The no-drain, no-quilt abdominoplasty: a single-surgeon series of 271 patients

Drains in Abdominoplasties: The Less the Better?

BACKGROUND

Drains are traditionally inserted during surgery for reduction of fluid accumulation in the post-operative period. The appearance of drained fluids and their quantity can be early predictors of complications. Over the years, several studies have been conducted in attempt to determine the optimal number of drains that result in low rates of fluid accumulation with minimal impairment of quality of life.

PURPOSE

Determine the optimal number of suction drains in abdominoplasty procedures.

METHODS

Retrospective cohort study, analyzing all abdominoplasty patients operated by a single surgeon. Patients were stratified into 3 groups based on number of drains inserted at the end of the procedure. Rate of complications was compared between the groups and a multivariate logistic regression model was computed for the development of complications.

RESULTS

Seven-hundred and forty three patients were included in the analysis of this study. No drains were inserted in 355 patients (45%), whereas a single drain was inserted in 153 (20.6%) 2 drains in 255 patients (34.4%). Patients for whom a single drain was inserted intra-operatively, experienced at a statistically significant lower rate, surgical site infections (OR = 0.235), hypertrophic scars (OR = 0.326), wound dehiscence (OR = 0.272), as compared to patients with no drains. On the contrary, insertion of single drain was associated with a statistically significant higher risk for development of seroma (OR = 6.276) and the need for revision surgery (OR = 2.452).

CONCLUSION

Insertion of a single drain is associated with a lower risk of SSI and wound- dehiscence, but a greater risk for seroma development that requires surgical intervention.

LEVEL OF EVIDENCE II

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.

Emesis as a Risk Factor for Postoperative Hematoma in Abdominoplasty: A Retrospective Study in 189 Cases

Background

Among aesthetic procedures, abdominoplasty is associated with an increased complication rate. In general, postoperative nausea and vomiting is frequently experienced. As vomiting increases the intraabdominal pressure and blood pressure, and results in an increased mechanical friction on the abdominal wall, intraoperatively ligated vessels are prone to reopen. However, previous studies have not investigated the impact of postoperative emesis on postoperative hematoma in patients undergoing abdominoplasty.

Methods

We performed a retrospective analysis on all patients who underwent abdominoplasty between 2017 and 2019 in our institution. Patients were divided into two groups, group 1 including patients experiencing postoperative vomiting and group two including patients without postoperative vomiting. Data extraction focused on patient characteristics, intraoperative characteristics, and postoperative complications, particularly the proportion of patients developing postoperative hematoma. Finally, statistical analysis was performed to analyze the impact of postoperative vomiting on the risk to develop a postoperative hematoma.

Results

We identified 189 patients fitting our inclusion criteria. Overall, the proportion of postoperative hematoma was 13.7%. Thereby, a statistically significant difference was found between both groups: 62.5% of patients in group 1 (vomiting group) and only 9.25% in group 2 (nonvomiting group) developed a postoperative hematoma [odds ratio: 16.4 (95% confidence interval, 5.3-50.9), P < 0.000001].

Conclusion

In patients undergoing abdominoplasty, postoperative vomiting increases the risk to develop a postoperative hematoma.

The Effect of Drains and Compressive Garments Versus Progressive Tensioning Sutures on Seroma Formation in Abdominoplasty

Seroma is a common problem following abdominoplasty surgery. Both compressive garments with drains and progressive tension sutures have their advocates to minimise seroma formation. This is a retrospective study in which patients underwent an identical surgical procedure, except for use of drains and garments in comparison to progressive tension sutures between 2005 and 2020. Two hundred thirty-two patients were included in the study 61 in the drains and garment group (DG group), and 171 with progressive tension sutures (PTS group) alone. There was a lower incidence of seroma formation in the PTS group (X2 (1, N = 232) = 6.35, P = .012). The weight of tissue excised in the PTS group was greater than the DG group (P < .001). There was there a significantly higher tissue excision weights for patients who developed a seroma, compared with those who did not (P=.02). Patients, who developed a seroma in the PTS group, had significantly greater excision weights than the DG group. Liposuction did not change the incidence of seroma in each group (X2 (4, N = 232) = 6.701, P = .08 n/s). This study demonstrates the effectiveness of progressive tension sutures in reducing the incidence of seroma formation following abdominoplasty, particularly when large excision weights are involved. The addition of small volume liposuction distant to the abdominal flap does not increase the incidence of seroma formation.Level of Evidence III 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 .

Clinical Evaluation of 310 Abdominoplasties and Measurement of Scar Level

BACKGROUND

Most published studies on abdominoplasty focus on methods to reduce the risk of seromas. These methods include limited dissection (lipoabdominoplasty), quilting sutures, and preservation of the Scarpa fascia. Quantitative evaluation of the aesthetic result has been lacking.

METHODS

A retrospective study was undertaken of all patients undergoing abdominoplasty in the author's practice from 2016 to 2022. A full abdominoplasty was performed, usually with liposuction (87%). All patients were treated under total intravenous anesthesia without paralysis or prone positioning. A single closed suction drain was removed 3 or 4 days after surgery. All procedures were performed as outpatients. Ultrasound surveillance was used to detect any deep venous thromboses. No patient received chemoprophylaxis. The operating table was flexed, often to 90°. Deep fascial anchoring sutures were used to attach the Scarpa fascia of the flap to the deep muscle fascia. Measurements of the scar level were made at intervals after surgery up to 1 year.

RESULTS

Three hundred ten patients were evaluated, including 300 women. The mean follow-up time was 1 year. The overall complication rate, which included minor scar deformities, was 35.8%. Five deep venous thromboses were detected. There were no hematomas. Fifteen patients (4.8%) developed seromas that were successfully treated by aspiration. The mean vertical scar level 1 month after surgery was 9.9 cm (range, 6.1-12.9 cm). There was no significant change in scar level at subsequent follow-up times up to 1 year. By comparison, the scar level in published studies ranged from 8.6 to 14.1 cm.

DISCUSSION

Avoidance of electrodissection reduces tissue trauma that causes seromas. Flexed patient positioning during surgery and deep fascial anchoring sutures are effective in keeping the scar low. By avoiding chemoprophylaxis, hematomas can be avoided. Limiting the dissection (lipoabdominoplasty), preserving the Scarpa fascia, and adding quilting (progressive tension) sutures are unnecessary.

CONCLUSIONS

Total intravenous anesthesia offers important safety advantages. Avoiding electrodissection is effective in keeping seroma rates at a tolerable level (5%), and the scar low and more easily concealed. Alternative methods present disadvantages that may contribute to a suboptimal aesthetic result and require additional operating time.

Biplanar Lipoabdominoplasty: Introducing the Subscarpal Lipo Aponeurotic System

Preservation of Scarpa’s fascia in abdominoplasty has been previously presented. Herein we introduce the subscarpal lipo aponeurotic system (SLAS) and the technique of preserving the SLAS and its tightening in lipoabdominoplasty.

The Global Prevalence of Seroma After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoplasty is one of the most common cosmetic surgeries performed worldwide. Seroma is also the most common local complication associated with abdominoplasty, which increases care costs, reduces patient satisfaction, and has serious complications for patients. Results of previous studies report different levels of seroma prevalence after abdominoplasty. The aim of this study is to standardize the statistics of the prevalence of seroma after abdominoplasty using meta-analysis.

METHODS

In this systematic review and meta-analysis study, data from studies conducted on the global prevalence of seroma after abdominoplasty was extracted using the keywords "Prevalence, Epidemiology, Complications, Abdominoplasty, Seroma, and Lipo abdominoplasty" in the databases of Science, Scientific Information Database, MagIran, Embase, Scopus, PubMed, Web of Science, and Google Scholar search engine without time limit until October 2020. The random-effects model was used to analyze the eligible studies, and the heterogeneity of the studies was investigated with the I² index. Data analysis was performed using Comprehensive Meta-Analysis software (Version 2).

RESULTS

In reviewing 143 studies (five studies related to Asia, 55 studies related to Europe, three studies related to Africa, and 80 studies related to the Americas) with a total sample size of 27834 individuals, the global prevalence of seroma after abdominoplasty was obtained as 10.9% (95% CI: 9.3-3.6.6%) and the highest prevalence of seroma was related to the Europe continent with 12.8% (95% CI: 10.15-3.9%). The results from meta-regression showed a declining trend in the global prevalence of seroma after abdominoplasty with an increase in the sample size, age of study participants, and the year of study (p < 0.05).

CONCLUSIONS

This study shows that the prevalence of seroma after abdominoplasty is high globally. Therefore, physicians and specialists must consider its importance and take the controlling and treatment measures seriously.

LEVEL OF EVIDENCE III

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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Abdominoplasty without Drains or Progressive Tension Suturing

BACKGROUND

Over the years, the techniques of performing abdominoplasty have been modified and altered. Some of these modifications include progressive tension suturing and preservation of sub-Scarpa fat. These alterations have been done to decrease the risk of postoperative seroma and hematoma formation. Abdominoplasty, without the use of drains, is well documented in the literature. Here, the authors describe that raising superficial flaps (in the sub-Scarpa fat plane) will reduce seroma formation risk. As a result, the use of drains and tension suturing can be avoided altogether.

METHODS

A retrospective study was conducted from January 2015 to January 2018. The data of patients were extracted from admission files and operative notes. All the procedures were done under general anesthesia using the same operative technique by a single surgeon at the same institute. This article describes the operative technique used, observations, and result in comparison to the literature.

RESULTS

A total of 100 patients were included in the study for over three years; 89% were females, and the average age was 40 years, with a mean BMI of 25.1 kg/m². Liposuction was performed concomitantly in 56 patients, and rectus plication was done in 47. The overall complication rate was 14%, with the incidence of seroma and hematoma formation being 6% and 2%, respectively. This is comparable to the incidence found in the literature. The average hospital stay was 1.7 days, and the patients were followed for up to 6 months.

CONCLUSION

Abdominoplasty, when performed in superficial planes with preservation of sub-Scarpa fat, is safe in terms of improved flap vascularity and beneficial in reducing the risk of seroma and hematoma formation. It can be safely performed without drains or progressive tension suturing and reduces the operative time required, patient discomfort, and hospital-stay period.

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 .

Dissection Technique for Abdominoplasty With Scarpa Fascia Preservation: Comparative Study on Avulsion Technique Versus Diathermocoagulation

BACKGROUND

Many strategies have been developed to lower the high complication rate associated with a full abdominoplasty. The dissection technique may have a role to achieve this goal.

OBJECTIVES

The present study compared 2 different dissection techniques to perform a full abdominoplasty with Scarpa fascia preservation: avulsion technique and electrodissection.

METHODS

A retrospective observational cohort study was performed in 2 health institutions from January 2005 to January 2019. A total of 251 patients were involved: 122 patients submitted to abdominoplasty employing the avulsion technique (Group A) and 129 with diathermocoagulation (coagulation mode) (Group B). The latter was further divided into group B1 (57 patients with device settings according to surgeon's preferences) and B2 (72 patients with a specific regulation aiming at minimal tissue damage). Several variables were analyzed: population characteristics, time of hospital stay, time to drain removal, total and daily drain output, emergency department visits, readmission, reoperation, and local and systemic complications.

RESULTS

The general characteristics of both groups did not statistically significantly differ except for previous abdominal surgery. The diathermocoagulation group had a significantly lower length of hospital stay and time to drain removal. Moreover, these advantages were maximized when electrocautery was conducted with a specific low-voltage setting as significant differences were found. The other outcomes were identical.

CONCLUSIONS

Limiting the extension of electrodissection with the avulsion technique did not present any advantage. Utilizing diathermocoagulation (coagulation mode) during a full abdominoplasty with Scarpa fascia preservation, especially when it is aimed at minimal tissue damage, reduces patients' time with drains.

LEVEL OF EVIDENCE: 3

[Abdominoplasties: Do we still need to drain in 2021?]

OBJECTIVE

The purpose of this study was to consider the use of drainage when performing an abdominoplasty with regards to postoperative complications for two groups of patients.

PATIENTS AND METHOD

From January 1st 2017 to December 31th 2019, 215 patients underwent an abdominoplasty in our institution. In this retrospective, comparative, single institution study, patients were divided into two groups: "drainage" D (n=162) when suction completed abdominoplasty, "no drainage" ND (n=53) when suction didn't completed abdominoplasty. Early and distant complications were retrieved for each group and compared.

RESULTS

There was no significant difference between the two groups concerning the occurrence of seroma postoperatively (8% of patients in group D and 11.3% of patients in group AD). The drainage group D experienced more seroma's punctures (2,3± 1,0) and the mean of punctured fluid was higher (386,5ml±350,4ml) compared to the no drainage group ND (1,3+- 0,5 number of punctures with a mean punctured fluid of 165,8mL± 224,2mL). The mean hospital stay was shorter for group ND (2,9± 1,8 days) than for group D (4,4+- 1,7 days), P<0,0001.

CONCLUSION

Performing an abdominoplasty with quilting suture but drainless doesn't seem to increase postoperative complications statistically. The authors recommend, under the guise of a quilting suture, not to systematically drain the abdominoplasties and to reserve this technique for patients at risk of complications (high BMI, significant weight loss and co-morbidities).

Efficacy of Progressive Tension Sutures without Drains in Reducing Seroma Rates of Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoplasty using progressive tension sutures (PTS) without drains has been reported to lower seroma risk. However, evidence regarding the reproducibility of PTS drainless abdominoplasty in lowering seroma risk is inconsistent and limited to a few studies.

OBJECTIVES

The purpose of this review and meta-analysis was to assess the efficacy of PTS without drains in reducing seroma rates associated with abdominoplasty.

METHODS

PubMed, EMBASE, and Cochrane databases were searched with no restrictions for randomized controlled trials (RCTs) and observational studies in which the number of patients who experienced postoperative seroma was indicated. The keywords included ''progressive tension sutures,'' ''quilting sutures,'' "drain," and "abdominoplasty.'' Review Manager software (RevMan, version 5.3) was utilized to compute the pooled effect estimate using a random-effects Mantel-Haenszel model. The outcomes were expressed as odds ratios (OR) and 95% confidence intervals (CI). Subgroup analysis was conducted based on whether abdominoplasty was combined with liposuction.

RESULTS

Five studies were included (one RCT and four retrospective studies) involving a total of 1255 adult patients. Patients who underwent abdominoplasty using PTS without drains experienced a significantly lower rate of postoperative seroma compared to those with drains (D) only (OR, 0.36; 95% CI, 0.19-0.70; P = 0.002; I² = 9%). There was no significant difference in postoperative seroma rates between the PTS and PTS + D groups (OR, 1.03; 95% CI, 0.30-3.54; P = 0.96; I² = 0%). The data analysis for the subgroup that included liposuction showed that compared with the use of drain only, PTS were associated with a significantly reduced number of seromas (OR, 0.24; 95% CI, 0.11-0.49; P = 0.0001; I² = 0%).

CONCLUSION

Abdominoplasty using PTS without drain and combined with liposuction was effective in reducing seroma rates. Additional RCTs with larger sample sizes and better comparability are needed to confirm the safety and effectiveness of the drainless abdominoplasty technique using progressive tension sutures.

LEVEL OF EVIDENCE III

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 Role of Tranexamic Acid in Aesthetic Plastic Surgery: A Survey of the British Association of Aesthetic Plastic Surgeons

BACKGROUND

Tranexamic acid (TXA) can reduce intra- and postoperative bleeding as well as minimizing postoperative swelling and ecchymosis. It can be administered both intravenously and topically during surgery with minimal side effects.

OBJECTIVES

To assess the evidence of TXA use in aesthetic surgery and to complete a survey of current practice of full British Association of Aesthetic Plastic Surgeons members.

METHODS

The authors performed a literature review and online survey of full British Association of Aesthetic Plastic Surgeons members.

RESULTS

There is an increased indication of TXA utilization in aesthetic surgery. It provides multiple surgeon and patient benefits.

CONCLUSIONS

TXA is a useful adjunct in aesthetic surgery.

[Abdominoplasty without closed-suction drains: a randomised controlled trial]

INTRODUCTION

 There is insufficient scientific evidence from randomised controlled trials to support the routine use of closed-suction drains in body contouring procedures. The aim of this study was to evaluate cumulative seroma volume, length of hospital stay and complication rates in abdominoplasty patients without drains in direct comparison with a cohort receiving drains.

MATERIAL AND METHODS

 Abdominoplasty patients were prospectively randomised in two study groups with (MD) and without (OD) placement of closed-suction drains. Patients with a BMI ≤ 30 kg/m² undergoing horizontal or combined horizontal/vertical incision abdominoplasty were included. Scarpa's fascia was preserved during dissection. Exclusion criteria comprised simultaneous liposuction, coagulation disorders and ASA score ≥ 3. Cumulative seroma volume over a four-week follow-up period was assessed as the primary outcome measure. Secondary outcome measures were complications requiring surgical revision and length of hospital stay.

RESULTS

 This trial did not identify a statistically significant difference in cumulative seroma volume between the MD (30/53) and OD (23/53) cohorts in 53 patients (M_MD 493 ± SD 407 ml; M_OD 459 ± SD 624 ml; p = 0.812). However, a significantly shorter average length of hospital stay was observed in the OD population (M_MD 5.1 ± SD 1.4 d; M_OD 4.2 ± SD 1.5 d; p = 0.023). Complication rates were equal in both study groups (n_MD = 1; n_OD = 1).

CONCLUSION

 The results of this trial do not justify routine placement of closed-suction drains in abdominoplasty procedures (horizontal or combined horizontal/vertical incision) in the pre-obese patient cohort (BMI ≤ 30 kg/m²). Drain placement should be evaluated on an individual patient-specific basis.

Evidenced-Based Approach to Abdominoplasty Update

The following publication was compiled as an evidence-based update for plastic surgeons performing abdominoplasty from a review of the published literature on that subject between January 2014 and February 2017. It is an overview of various aspects of abdominoplasty including preoperative patient assessment, variations and advances in both surgical and anesthetic technique, patient safety, and outcomes. It is intended to serve as an adjunct to previously published evidence-based reviews of abdominoplasty.

Ligasure impact™might reduce blood loss, complications, and re-operation occurrence after abdominoplasty in massive-weight-loss patients: A Comparative Study

Background and Aims:

The most effective dissection technique for raising the flap in abdominoplasty is still controversial, particularly in high-risk massive-weight-loss patients. LigaSure Impact™vessel-sealing system (Medtronic, Dublin, Ireland) is an energy device commonly used among different surgical specialties to reduce morbidity and implement outcomes. The aim of this study was to investigate the effectiveness of LigaSure Impact in abdominoplasty compared with the conventional techniques, diathermia.

Material and Methods:

Patients underwent primary abdominoplasty after massive weight loss at a single center from 1 January 2008 to 31 May 2015 and were retrospectively reviewed. A total of 94 patients eligible for the study were divided into two groups on basis of the dissection technique: LigaSure Impact group (29 patients) and the conventional technique group (65 patients). Total intraoperative blood loss was the primary endpoint. Duration of the operation, perioperative complications and re-operation were recorded as secondary endpoints.

Results:

Baseline characteristics were well balanced between the groups. Significant differences were found in intraoperative blood loss favoring LigaSure Impact group (259.6 ± 198.8 mL vs 377.9 ± 190.0 mL, p = 0.004) and blood transfusion rates (13.8% vs 35.4%, p = 0.047). In contrast, operative time was significantly longer in LigaSure Impact group (168.6 ± 121.2 vs 179.7 ± 57.6 min, p = 0.005), while a tendency to shorter hospital stay was found in LigaSure Impact group (3.6 ± 1.1 days vs 4.6 ± 3.2 days, p = 0.081). Overall complications occurrence, Clavien–Dindo grade II (24.1% vs 55.4%) and grade III (13.8% vs 30.8%) complications were significantly lower in LigaSure Impact group (respectively, p = 0.005, p = 0.007, p = 0.016). Late (>30 days) re-operation rate was significantly lower in the LigaSure Impact group (6.9% vs 27.70%, p = 0.0028). Specific wound complications showed no significant difference.

Conclusion:

LigaSure Impact vessel-sealing system may be beneficial in improving abdominoplasty outcomes in massive-weight-loss patients because it might reduce blood loss, need for transfusions, complications, and re-operations.

Hematomas in Aesthetic Surgery

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.

Minimizing the Short-term Reoperation Rate in Abdominoplasty Procedures by Prolonged Postoperative Immobilization

BACKGROUND

Abdominoplasty is a common procedure in postbariatric surgery. Over the years, a high number of technical refinements of the procedure have been established to improve safety and reduce associated complications. Nevertheless, the complication rate is high. The purpose of this study was to examine the incidence of postoperative complications in patients undergoing abdominoplasty in association with prolonged postoperative immobilization.

METHODS

Retrospective analysis of 82 patients who underwent abdominoplasty was performed. Patients were divided in two study groups regarding their immobilization period. Group 1 included patients with an immobilization period defined as strict bed rest for at least 45 h after surgery. Group 2 included all patients with shorter immobilization time, but earliest mobilization in the evening on the day of surgery.

RESULTS

Overall, complication rate was 27%. Major complications were observed in 15% in group 1 and in 23% in group 2. Hematoma requiring surgical revision was observed in 5% in group 1 and in 14% in group 2. Surgical revisions within the first 60 days were necessary in 5% in group 1 and in 20% in group 2.

CONCLUSION

Prolonged immobilization after abdominoplasty does not crucially lower the overall complication rate, but influences the severity of complications in a positive way. Increasing the duration of postoperative immobilization up to 45 h after abdominoplasty significantly decreases the reoperation rate in our practice. The risk for a surgical revision is nearly four times higher if the patient leaves bed earlier. Surgeons should consider this option especially in patients with a high risk for complication development.

[Should surgeons keep performing drainage after breast reduction?]

OBJECTIVE

Despite the absence of "evidence-based medicine", the use of closed suction drainage in breast surgery is currently the standard practice. Its goal is to minimize the amount of fluid at the operation site, the dead space that can involve postoperative complications. The purpose of this study is to demonstrate that with or without drainage the complication rate is unchanged.

METHODS

We conducted a retrospective and comparative study of two groups of breast reduction with and without drainage. Every complication has been recorded and statistically analyzed: seroma and hematoma, infections, wound breakdown, skin flap or nipple-areola complex necrosis, fat necrosis and reoperation.

RESULTS

A total of 138 breast reductions were performed (37 drained patients and 32 non-drained). Data collection of complications was done on average 10months after the operation (1-15). There was no statistical difference between the two groups regarding the complication rate. Our results confirm the ones found in the literature.

CONCLUSION

Except for specific cases (e.g. gigantomasty), this study demonstrates that after breast reduction, drainage is not appropriate. Drains do not reduce postoperative complications and can increase hospitalization length of stay (inducing higher costs). Furthermore, it is often source of pain, anxiety and discomfort for patients.