What is a Drainless Tummy Tuck?
Abdominoplasty, or popularly, Tummy Tuck, is an operation that we plastic surgeons have been doing for decades. As with any technical craft, modifications to the technique by accident or design result in evolution so that the original bears less and less resemblance to the modern version. Over 30 years of practice, I have tried to gain feedback from my patients to direct me towards improvements that they, themselves will value. Modifications to a tummy tuck technique that result in a faster procedure, less costly, more efficient, or even safer are laudable but not always noticed by the patient. When I have asked a recovered abdominoplasty patient to tell me the single worst part of their experience, they would almost always say, “Are you kidding? It was those drain tubes coming out of me! I hated them!” I thought it would have been the postoperative pain, disability, lack of energy. No. It was the drains. We needed to go drainless. Yes, a drainless tummy tuck.
Drain vs. Drainless in Regards to Surgery
Surgeons have used drain tubes of some kind since the middle ages. In medieval England, barbers would lance, and often drain, abscesses and infections that the medieval medical doctors failed to cure with their poultices and potions. This gave rise to the notion of “bloodletting” to let the “evil humor” out. More likely, it was the practice of draining an abscess in the tummy, an often bloody, but equally often cure in an age before antibiotics. To this day, British surgeons are proud of their barber heritage and are called “Mister”, not “Doctor”.
From this comfort and facility with drains, and with technological advances in sterility and closed reservoir suction, surgeons readily began using them as devices to prevent the occurrence of fluid build-up. Blood build-up in a cavity or underneath a structure such as skin is called a “hematoma”, serum, or body fluid without the red cells, a “seroma”. It was assumed that drains could reduce the rate of these troublesome complications, particularly in tummy tucks. Studies comparing drained with undrained similar procedures often showed some benefit.
Drainless Tummy Tuck – A Change in Perspective
In 2000, a paper appeared in the U.S. journal, “Plastic and Reconstructive Surgery” by father and son plastic surgeons Harlan and Todd Pollock. I was present at their presentation in Dallas, Texas nearly two decades ago. Their innovation has changed my tummy tuck (abdominoplasty) patient’s lives for the better, since then.
A tummy tuck not only removes a very large piece of skin and fat from the lower abdomen, but it also, of necessity releases all the attachments of the upper abdominal skin and fat layer to the underlying muscular layer of the tummy. This allows that skin and fat “flap” to stretch all the way to close the large defect left by the lower abdominal tissue removal. We plastic surgeons, realizing that the layers must then re-adhere to each other, would place one or two drain tubes laying in that large flat space and exiting through a small, separate puncture wound in the skin on the tummy. A small suction bulb was attached to the end outside the patient to collect the normal body fluid that would be elaborated as part of the healing process and to, theoretically, “suck” the flap to the underlying muscle. The Pollocks tried something that probably most of us had tried at one time or another. They placed sutures from the skin/fat flap, the “roof” to the muscular “floor” to try to obliterate the space and obviate the need to place drains to “suck” it down. I had tried these sutures, myself, years ago. The trouble was that dimples in the skin on the tummy resulted from each stitch, rendering my “beautiful” result quite lumpy. I would cut those sutures out, place drains, and close the wound in a conventional fashion. I tried what we called this “quilting technique” a few more times over the years until I gave up trying.
Drainless Tummy Tuck
So what did the Pollocks do that I had not? Whether it was by accident or design, they noticed that if, after placing a row of these sutures, the dimpling on the outside of the skin went away when they pulled down on the flap. Placing tension on the flap, they put another row below the first. Now, there were dimples from the new row, but the dimples just above were gone. This was the defining point of their observation: placing progressive tension after each subsequent row smoothed out the abdominal skin above as the rows marched toward the final wound closure line.
I believe that pure genius is not always at the planning or theoretical stage. It is often in the noticing. Realizing the significance of their observation, they wrote a paper to tell the rest of us. Over the seventeen plus years that I have been doing the drainless tummy tuck (abdominoplasties), I have seen other benefits to this technique. Those progressive tension sutures give me more control of the exact direction of pull and tension each area needs to result in a curved, athletic, contour. In contrast, merely stretching an abdominoplasty wound closed over drains results in a straight, board-like closure. Further, the tension on the main wound closure must be favorably diminished by the force of the closure being shared among the many progressive tension sutures. Plastic surgeons will tell you that tension on a suture line in the skin is the main cause of wound separation early in the postoperative period, and scar thickening, or hypertrophy, later on.
Drainless Tummy Tuck – Where Credit is Due
I try to tell my patients of Pollock’s innovation, not only to give credit where it is due but also to let them know that we are constantly trying to improve our technique. Certainly, safety, analgesia, a low complication rate are all due to our attention and occasional innovation. Drainless abdominoplasty is a wonderful example of how a goal of an improved patient experience can also lead to improvements in all the other aspects of good care.
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