No Drain Abdominoplasty: No More Excuses · Drains in Breast Augmentation •No evidence to support...
Transcript of No Drain Abdominoplasty: No More Excuses · Drains in Breast Augmentation •No evidence to support...
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No Drain Abdominoplasty: No More Excuses
Karol A Gutowski, MD, FACS
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Disclosures
NO financial interests in any suture company
Will use brand names due to lack of
distinguishing generic names
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Objectives
• Explain why drains aren’t needed
• Present data on No-Drain Abdominoplasty
• Learn PTS technique
• Discuss pitfalls & key points
• Know how to manage complications
Rethink the need for drains
to improve patient experience
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Drain Free Procedures
• Breast • Reduction
• Mastopexy
• Augmentation
• Trunk• Abdominoplasty
• Body lift
• Extremity• Arm lift
• Thigh lift (depends)
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• “Standard of care” for many procedures
• Benefit: often NOT proven
• Downside: pain, cost, less mobility, anxiety, phone calls, infection, scars
• Not substitute for good surgical technique
Drains
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PTS Criticisms
• Requires an assistant
• Takes too long
• Does it really work?
• Cost
But I was trained to do it this way…….
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PTS Criticisms
• Requires an assistant
• Takes too long
• Does it really work?
• Cost
But I was trained to do it this way…….
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Evidence?
Conclusions: Many surgical operations can be performed safely without prophylactic drainage….breast reduction, abdominal wounds, femoral wounds….. Furthermore, surgeons should consider not placing drains prophylactically in obese patients.
2013
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Drains in Breast Reduction
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Drains in Breast Augmentation
• No evidence to support drains in primary breast augmentation
• Drains may increase risk of capsular contracture 4x
• No guidelines for secondary cases with capsulectomy or with biological products
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Enhanced Patient Experience
ASJ 2009
PRS 2010
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Patient’s Perception of Drains
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Patient’s Perception of Drains
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Tissue Adhesives
• Lack of high-quality evidence to support TAs to prevent seroma after abdominoplasty
• Well-designed RCTs are needed
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Clinical Experience
• 270 consecutive abdominoplasties• 53 circumferential
• 241 with flank liposuction
• 71 massive weight loss
• 223 outpatient
• Tumescent technique
• Modified Progressive Tension Suture Technique• Bidirectional barbed sutures
• 8 to 10 minutes (vs 15 to 18 min, up to 50 min)
• No drains
• Compression garment + binder for 2 weeks
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Results
• 1 epigastric seroma• One aspiration
• 13 lower abdominal seromas• Multiple aspirations
• 6 required SeromaCath drain
• 1 major wound dehiscence
• 2 hematomas drained in OR
• 3 infected seromas• Incised & drained
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Pivotal Publication
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Individual Sutures
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Progressive Inferior Tension
30 to 40 minutes
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Introduction of Barbed PTS
ASJ 2009
PRS 2010
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Subsequent Publications
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Subsequent Publications
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Barbed Suture Technology
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Barbed Suture Technology
Quill & Ethicon Quill & V-Loc
Cost: $10 to $20
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Use size 0 PDO suture
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Place medial suture line to umbilical stalk
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Place lateral suture line to same level
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Advance needle 2 cm with each placement on abdominal flap
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Secure to abdominal wall fascia while maintaining progressive inferior tension on flap
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The PTS should include no more than half of the abdominal flap thickness
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Place contralateral medial and lateral sutures to level of umbilical stalk
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Finish lower abdominal PTSAddress the umbilical transposition
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Barbed Progressive Tension Sutures
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Barbed Progressive Tension Sutures
Finish lower abdominal PTS
Address the umbilical transposition
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Barbed Progressive Tension Sutures
Finish lower abdominal PTS
Address the umbilical transpositionProtect the Needles
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Barbed Progressive Tension Sutures
Use Non-Dominant Hand for Traction Toward Incision
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Rosen, PRS 2010
Rosen, PRS 2010
Unidirectional Barbed Suture
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Layers of PTS
Rectus
Fascia
Scarpa’s
Fascia
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Layers of Quill Sutures
Rectus Fascia Plication: Choice
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Layers of Quill Sutures
Progressive Tension Suture
Quill PDO Taper Point
Size 0, 24 cm or 30 cm
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Layers of Quill Sutures
Scarpa Fascia Suture
Quill PDO Taper Point
Size 0, 24 cm or 30 cm
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Layers of Quill Sutures
Dermal Closure
Quill Monoderm Diamond Point
Size 2-0
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No Drain Body Contouring Patient
Arm lift
Mastopexywith lateral auto-
augmentation
Body lift
Thigh lift
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No Drain Body Contouring Patient
No undermining = no PTS
Undermining = PTS
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No Drain Body Contouring Patient
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No Drain Body Contouring Patient
After 2 weeks
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No Drain Body Contouring Patient
After 4 weeks
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No Drain Body Contouring Patient
After 3 months
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Lipo-Abdominoplasty
• Rethink Matarasso’s classification
• Lipo-abdominoplasty with minimal lateral undermining is safe*
*Weiler 2010, Heller 2008, Samra 2010
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Liposuction of Abdominoplasty Flap
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Extended Lipo-Abdominoplasty
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Extended Lipo-Abdominoplasty
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No Drains No Suture
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No Drains No Suture
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Treat Entire Trunk
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No Drain Lipo-Abdominoplasty
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No Drain Lipo-Abdominoplasty
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No Drain Lipo-Abdominoplasty
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No Drain Lipo-Abdominoplasty
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No Drain Lipo-Abdominoplasty
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No Drain Lipo-Abdominoplasty
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No Drain Lipo-Abdominoplasty
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Compression
TopiFoam
+ Compression Garment+/- Soft Abdominal Binder
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Practical Tips
• Instruct assistants on principals of this technology
• More familiarity = faster incorporation it into your practice
• Don’t cut off one of the two needles of the bidirectional sutures
• Suture is more firm
• Gentle stretching prevents loop and knot formation
• Avoid contact with gauze, lap sponges & similar materials
• Barbs may attract lint-like material onto the suture
• Two needles on operative field with each suture
• Protect the needle not in use with a needle holder
• If a barbed suture breaks
• Start a new suture with 3-4 cm of overlap with the old suture
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More Practical Tips
• Keep abdominal flap aligned • Mark undersurface & avoid tendency to pull flap to one side
• Avoid excess tension as fat necrosis may result
• May apply techniques to circumferential abdominoplasty• Use posterior “3-point” tissue fixation to close dead space
• Advise patients• Small abdominal contour irregularities resolve in 1 to 2 weeks
• May feel “popping” sensation in 2 to 6 weeks
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Lessons Learned
• Quill PDO in dermis will “spit”
• Resist temptation to advance suture too far• Fascia – tissue contour• Dermis – puckers
• Teach nurses & scrub techs
• Don’t place on certain material
• Patient expectations
• Favorable learning curve
• Try it on a TRAM
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Technique Advantages
• Fast closure• 8 to 10 minutes additional time for PTS
• Can do without an assistant
• Maintains tissue approximation• Less tissue pull-through
• Eliminate abdominal drains
• Need for abdominal binder?
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Seroma Treatment
• Aspirate if in doubt
• SeromaCath
• Sclerosis• Doxycycline
• Ethanol
• Excision
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Not Using Drains is an Uplifting Experience!
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Internal Guidelines
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Contact Information
773-870-0732
Copy of this presentation
DrGutowski.com For Physicians
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No Drain Abdominoplasty: No More Excuses
Karol A Gutowski, MD, FACS
Copy of this PresentationDrGutowski.comFor Physicians