no drain abdominoplasty: evidence & execution · 2019. 11. 21. · • may apply techniques to...
TRANSCRIPT
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No Drain Abdominoplasty:Evidence & Execution
Karol A Gutowski, MD, FACS
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Disclosures
Suneva Medical – Instructor
Merz – Advisory Board
NO financial interests in any suture company
Will use brand names due to lack of distinguishing generic names
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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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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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Patient’s Perception of Drains
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Clinical Experience
• 281 consecutive abdominoplasties– 54 circumferential– 171 with abdominal flap liposuction– 262 with flank liposuction– 76 massive weight loss– 230 outpatient
• Tumescent technique• Modified Progressive Tension Suture Technique
– Bidirectional barbed sutures– 8 to 10 minutes– No drains– Compression garment +/- binder for 2 weeks
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Results
• 1 epigastric seroma– One aspiration
• 9 lower abdominal seromas– Multiple aspirations
– 4 required drain (SeromaCath placed in office)
• 1 major wound dehiscence
• 2 hematomas drained in OR
• 2 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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Tissue Adhesives
• Lack of high-quality evidence to support TAs to prevent seroma after abdominoplasty
• Well-designed RCTs are needed
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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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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
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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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
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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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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Compression
TopiFoam
+ Compression Garment
+/- Soft Abdominal Binder
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No Drain Abdominoplasty
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No Drain Abdominoplasty
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No Drain Abdominoplasty
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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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No Drain 360o Lipo Abdominoplasty
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No Drain 360o Lipo Abdominoplasty
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No Drain 360o Lipo Abdominoplasty
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No Drain 360o Lipo Abdominoplasty
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Not Using Drains is an Uplifting Experience!
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Contact Information
773-870-0732
Copy of this presentation
DrGutowski.com For Physicians
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Video Presentation
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No Drain Abdominoplasty:Evidence & Execution
Karol A Gutowski, MD, FACS