No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential...

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No Drain Abdominoplasty: No More Excuses Karol A Gutowski, MD, FACS

Transcript of No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential...

Page 1: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Abdominoplasty: No More Excuses

Karol A Gutowski, MD, FACS

Page 2: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Disclosures

NO financial interests in any suture company

Will use brand names due to lack of

distinguishing generic names

Page 3: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 4: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Drain Free Procedures

• Breast • Reduction

• Mastopexy

• Augmentation

• Trunk• Abdominoplasty

• Body lift

• Extremity• Arm lift

• Thigh lift (depends)

Page 5: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

• “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

Page 6: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

PTS Criticisms

• Requires an assistant

• Takes too long

• Does it really work?

• Cost

But I was trained to do it this way…….

Page 7: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

PTS Criticisms

• Requires an assistant

• Takes too long

• Does it really work?

• Cost

But I was trained to do it this way…….

Page 8: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 9: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Drains in Breast Reduction

Page 10: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 11: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Enhanced Patient Experience

ASJ 2009

PRS 2010

Page 12: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Patient’s Perception of Drains

Page 13: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Patient’s Perception of Drains

Page 14: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Tissue Adhesives

• Lack of high-quality evidence to support TAs to prevent seroma after abdominoplasty

• Well-designed RCTs are needed

Page 15: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 16: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 17: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Pivotal Publication

Page 18: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Individual Sutures

Page 19: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Progressive Inferior Tension

30 to 40 minutes

Page 20: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Introduction of Barbed PTS

ASJ 2009

PRS 2010

Page 21: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Subsequent Publications

Page 22: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Subsequent Publications

Page 23: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Barbed Suture Technology

Page 24: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Barbed Suture Technology

Quill & Ethicon Quill & V-Loc

Cost: $10 to $20

Page 25: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise
Page 26: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Use size 0 PDO suture

Page 27: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Place medial suture line to umbilical stalk

Page 28: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Place lateral suture line to same level

Page 29: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Advance needle 2 cm with each placement on abdominal flap

Page 30: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Secure to abdominal wall fascia while maintaining progressive inferior tension on flap

Page 31: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

The PTS should include no more than half of the abdominal flap thickness

Page 32: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Place contralateral medial and lateral sutures to level of umbilical stalk

Page 33: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Finish lower abdominal PTSAddress the umbilical transposition

Page 34: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Barbed Progressive Tension Sutures

Page 35: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Barbed Progressive Tension Sutures

Finish lower abdominal PTS

Address the umbilical transposition

Page 36: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Barbed Progressive Tension Sutures

Finish lower abdominal PTS

Address the umbilical transpositionProtect the Needles

Page 37: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Barbed Progressive Tension Sutures

Use Non-Dominant Hand for Traction Toward Incision

Page 38: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Rosen, PRS 2010

Rosen, PRS 2010

Unidirectional Barbed Suture

Page 39: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise
Page 40: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise
Page 41: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise
Page 42: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Layers of PTS

Rectus

Fascia

Scarpa’s

Fascia

Page 43: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Layers of Quill Sutures

Rectus Fascia Plication: Choice

Page 44: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Layers of Quill Sutures

Progressive Tension Suture

Quill PDO Taper Point

Size 0, 24 cm or 30 cm

Page 45: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Layers of Quill Sutures

Scarpa Fascia Suture

Quill PDO Taper Point

Size 0, 24 cm or 30 cm

Page 46: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Layers of Quill Sutures

Dermal Closure

Quill Monoderm Diamond Point

Size 2-0

Page 47: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Body Contouring Patient

Arm lift

Mastopexywith lateral auto-

augmentation

Body lift

Thigh lift

Page 48: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Body Contouring Patient

No undermining = no PTS

Undermining = PTS

Page 49: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Body Contouring Patient

Page 50: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Body Contouring Patient

After 2 weeks

Page 51: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Body Contouring Patient

After 4 weeks

Page 52: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Body Contouring Patient

After 3 months

Page 53: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Lipo-Abdominoplasty

• Rethink Matarasso’s classification

• Lipo-abdominoplasty with minimal lateral undermining is safe*

*Weiler 2010, Heller 2008, Samra 2010

Page 54: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Liposuction of Abdominoplasty Flap

Page 55: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Extended Lipo-Abdominoplasty

Page 56: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Extended Lipo-Abdominoplasty

Page 57: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drains No Suture

Page 58: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drains No Suture

Page 59: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Treat Entire Trunk

Page 60: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Lipo-Abdominoplasty

Page 61: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Lipo-Abdominoplasty

Page 62: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Lipo-Abdominoplasty

Page 63: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Lipo-Abdominoplasty

Page 64: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Lipo-Abdominoplasty

Page 65: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Lipo-Abdominoplasty

Page 66: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Lipo-Abdominoplasty

Page 67: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Compression

TopiFoam

+ Compression Garment+/- Soft Abdominal Binder

Page 68: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 69: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 70: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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

Page 71: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

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?

Page 72: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Seroma Treatment

• Aspirate if in doubt

• SeromaCath

• Sclerosis• Doxycycline

• Ethanol

• Excision

Page 73: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Not Using Drains is an Uplifting Experience!

Page 74: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Internal Guidelines

Page 75: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise
Page 76: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise
Page 77: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

Contact Information

[email protected]

773-870-0732

Copy of this presentation

DrGutowski.com For Physicians

Page 78: No Drain Abdominoplasty: No More Excuses€¦ · • May apply techniques to circumferential abdominoplasty • Use posterior “3-point” tissue fixation to close dead space •Advise

No Drain Abdominoplasty: No More Excuses

Karol A Gutowski, MD, FACS

Copy of this PresentationDrGutowski.comFor Physicians