How to decide between drainless vs drains?

Question

I have been going back and forth on one Dr. who does drainless TT's and the other who does not. Both have great results but when asking both about drains vs not drains they both seem to contradict each other. I am torn because drains seem like more work and kind of scary. But I was told you cannot pull as tight if doesn't have drains. How do you decide? Is it this big of a deal that I'm making it out to be?

Garrett Wegerif, MD · Answer

I will preface my answer by saying I do primarily drainless abdominoplasties. With that being said I think both techniques are very effective and as others have mentioned you should choose the surgeon you trust and get consistent results. The complication profile between the two techniques when done correctly is very similar, specifically the risk of seroma formation. Some studies actually showed a decreased risk of seroma with the drainless. 
Some patients just have a significant aversion to drains for a multitude of reasons; pain, squeamish about bodily fluids, anxiety about drain removal, the headache of recording drain outputs, restrictions on showering after surgery, etc. For these patients the drainless technique will provide great benefit. 
I strongly disagree that you "cannot pull as tight" with the drainless technique. The progressive tension sutures that make the drainless technique possible actually offloads tension on the incision allowing you to pull the flap very tight. 
I will be the first to admit that there are tradeoffs with the drainless technique. Most notably, increased operative time to place the progressive tension sutures (usually 15-30min). There can also be temporary dimpling of the skin in areas of the progressive tension sutures but this goes away within a few weeks. There are also rare circumstances during surgery that I may feel inclined to leave a single drain for a few days but this is uncommon. 
You should go with your gut and choose the surgeon you are most comfortable with. Best of luck with your decision!

Krishna Vyas, MD, PhD, MHS · Answer

Our meta-analysis research (link below) showed that "drainless tummy tuck (abdominoplasty) with progressive tension sutures" were more effective than "tummy tuck with drains" in reducing seroma (fluid buildup) and reoperation rates, with no difference for hematomas or infections.
Many plastic surgeons continue to use drains during tummy tucks because it has been the standard practice for many years. Drains are traditionally used to prevent fluid accumulation under the skin, a common occurrence after the procedure. The accumulation of fluid, known as a seroma, can slow healing and lead to complications. Using drains helps remove this fluid, ensuring proper healing and minimizing the risk of complications. However, drains can be uncomfortable, require additional care, and increase the risk of infection at the insertion points. They can also leave scars, even after they are removed.
The advent of the "drainless" tummy tuck, typically achieved through the use of progressive tension sutures, offers an alternative to this approach. These sutures help to close any dead space in the skin flap, significantly reducing the likelihood of fluid buildup and seromas. This technique not only eliminates the need for drains but can also result in faster recovery times and less post-operative discomfort for patients. While it has been shown to be highly effective, it is not without its challenges, such as a slightly longer surgical time and the need for a highly skilled surgeon to perform the procedure. Some surgeons may still prefer to use drains out of familiarity or due to concerns about fluid accumulation, especially in patients with certain body types or those undergoing significant liposuction. However, as more evidence supporting the benefits of drainless tummy tucks accumulates, this method is becoming increasingly popular for its enhanced patient comfort and streamlined recovery process.
While not every patient is a suitable candidate for a drainless approach, the procedure has proven to be a highly effective option. Your plastic surgeon needs experience in this technique, because incorrect placement of the sutures can cause major problems including contour deformities or dimpling and possible need for re-operation. Be sure to consult with an experienced plastic surgeon to determine if a drainless tummy tuck is right for you! 
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York

Rodger Shortt, FRCSC · Answer

I think patient's make a bigger deal of drains than doctors do.  I think the "drainless tummy tuck" has become a marketing term.  I think all skilled surgeons could do a tummy tuck with or without drains.  There are different considerations depending on whether you use it or not.  Personally I have used drains and I have not used drains over the years and currently see value in a drain for most people.  Essentially there are 3 possible options and a drain is the least inconvenient of the 3 in my opinion:

1.  Place a drain for 5 or 6 days.  Use a dressing that allows patients to shower.  It is simple to empty the fluid.  Drain can be removed essentially painlessly at first follow-up appointment.  The benefit includes minimizing the risk of a fluid collection (seroma).  After doing this as long as I have and performing countless tummy tucks this is my preferred treatment.

2.  Do not use a drain but place a number of progressive tension sutures.  The purpose is to further attach the skin and fat layer to the muscle layer.  This minimizes the size of the pocket that can fill with swelling fluid.  This is very effective at preventing a seroma.  Unfortunately, it does tether the tissue a fair bit which can lead to unnatural looking contours.  It can require a lot of massage therapy to get things moving.  It also probably has a higher chance of needing a revision procedure to improve the contour.

3.  Finally, you can not use a drain and not use the progressive tension sutures.  Unfortunately there is a high risk of a seroma forming.  Regular aspirations might be needed in the office for couple of weeks to resolve that.

There is no perfect answer.  Personally I think a drain for a few days is the preferred method.  If I have a patient who strongly opposes a drain it is easy enough to do a tummy tuck without a drain.

I think even more important questions than, "Does this surgeon use a drain or not?" would be, "Can they create a nice belly button?", "Are the scars discreet and hidden?", "If there is a problem, will they be there for me".  If the answer is yes to all these, whether they use a drain or not is far less important.

Dr. Rodger Shortt, Oakville, Ontario, plastic surgeon.

Ramin Behmand, MD, FACS · Answer

This is an excellent question.  In short, it appears that you are happy with the results you have seen from both surgeons, so either way, it is unlikely that you would make a mistake in your choice of surgeons.  That said, there are advantages to each technique, with drainless coming out ahead.

1. In a traditional tummy tuck, drains are necessary because after the removal of the excess abdominal tissue, the remaining abdominal skin is stretched down to the level of the lower abdominal incision without closing the open space between that tissue, and the muscle layer. So, there is a space there where fluid can collect.  By placing drains, that fluid is removed, and the two layers can heal together.

2. In a drainless tummy tuck, the above-mentioned space between the abdominal skin, and the muscle layer is eliminated (closed) with sutures, placed in a quilting fashion. Therefore, there is no need to place drains that remove fluid because there is not a space in which fluid could collect.

Advantages of a traditional tummy tuck: 
- there is less sewing to be done, so it is a bit faster. But not by much.

Disadvantages of a traditional tummy tuck:
- the obvious disadvantage is drains. They can be uncomfortable, and generally, what patients complain about the most.
- drain hole scars.  But, these are relatively minor.
- A lower abdominal scar that migrates up as you heal. This is probably the biggest disadvantage. The upper abdominal skin, which was pulled down tight, wants to pull back up as it heals (think window shade). Because there are no sutures anchoring it in place, it can actually move the lower abdominal scar higher as the patient heals. The tighter the closure, the more likely that this may happen.

Advantages of a drainless tummy tuck:
- no drains
- no drain scars
- better mobility early on after surgery
- generally a better shaped, and better positioned lower abdominal scar when healed. There is no upward scar migration.

Disadvantages of a drainless tummy tuck:
- It takes slightly longer to perform the surgery
- In the first 1–2 weeks, you may see the impression of the quilting sutures on the skin. But as that initial swelling goes down, these disappear.  This is a non-issue long-term.

I hope this helps.  Dr. B.

Jared Blau, MD · Answer

Hi there- both drain and drainless work, and you can get the same amount of tightening from both. Drainless has a lower rate of seroma based on the published data

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How to decide between drainless vs drains?

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Answer: Deciding between a drainless tummy tuck, and a traditional tummy tuck with use of drains

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