% incidence
of seroma (935 plastic surgeons with data on 26,562 patients.) The authors, Teimourian
and Rogers.[[9]] felt that seroma was underreported. In our series, one patient had seroma despite
drains, and it responded to multiple aspirations and debridement of small area of
necrosed fat. The wound healed without any surgical intervention.
In an interesting paper, Zuelzer et al.[[25]] have demonstrated lower wound complication rate in patients with BMI above 40.
In our series also, high BMI panniculectomies healed well despite the absence of drains.
Zuelzer et al. have also demonstrated significant reduction in incidence of abdominoplasty complications
from 40% in a study in 1999 to 9% in a study from 2003 to 2008; in high BMI patients.
CONCLUSION
In a vast majority of patients undergoing abdominoplasty with liposuction, insertion
of drains is unnecessary. Avoidance of drains was not found to be associated with
seroma formation or wound-related complications. Although author would put a drain
in case of doubt, first priority is to eliminate common reasons for the doubt, namely,
excessive infiltration; gliding, thick and rigid flaps; poor haemostasis. Manoeuvres
including toilet liposuction, multi-layered suturing with adequate tension relief,
early mobilisation and uninterrupted 4-day pressure garment support help eliminate
need for the drains without compromising extent of dissection and the final aesthetic
result. Heat-based liposuction techniques like Vaser and laser would probably leave
too much damaged tissue to be benefited by this policy.
Financial support and sponsorship
Nil.
