Why I don’t use drainage tubes in my tummy tuck procedures anymore.
Dr. Robert Shenker explains why he now prefers the drainless tummy tuck.
Surgeons, like other highly skilled technical professionals, are trained (at least in part) through an apprenticeship system. We spend many years studying, assisting, and operating with highly-skilled and very experienced surgeon-teachers. We trust and respect those mentors, and we emulate them. Very often, we spend our whole careers doing exactly what we were taught to do during our residency programs. When asked why we do a particular procedure in a certain way, or why we make a decision about a certain maneuver, we often say with pride: “Because my teacher did it that way”.
But the world of plastic surgery is not stagnant. Ideas evolve. Techniques and equipment are modernized. Older techniques that were once dogmatically followed are shown to be wrong or simply unnecessary.
In years gone by, doing a tummy tuck and not placing a drain in the surgical site would have been total heresy. Absolutely everyone used drains. The thinking was that there would surely be an accumulation of swelling fluid in the large space under the skin, and that puddle of fluid, or “seroma”, could be unsightly at best, or get infected at worst. A troublesome seroma could even necessitate additional surgery. The drain was thought to remove the excess fluid and through a bit of negative-pressure suction, aid the adherence of the freshly elevated skin flap down to the abdominal wall.
Surgeons tolerated the drains; patients and their families hated them. They were awkward, they were cumbersome, and let’s face it, they were gross! Patients watched them slowly fill with blood, then had to empty them periodically. And don’t even get me started on the debate about when to take them out! Two days? Five? When the drainage is less than 50ml per day? 30ml? When it stops draining completely? Should we keep a patient on antibiotics as long as the drain was in? How many drains should we use? One? One on each side of the tummy? I always used two. Why? Because my teacher did it that way.
I am happy to say that I have not used a drain in a tummy tuck for about two years. So, what changed? Well, like in many instances of scientific endeavour, what eliminated the use of drains had nothing to do with drains at all!
What changed was the onset of using progressive tension sutures as part of the tummy tuck closure. Tension across an incision has an adverse effect on scar quality. High tension produces thicker, wider, and uglier scars. High tension also predisposes to wound healing problems such as separation of the edges, or even the “death” of the skin along the wound edges. Skin edges that fall together without tension is always the goal in any operation but was always impossible in a tummy tuck. The removal of the excess tummy skin and fat always produced skin edges that were many centimetres apart, and were always closed with tension.
An ingenious way to decrease the tension at the skin closure is to aggressively pull the abdominal skin flap down, and tack it down to the abdominal wall at multiple points along the way. That way the tension is distributed along many points along the flap, and it is not concentrated at the skin incision edges. As if by magic, the skin edges that were 15 or 20 centimetres apart after the removal of the excess tummy skin now fall together essentially tension free. Less tension. Better scars. Fewer complications. What could be better than that?
It turns out that by putting those progressive tension sutures in we are also “quilting” the abdominal flap down on to the abdominal wall. We are essentially taking the one very large space that we’ve created and dividing it into multiple small little spaces where no fluid can accumulate and cause trouble. In addition, the progressive tension/quilting sutures unify the abdominal wall and the overlying skin and fat flap, which minimizes the movement of the two on each other, and decreases the amount of irritation, inflammation and swelling fluid.
So with just a few carefully placed stitches, we get less tension at the wound edges, we get better wound healing, a better quality scar, and because we don’t get a large pool of fluid accumulating, we don’t need drains anymore!
I was skeptical at first. I doubted that the new technique would work in my patients. After all, if it was such a good idea, why hadn’t my teachers been doing it when I was a resident?
I was slow to adapt to the emerging trend, but the evidence was solid, and my colleagues around the world were doing drainless tummy tucks with great success. So, I stopped using drains in tummy tucks a few years ago. I have had zero complications. I have had zero regrets. I have loved the technique from the first day, but I suspect I don’t love it as much as my patients do.
And now, when the medical students and plastic surgery residents who I teach are someday asked why they don’t use drains in their tummy tucks, they will say: “Because my teacher did it that way”.