Why do so many doctors use drains when drainless Tummy Tucks seem to have no "cons" aside from longer under anesthesia?! (photo)

Most surgeons still use drains because they were trained that way and they have been getting nice results with their technique. We used to get very nice results using drains as well. However, we transitioned from using drains to the no drain tummy tuck procedure 4 years ago and the addition of this technique of the best things I have done for my patients.  We used to use drains in order to supposedly prevent fluid collections after surgery (called seroma). It only takes an extra 15-20 minutes to place the progressive tension sutures in the operating room. In a study we conducted in over 450 tummy tucks over 7 years we found the the seroma rate was 9% when drains were used and it dropped to 2% when the no drain tummy tuck procedure was introduced to our practice. The drains are not only annoying to care for, they are painful at the exit site, are a possible source of infection and always leave some additional scar (even if they come out the ends of the incision). I believe that someday drains in tummy tucks will be a thing of the past as more plastic surgeons realize how much better it is to not have the drains.

Our meta-analysis research 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 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

I too performed abdominoplasty for many years with drains. This was the standard teaching since there was a large open space that tended to collect fluid, and drainage would be the logical approach to avoid fluid collection.
With the progressive tension technique, there is not only the advantage of elimination of the dead space and potential for excess fluid collection, but there is the additional advantage of spreading the tension out and having better healing of the suture line.
I would therefore recommend that you seek a plastic surgeon who does use this technique.
Just one point that I would like to make, and that is that this does not guarantee that you won't have a hematoma or fluid collection. Neither does a drain however. In general my experience is that the incidence of fluid collection or hematoma is lower with the drainless technique.

Unless you suture the  abdominal flap back down, you have to use drains to absorb the fluid that collects.  The fluid will prevent the surfaces from sticking and healing and may form a cavity called a bursa that may require surgery to correct.  However drains do not prevent all fluid collection, called seromas, and then the surgeon  has  to puncture the fluid collection (aspirate the fluid), 1-3  times on  average, until no more fluid keeps accumulating.  By carefully suturing the abdominal flap back down to the  abdominal wall, fluid collection is kept to such a minimum that no seroma can form.
Why more surgeons do not use them may be multifactorial, e.g. feeling there is some risk of seroma, thinking that their current technique works for them, so why change? Not wanting to take the extra time, or not wanting to have the added expense involved in taking more time.
I have used a drainless tummy tuck for the last five years, and have not had a clinically significant seroma, so this is my method of choice.  I originally started with the suturing technique and drains, but there was insufficient fluid in the drain to justify using them, so I evolved to using the suturing technique without drains.  The literature supports this:
Even
with drains or tissue glue there is a a 5-45 % incidence of seroma per the
literature. A meta-analysis in the Aesthetic Surgery Journal, 
Aesthet
Surg J. 2017 Mar 1;37(3):316-323. doi: 10.1093/asj/sjw192.
Seretis
K, Goulis, D, Demiri EC, Lykoudis, EG
Prevention
of Seroma Formation Following Abdominoplasty: A Systematic Review and
Meta-Analysis
reviewed
all the literature on this topic, and found that "preventive
measures" decreased the incidence of seroma four-fold. One of the studies
included in the "preventive group" that
used only progressive tension sutures, from 2006, showed fluid
accumulation between the sutures, detected only on ultrasound. This fluid was
not clinically detectable by palpation or inspection and resulted in no need
for seroma aspiration or any complication. The total amount of fluid associated
with clinical complications including drainage in the other groups was
greater than 80 cc, and the total amount of non-clinically
detectable fluid in the progressive-tension group was always 80 cc or
less. The use of drains plus progressive tension sutures did not change the
amount of fluid, so there is really no benefit to using drains plus progressive
tension sutures.

  

It is typical for a surgeon to stick with a technique that he/she is comfortable with. While the drainless technique is not new, it has gained some recent popularity due to recent publications. I personally think the drainless technique is superior because it reduces your risk of complications and you can advance the skin further with the progressive stitches. This allows the surgeon to remove more loose skin from your tummy. Hope this helps!
Phillip Dauwe, MD

The reason many surgeons still use drains after a tummy tuck is because this is the way everyone used to do it. Many surgeons tend to stick to the technique with which they feel most comfortable. However, more and more surgeons are now realizing that tummy tucks can be safely performed WITHOUT drains. And that patients love it!
A drainless tummy tuck procedure usually involves placement of multiple "progressive tension sutures" deep under the skin. By helping to quilt down the skin flap to the underlying abdominal wall, this eliminates "dead space" where fluid collections (or seromas) could form. These sutures also prevent shearing forces between the skin and abdominal wall, which reduces inflammation and fluid production under the skin. Both these factors help to make drains unnecessary. These sutures are resorbable and will dissolve over time. Although it takes some additional time to place these sutures, it only adds about 15-30 minutes at most to the procedure time. The additional OR costs for this are not very much - plus drains themselves cost money too. I believe the enhanced patient comfort without drains is well worth this small amount of additional operative time.
The other benefit of "progressive tension sutures" is that they help to take tension off the skin closure, and could help prevent scar widening as you heal.
There have now been multiple studies with hundreds of patients that had drainless tummy tucks. And these have shown that drainless tummy tucks are indeed very safe - in fact, this technique might result in even fewer seromas than when drains are used. I recommend drainless tummy tucks to tall my patients.
Emile N. Brown, MD 
Johns Hopkins & Harvard Trained Plastic Surgeon