Whenever I talk to patients about tummy tucks, the issue of drains always comes up. Patients hate drains, especially when they are coming out of the sensitive pubic area or around the incision line that is always tender after surgery. Are they absolutely necessary?
Drains are used for two reasons:
• One is to drain out blood and the other is to drain out serous fluid – the clear liquid that the body produces in response to an injury. The reality is that there is usually very little bleeding after a tummy tuck since the surgeon spends considerable time coagulating the bleeding points with a cautery. I even have the anesthetist elevate the blood pressure during surgery to mimic the effect of postoperative discomfort on the blood pressure. Any additional bleeding points produced by this maneuver are also coagulated. Bottom Line – you usually don’t need drains for blood drainage.
• The 2nd reason for drains is to remove serous fluid that is produced when the skin is lifted off of the muscle. The body naturally removes this via the lymphatics, but these are partially disrupted with surgery. Fortunately we can preserve many of these lymphatics by leaving a layer of fat on the muscle as we are lifting the skin, something that I always do. Even with this, however, some serous fluid may still form and collect. We call that a seroma, and if it is large, it will need to be drawn off with a needle and syringe after surgery. This aspiration of a seroma may be required several times to eliminate it.
How do we prevent seromas?
• #1 – Drains – The drains suction the seroma fluid off and the skin then seals itself down to the muscle, allowing removal of the drains by 5 or 6 days after surgery in most cases.
• #2 – Suture the skin down to the muscle at the time of surgery!
Method #2 is preferable as it allows us to do the surgery without drains. Is it effective? A paper published in the Aesthetic Surgery Journal this year (ASJ 32(6) 729-742) goes into this topic in detail. The article reviews 597 consecutive cases of tummy tuck in which Progressive Tension Sutures (PTS) were used to suture the skin down to the muscle. Was it effective? Most definitely, YES! There was only 1 seroma in the 597 cases!!
What is a PTS? It describes how the “skin” is sutured down to the muscle. Instead of the “skin”, it’s actually a thin layer of material called the superficial fascia that is located several millimeters below the skin surface that is engaged by the suture. This fascia is sutured to the muscle fascia located underneath it. As one sutures the superficial fascia to the muscle fascia, one pulls the skin downward, putting a bit of tension on it. The next suture pulls the skin down a bit further, hence the name “Progressive Tension.” At the end of the suturing process, one has effectively pulled the abdominal skin downward so that the abdominal skin and the pubic skin edges come together easily, minimizing tension on the scar and thus minimizing spreading of the scar. This lesser amount of tension also increases the blood flow at the skin edge which maximizes the excellence of healing. The result is theoretically a better looking scar. We’ve also avoided drains – A WINNER!!
I have been using the PTS Technique and am a believer! I recently had occasion to speak with Dr. Harlan Pollock, the author of the paper I referred to above, at the New York ASAPS meeting in April, 2013. He continues to use the technique and is delighted with the results. More and more plastic surgeons are also recognizing the advantages of this technique. The additional 15 minutes of surgical time required are well worth it in exchange for a much easier recovery for the patient and a potentially better scar.
Please give my office a call to arrange for a consultation if you would like to know more about how you can avoid drains following your tummy tuck. If you have an opinion in the matter, please leave a comment or reply.
George Sanders, M.D.