Running barbed suture quilting reduces abdominal drainage in perforator-based breast reconstruction

Initial Experience with Unidirectional Barbed Suture for Abdominal Donor Site Closure in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Background

The deep inferior epigastric perforator (DIEP) flap is a predominant technique for autologous breast reconstruction. However, the best method of abdominal fascial closure in this technique is not well defined. This study details our initial experience with unidirectional barbed suture-only repair of abdominal donor site fascia.

Methods

Patients who underwent DIEP flap breast reconstruction and abdominal fascial closure with Stratafix Symmetric Polydioxanone PDS Plus were retrospectively reviewed. Information regarding pertinent patient history, medical comorbidities, risk factors, and surgical technique was extracted, along with the incidence of eight separate postoperative abdominal surgical site occurrences.

Results

Retrospective review identified 43 patients who underwent 19 unilateral and 24 bilateral DIEP flap breast reconstruction procedures (n = 67). Average patient follow-up was 791 days (range 153-1769). Six patients (14%) had a complication of the donor site. Seroma was most frequent (n = 3, 7%), followed by surgical site infection (n = 2, 5%). One patient had incisional dehiscence (2%) and another patient developed bulging (2%). No patients had chronic pain, weakness, hematoma, or hernia postoperatively. Patients with donor site complications had a history of abdominal/pelvic surgery significantly more often than the patients without donor site complications (100% versus 49%; P = 0.032).

Conclusions

Abdominal fascial repair with Stratafix Symmetric suture alone led to low rates of abdominal donor site morbidity, including no hernia and rare bulging, following DIEP flap breast reconstruction. Additional advantages of this technique may be reduced operative times and lower operative costs compared with alternative methods of fascial repair, although prospective and randomized studies are warranted.

Safety of Drainless Donor Closure in DIEP Flap-Based Breast Reconstruction: A Prospective Analysis Using Ultrasound

BACKGROUND

 Although drainless donor closure with progressive tension suture (PTS) technique has been attempted to further reduce donor morbidity in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, its clinical safety has not yet been fully elucidated. This study prospectively investigated donor morbidity after DIEP flap elevation and drain-free donor closure.

METHODS

 A prospective cohort study was performed on 125 patients who underwent DIEP flap-based breast reconstruction and drainless donor closure. Postoperatively, the donor site was evaluated repetitively using ultrasonography. Development of donor complications, including any fluid accumulation and seroma (defined as detection of fluid accumulation after postoperative one month), was prospectively noted, and independent predictors for the adverse events were evaluated.

RESULTS

 On ultrasound examination conducted within postoperative 2 weeks, 48 patients were detected to have fluid accumulation at the donor site, which were more frequently detected in cases of delayed reconstruction and those with lesser number of PTS conducted. The majority of those events (95.8%) were resolved with one- or two-times ultrasound-guided aspirations. Five patients (4.0%) showed persistent fluid accumulation after postoperative 1 month, which were successfully treated with repetitive aspiration without requiring reoperation. No other abdominal complications developed except for three of delayed wound healing. On multivariable analyses, harvesting larger-sized flap and conducting lesser number of PTS were independent predictors for the development of fluid accumulation.

CONCLUSION

 The results of this prospective study suggest that drainless donor closure of the DIEP flap with meticulous placement of PTS followed by postoperative ultrasound surveillance appears to be safe and effective.

Effectiveness and safety of knotless barbed sutures in cosmetic surgery: A systematic review and meta-analysis

BACKGROUND

The barbed suture, which can eliminate knot tying and accelerate the placement of sutures, is an innovative type of suture, whereas the benefits of cosmetic surgeries (CS) are controversial. This study aimed to comprehensively evaluate the effectiveness and safety of barbed sutures in CS.

METHOD

PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched for English studies comparing the use of barbed with conventional sutures in CS up to October 2020. The updated Cochrane risk-of-bias tool (ROB2.0) and Newcastle-Ottawa Scale (NOS) were utilized to evaluate the risk of bias. Subgroup analysis was performed according to study designs and barbed suture types.

RESULTS

A total of 14 studies, including 5 randomized controlled trials and 9 cohort studies, were included (risk of bias: moderate to low), representing 2259 patients. The barbed suture was identified to reduce suture time (mean difference [MD]=-6.18, 95% confidence interval [CI]: -8.75 to -3.60, P < 0.00001) and operative time (MD=-10.80, 95% CI: -20.83 to -0.76, P = 0.03) without increasing the hospital stays and total postoperative complications (most were Clavien I and IIIa). No significant difference was detected for incisional infection, delayed wound healing, and hematoma; however, increasing incidence of wound dehiscence (odds ratio [OR]=1.60, 95% CI: 1.09-2.34, P = 0.02) and suture extrusion (OR=3.97, 95%CI: 1.96-8.04, P = 0.0001) were found, particularly in the unidirectional barbed suture subgroup. Barbed sutures might also help CS advance and reduce seroma formation.

CONCLUSION

The barbed suture was effective in CS; however, its safety needs to be cautiously interpreted as it might be related to more wound dehiscence and suture extrusion despite similar total postoperative complications with conventional sutures. This study might provide important references for decision-makers and clinicians, though further evidence of randomized design, larger sample size, longer follow-up, and standardized rating approaches are warranted.

Are Surgical Drains Needed in DIEP Flap Surgery? The Drain-Free DIEP Flap Concept

BACKGROUND

Studies support an inherent morbidity associated with the use of surgical drains-such as postoperative pain, infection, reduction in mobility, and delay in patient discharge-and they do not prevent seroma or hematoma. The authors' series aims to evaluate the feasibility, benefits, and safety of performing drainless deep inferior epigastric perforator (DIEP) flap surgery and to formulate an algorithm for when this can be used.

METHODS

A retrospective review of DIEP reconstruction outcomes of two surgeons was performed. Over the course of 24 months, consecutive DIEP flap patients were included from the Royal Marsden Hospital in London and Austin Hospital in Melbourne, and drain use, drain output, length of stay (LOS), and complications were analyzed.

RESULTS

A total of 107 DIEP flap reconstructions were performed by two surgeons. Thirty-five patients had abdominal drainless DIEP flaps, and 12 patients had totally drainless DIEP flaps. Mean age was 52 years (range, 34 to 73 years) and mean body mass index was 26.8 kg/m 2 (range, 19.0 to 41.3 kg/m 2 ). Abdominal drainless patients showed a potential trend toward shorter hospital stays as compared with the ones with drains (mean LOS, 3.74 days versus 4.05 days; P = 0.154). Totally drainless patients had an even shorter, statistically significant, mean LOS of 3.10 days, as compared with patients with drains (4.05 days, P = 0.002), with no increase in complications.

CONCLUSIONS

The avoidance of abdominal drains in DIEP flaps reduces hospital stay without increasing complications, and this has become our standard practice for patients with a body mass index of less than 30 kg/m 2 . It is our opinion that the totally drainless DIEP flap procedure is safe in selected patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

"Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review

The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy.

Methods

MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al.

Results

There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin.

Conclusions

The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.

Trends and Innovations in Autologous Breast Reconstruction

More than 40 years have passed since the description of the first "free abdominoplasty flap" for breast reconstruction by Holmström. In the meantime, surgical advances and technological innovations have resulted in the widespread adoption of autologous breast reconstruction to recreate the female breast after mastectomy. While concepts and techniques are continuing to evolve, maintaining an overview is challenging. This article provides a review of current trends and recent innovations in autologous breast reconstruction.

EFFECTS OF DIEP FLAP-BASED BREAST RECONSTRUCTION ON RESPIRATORY FUNCTION

BACKGROUND

Breast reconstruction (BR) is an essential part of breast cancer treatment, and the DIEP flap is considered the gold standard reconstruction technique, which uses a free abdominal flap. Concerns have been raised regarding the effects of abdominoplasty on respiratory functions. This topic has not been addressed regarding donor-site closure of DIEP flaps. Our aim is to prospectively compare preoperative and postoperative spirometry in patients undergoing DIEP flap-based BR, investigating its impact on respiratory function.

MATERIALS AND METHODS

We enrolled 21 patients who received BR with DIEP flap in our institution, who underwent pulmonary function assessment by spirometry 1 month preoperatively and 1 year postoperatively. We assessed Forced Expiratory Volume in the first second (FEV1), Forced Vital Capacity (FVC), FEV1/FVC ratio, and Peak Expiratory Flow (PEF). Statistical analysis was performed using the paired samples test.

RESULTS

An improvement in the mean values of all 4 variables was found at 1 year from surgery. Namely, FEV1 improved by 0.1 L with a standard deviation (SD) of 0.39 L, FVC by 0.04 L with SD of 0.627, FEV1/FVC by 2.11 L with SD of 7.85 L, and PEF by 1.2 L with SD of 1.45 L. Only PEF was statistically significant [P = 0.001].

CONCLUSION

Our results suggest that DIEP flap BR does not negatively impact respiratory function. Although further knowledge is required, we confirm the possibility of considering the indication for abdominoplasty and DIEP flap reconstruction in patients with altered and reduced pulmonary function.

Comparing Seroma Formation at the Deep Inferior Epigastric Perforator, Transverse Musculocutaneous Gracilis, and Superior Gluteal Artery Perforator Flap Donor Sites after Microsurgical Breast Reconstruction

Background  Seroma formation is the most common donor site complication following autologous breast reconstruction, along with hematoma. Seroma may lead to patient discomfort and may prolong hospital stay or delay adjuvant treatment. The aim of this study was to compare seroma rates between the deep inferior epigastric perforator (DIEP), transverse musculocutaneous gracilis (TMG), and superior gluteal artery perforator (SGAP) donor sites. Methods  The authors conducted a retrospective single-center cohort study consisting of chart review of all patients who underwent microsurgical breast reconstruction from April 2018 to June 2020. The primary outcome studied was frequency of seroma formation at the different donor sites. The secondary outcome evaluated potential prognostic properties associated with seroma formation. Third, the number of donor site seroma evacuations was compared between the three donor sites. Results  Overall, 242 breast reconstructions were performed in 189 patients. Demographic data were found statistically comparable between the three flap cohorts, except for body mass index (BMI). Frequency of seroma formation was highest at the SGAP donor site (75.0%), followed by the TMG (65.0%), and DIEP (28.6%) donor sites. No association was found between seroma formation and BMI, age at surgery, smoking status, diabetes mellitus, neoadjuvant chemotherapy, or DIEP laterality. The mean number of seroma evacuations was significantly higher in the SGAP and the TMG group compared with the DIEP group. Conclusion  This study provides a single center's experience regarding seroma formation at the donor site after microsurgical breast reconstruction. The observed rate of donor site seroma formation was comparably high, especially in the TMG and SGAP group, necessitating an adaption of the surgical protocol.

Postoperative Showering for Patients With Closed Suction Drainage: A Retrospective Cohort Study of Deep Inferior Epigastric Perforator Flap Breast Reconstructions

Background

The deep inferior epigastric perforator (DIEP) flap has been widely used in breast reconstruction. During surgery, many surgeons use closed suction drainage for both the donor site and the reconstructed breast. However, the criteria for drainage removal depend on the surgeon’s preference and remain controversial. Moreover, it is well known that early postoperative showering is harmless to the surgical site and is recommended in many reports. However, it has not been discussed whether it is acceptable for patients with closed suction drainage to take a shower.

Methodology

We conducted a retrospective study of postoperative showering in 30 patients who underwent breast reconstruction with a DIEP flap. During the surgery, a total of three closed suction drains were connected to the patient’s body (one was connected to the reconstructed breast, and the other two were connected to the abdominal donor site). After the surgery, patients were allowed to shower when the number of connected drainage tubes was ≤2.

Results

The patients were divided into three groups according to the number of remaining drainage tubes connected to their bodies when they started postoperative showering. Group A included patients with no drainage tubes. Group B included patients with one remaining drainage tube. Group C included patients with two drainage tubes. No significant differences in the incidence of postoperative individual complications were observed among the three groups.

Conclusions

Postoperative showering for patients with closed suction drainage is safe and does not increase the incidence of postoperative complications, including surgical site infection.

Randomized Single-Center Study of Effectiveness and Safety of a Resorbable Lysine-Based Urethane Adhesive for a Drain-Free Closure of the Abdominal Donor Site in a DIEP Flap Breast Reconstruction Procedure

OBJECTIVE

The hypothesis of this parallel group randomized trial testifies if TissuGlu is a safe and an effective alternative to the conventional drainage placement in regard to post-operative fluid management in the abdominal donor site for autologous (DIEP flap) breast reconstruction with a higher postoperative patient quality of life.

PATIENTS AND METHODS

Data was collected for 58 women who required to be at min.18 years old with a BMI < 30 and not taking any SSRIs (Selective Serotonin Reuptake Inhibitors).Exclusion criteria: Discharge with indwelling suction drains at the abdominal site or signs of wound infection during hospital stay.The patients were randomized into a study group (donor site closure with application of surgical adhesive without drains) and a control group (donor site closure with drains) using a randomly sorted sealed envelope system.Th e primary outcome was defined as the number of post-operative seroma formations.The secondary endpoint was the evaluation of patient satisfaction with both methods.

RESULTS

58 patients underwent a DIEP reconstruction (29 in the control- and 29 in the study group).Both groups were homogenous. Rate of seroma was 17%(5/29) in the study group and 10%(3/29) in the control group which showed no statistical significance (p-value = 0.71).Smoking and previous abdominal surgery turned out to be a risk factor for seroma formation in the study group.Overall satisfaction was evaluated with a questionnaire and was higher in the study group.

CONCLUSION

The abdominal closure with the surgical adhesive seems to be a safe procedure that contributes to patient satisfaction and increases the independence upon discharge in patients with adequate inclusion criteria.

The Drain Dilemma: A Systematic Review and Meta-Analysis of Drain-Free Abdominal Closure With Progressive Tension Sutures Against Drain-Assisted Closure for Abdominal Flaps in Breast Reconstruction

The use of abdominal drains in donor site closure following breast reconstruction with abdominal flaps is widespread. Our review aimed to compare the outcomes of donor site closure with and without the use of abdominal drains following breast reconstruction with abdominal flaps.

Randomized, non-randomized, and observational studies that compared the use of drains vs. no drain in breast reconstruction were included by searching MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL).

Four studies enrolling 327 participants were identified. A statistically significant difference was found in terms of duration of hospital stay favouring abdominal closure without the use of drains (MD = -1.15, 95% CI = -1.88 tom-0.42, P=0.002), with a similar difference found in terms of overall complication rate (OR = 0.44, 95% CI = 0.23 to 0.83, p=0.01). Likewise, a statistically significant difference was found favouring abdominal closure without the use of drains for the secondary outcome of operative time (MD = -55.95, 95% CI = -107.19 to -4.74, p=0.03).

Abdominal closure without drains following breast reconstructions with abdominal flaps is superior to closure with drains.

Local Triamcinolone Treatment Affects Inflammatory Response in Seroma Exudate of Abdominoplasty Patients: A Randomized Controlled Trial

BACKGROUND

As the leading complication of abdominoplasty, seroma formation might represent an inflammatory process in response to surgical trauma. This prospective randomized trial investigated whether local administration of the antiinflammatory agent triamcinolone could prevent seroma accumulation.

METHODS

Weekly and cumulative seroma volumes were compared between the study groups A, B, and C over a 4-week follow-up (group A, with drain, without triamcinolone; group B, without drain, without triamcinolone; group C, without drain, with triamcinolone). Aspirated seroma samples were analyzed by enzyme-linked immunosorbent assay for selective inflammatory mediators.

RESULTS

Triamcinolone significantly reduced cumulative seroma volume (n = 60; mA 845 ± SDA 578 ml, mC 236 ± SDC 381 ml, p = 0.001). The most accentuated suppressive effect of triamcinolone was observed shortly after the treatment (week 1) (mA1 616 ± SDA1 457 ml, mB1 153 ± SDB1 161 ml, mC1 22 ± SDC1 44 ml, pA1/C1 < 0.001, pB1/C1 = 0.014). Local triamcinolone administration resulted in a differential concentration of interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9 (week 1) in seroma exudate as measured by enzyme-linked immunosorbent assay (mIL-6A1 1239 ± SDA1 59 pg/ml, mIL-6C1 848 ± SDC1 80 pg/ml, p < 0.001; mMMP-9A1 2343 ± SDA1 484 pg/ml, mMMP-9C1 376 ± SDC1 120 pg/ml, p = 0.001).

CONCLUSIONS

Local administration of 80 mg of triamcinolone reduced postabdominoplasty seroma accumulation significantly. Under triamcinolone treatment, suppressed levels of IL-6 and MMP-9 in seroma fluid were observed. Notably, inflammatory marker suppression correlated clinically with a decrease in seroma accumulation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

How to Maximize Aesthetics in Autologous Breast Reconstruction

With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.

Influence of closed incision negative-pressure therapy on abdominal donor-site morbidity in microsurgical breast reconstruction

INTRODUCTION

Closed incision negative-pressure therapy (CINPT) has been shown to shorten the time to heal in post-bariatric abdominoplasty and to lower seroma rates in cosmetic abdominoplasty. The objective of this study was to assess the effect of CINPT on donor-site morbidity following abdominal-based free-flap breast reconstruction.

PATIENTS AND METHODS

We reviewed medical records from 225 women who had undergone 300 microsurgical free-flap breast reconstructions from the abdomen from November 1, 2007 to March 31, 2019. Patients were grouped according to wound therapy, including 127 patients in the standard of care group and 98 patients in the CINPT group. Primary outcomes were minor (non-operative) and major (operative) surgical site complications. Secondary outcomes were time to drain removal, in-hospital length, and scar quality.

RESULTS

Analysis of patient demographics showed an equal distribution with regard to the age, smoking status, prevalence of diabetes mellitus, preoperative chemotherapy, and previous abdominal surgery in both groups. Significantly more patients with obesity (29.6 vs. 15.8%; p = .01) and bilateral breast reconstruction (40.8 vs. 27.6%; p = .04) were included in the CINPT group. Compared to standard of care, the CINPT group had a lower incidence of major surgical site complications (26.0 vs. 11.2%; p = .001). There was no difference in minor surgical site complications and secondary outcomes between groups.

CONCLUSION

The CINPT represents a reliable tool to reduce surgical site complications on the abdominal donor-site in abdominal-based free-flap breast reconstruction.

No-drain Technique in Abdominal Closure for Breast Reconstruction: Lower Complication Rate, Shorter Hospitalization Stay

Background:

Progressive tension suture (PTS) technique in cosmetic abdominoplasty is safe in terms of seroma rates. This was extrapolated to deep inferior epigastric perforator (DIEP) flap donor site closure. No study to our knowledge has analyzed the PTS technique alone without drains in transverse rectus abdominis musculocutaneous (TRAM) flap donor sites. We aim to show that no-drain closure has similar complication rates and this may be applied to TRAM flaps safely even though they have higher drain output.

Methods:

A single-center, single-surgeon retrospective study was performed over 4 years. Patients undergoing breast reconstruction with an abdominal flap were included. Data collected included patient's demographics, type of flap, usage of drains or PTS technique, drain output, date of fitness for discharge, date of discharge, and seroma rates. The outcomes studied were drain volumes, seroma rates, and duration of hospital stay.

Results:

Fifty patients were recruited. The first 25 patients (13 DIEP and 12 TRAM) underwent conventional closure. The subsequent 25 patients (17 DIEP and 8 TRAM) underwent PTS technique. TRAM flaps had higher drain volume (785.6 mL) compared to DIEP flaps (366.2 mL) (P = 0.047). No patients developed a seroma. Patients who underwent the PTS technique had lower abdominal-specific complications (P = 0.021). Patients without drains were discharged faster at 5.4 versus 8.2 days (P ≤ 0.001).

Conclusions:

Patients who underwent the PTS technique had lower complication rates, faster time to fitness for discharge and shorter hospitalization stay. The PTS technique may be applied to TRAM flaps safely.

External Quilting: New Technique to Avoid Haematoma in Gynaecomastia Surgery

BACKGROUND

Haematoma after gynaecomastia surgery is the most common early complication. It may necessitate a return to the theatre and cause increased infection risk, poor wound or delayed healing, and abnormal scar. Strategies to avoid haematoma range from perioperative blood pressure control to the use of tranexamic acid and compressive dressings.

OBJECTIVE

To demonstrate a new technique that would avoid haematoma or limit its expansion should it occur, after gynaecomastia surgery.

METHODS

One hundred and forty-nine patients had surgery for gynaecomastia between 2018 and 2019 by the senior author. External quilting sutures are used to obliterate any dead space following liposuction and piecemeal excision to address fatty, stromal, and glandular components. No drains are used. Patients receive cooling therapy before discharge, and they reattend clinic the following day for suture removal.

RESULTS

Two patients had haematomas which were managed conservatively and healed well. Fine suture tracks, which were observed in another two patients, became unnoticeable at 3 months. Overall, the complication rate in our cohort was 2.7% (haematoma 1.3%, temporary suture track 1.3%).

CONCLUSIONS

Our method is useful in minimising haematoma. It limits expansion of haematoma should it occur. Suture track is the other transient complication. This new technique in gynaecomastia correction is simple, yields good results, and gives the surgeon another option to deal with haematoma.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The use of surgical site drains in breast reconstruction: A systematic review

BACKGROUND

Use of drains has been advocated in order to prevent seroma and hematoma; however, specific recommendations vary widely. The goal is to perform a systematic analysis of published literature on the use of drains for breast reconstruction.

METHODS

The literature search was performed according to the PRISMA guidelines. The search included the Cochrane Library, Embase, and Pubmed databases using the terms "breast reconstruction" and "breast flap" combined with "drain", "seroma," and "seroma prevention". The references were appraised in two rounds, by two independent reviewers; studies were included/excluded based on relevance of title and subsequently by the content of their abstracts/manuscripts. Outcomes regarding seroma, infection rate, length of stay (LOS), drainage, reconstruction type and complications were analyzed.

RESULTS

Of 2252 studies identified via search, 64 were relevant and 21 met inclusion criteria. Most of the study designs were case series or retrospective cohort studies (Level of Evidence III or IV), with the exception of one prospective randomized-controlled trial. Seroma rate was given in 18 studies, infection rate in 11, and criteria for drain removal in 19. Reoperation rate was available in 7 and LOS in 18 studies. The majority of studies (13) agreed to remove the drain when the output was less than 30 ml/24 h. Drain output was reported in 11, and 20 reported drain type used.

CONCLUSION

There is sparse literature available with which to make evidence-based guidelines. A standardized guideline for reporting drain use is crucial to providing a better understanding of complications in breast reconstruction related to surgical drains.

Can drains be avoided in lipo-abdominoplasty?

Context:

Seroma formation is a common complication after lipoabdominoplasty. Conventionally, drains have been placed to prevent seroma; however, there are problems with drains, namely, pain, compromised mobilisation, breakage, tissue irritation and infection. Strategies to prevent seroma, such as the use of glue or quilting sutures have all been attempted with variable and unpredictable benefit.

Aims:

The author extrapolated the experience with own liposuction protocols to lipoabdominoplasty and began doing away with drains from the year 2006 onwards unless absolutely indicated. Incidence of complications is evaluated here.

Settings and Design:

This retrospective study is the report of our experience with 204 lipoabdominoplasties performed since 2006 upto December 2016.

Subjects and Methods:

Consecutive abdominoplasty patients were evaluated for seroma formation, wound dehiscence till suture removal. Nuances of operative details that helped avoid drains were contemplated.

Results:

Only one patient who had drainless abdominoplasty had seroma formation and wound dehiscence.

Conclusions:

We found that (a) 'toilet liposuction', (a term the author would like to introduce) (b) multilayer wound closure without tension, (c) avoidance of gliding surfaces d) continuous use of pressure garment for 4 days post-operative and (e) reducing the amount of infiltration are the key factors in avoidance of collections and thus seroma formation. If such a technique is diligently followed, desired results are obtained; yet there is no need to insert drains in most patients. Reducing the need of drains permits early ambulation and better patient comfort without seroma and other complications.

Seroma Rates Are Not Increased When Combining Liposuction With Progressive Tension Suture Abdominoplasty: A Retrospective Cohort Study of 619 Patients

BACKGROUND

Several studies have demonstrated that progressive tension sutures (PTS) reduce seroma. Many fear that adding liposuction to abdominoplasty will increase seroma rates and avoid drainless abdominoplasty when performing concomitant liposuction.

OBJECTIVES

We sought to identify whether liposuction increases seroma in PTS and non-PTS abdominoplasty.

METHODS

In this retrospective study, 619 patients underwent abdominoplasty between 2009 and 2017, of which 299 patients had drainless abdominoplasty with PTS and 320 had drain-based abdominoplasty. We compared complications among PTS patients with and without liposuction and among drain-based abdominoplasty patients with and without liposuction.

RESULTS

Demographics were similar between PTS and drain patients and between liposuction and nonliposuction PTS. Mean liposuction volume with PTS was 1592 ± 1048 mL. Seroma in the PTS group was found to be 2.6%, which is consistent with previous data. PTS without liposuction had a rate of seroma of 6.67% compared to a rate of 2.2% with liposuction; these rates were not significantly different (P = 0.20). A total of 207 patients had drain-based abdominoplasty with liposuction, and 113 had it without liposuction. Seroma with liposuction was 9.17% and without liposuction was 6.19%, although these differences were not significant (P = 0.52). PTS lipoabdominoplasty had less seroma compared with drain-based lipoabdominoplasty (P = 0.01).

CONCLUSIONS

Liposuction was performed in 80% of the patients, and patients with lipoabdominoplasty were not at a higher risk of seroma, in the drain group or the PTS group. More patients may allow validation that liposuction may actually be protective with PTS. Regardless, there is no increase in seroma with the addition of liposuction to PTS drainless abdominoplasty.

LEVEL OF EVIDENCE 3

The Influence of a Pfannenstiel Scar on Venous Anatomy of the Lower Abdominal Wall and Implications for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

BACKGROUND

A Pfannenstiel incision involves the obstruction of superficial venous pathways and functional diversion of flow through alternative pathways and adjacent vessels. This study investigated the effect of a prior Pfannenstiel incision on venous anatomy of the lower abdominal wall; specifically, the superficial inferior epigastric vein (SIEV), using computed tomographic angiography.

METHODS

A case-control study was performed of 50 patients with Pfannenstiel scars and 50 age-matched, body mass index-matched control patients without Pfannenstiel scars. The authors compared the number of direct/indirect and total communications between the SIEV and deep inferior epigastric artery perforator (DIEP) venae comitantes, midline crossover, and other SIEV-related anatomical changes by using computed tomographic angiography. Flap-related clinical outcomes and donor-site-related complications were also assessed.

RESULT

The median number of direct and total communications between the SIEV and DIEP venae comitantes in the study group was greater than in the control group. The percentage of SIEVs having more than two branching patterns per hemiabdomen was significantly higher in the study group than in the control group. The study group also showed a significantly lower rate of fat necrosis compared with the control group (p = 0.03). The rate of donor-site seroma was significantly higher in the study group.

CONCLUSION

This study suggests that the presence of a Pfannenstiel scar may promote the development of direct and total communications between the SIEV and DIEP venae comitantes and branching within the SIEV in the lower abdominal wall, which may facilitate venous drainage of adipose tissue in DIEP flap breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.