What is the Quilting Method and Why Does It Rule out the Need for Drains?

Great Question about Quilting.

In my Denver plastic surgery practice, I have been "Quilting" under all of my "Flaps" for Mommy Makeover, Tummy Tuck and Body Lift procedures for several years.

Quilting is the process of tacking down any tissue flaps that have been raised with sutures. There are two main benefits from this:


Closing down the open tissue plane (we will sometimes call this "dead space" or a potential space). The major benefit here is in preventing the formation of a pocket of fluid.

Spreading the tension out over the entire flap and many sutures. Sharing the tension and resupporting forces via multiple sutures lessens the tension placed at the incision closure line.


Some surgeons have eliminated drains when using "progressive tension" or multiple quilting sutures, however I typically still place drains. Perhaps I could stop using drains, but the length of time drains are needed and the rate of seeing fluid collections under my flaps (these are called "seromas") has dramatically decreased. I haven't seen a seroma in a tummy tuck patient in at least three years!

Hope this helps,

Nick Slenkovich MD, FACS

Thank you for your post. Whenever there is a potential space in your body, your body tends to fill that space with serous fluid (the yellow type of fluid that also comes out of a 'weeping wound'. This is similar to when you get a blister: the layers of skin separate and fluid is deposited in to the space. In a tummy tuck, the space is in between the skin/fat layer and the muscle layer. Most surgeons will place a drain to remove this fluid while your body is secreting it until the fat layer grows back together with the muscle layer. At that point, no more fluid is secreted into the area, because there is no more space for fluid. The length of time that this takes varies from patient to patient. Some patients heal much faster, thus the layers seal together much faster. Also, the more twisting motion you have in your belly area, the slower the two layers grow back together because they are moving in relation to each other. The fluid coming through the drain can be initially dark red, and eventually clears to pink then yellow. This is because it takes just a little bit of blood to make the fluid dark red. Also, initially, there can be a large amount of fluid (few hundred cc's in the first day is not out of the range of normal) and this should slow down substantially over next few days. Once the fluid slows down to the amount that your surgeon is comfortable with (usually 25-50 cc in 24 hours) then they will be pulled. There is minimal discomfort in pulling the drain in most patients. More recently, 'drain free' surgery has become more popular. Fat layer is sutured down to the muscle layer starting at the ribs and progressively down to the lower incision. This makes the space for the fluid to collect much smaller, and in many patients can have surgery without drains. However, I have seen multiple patients come from other surgeons because they developed a seroma despite the suturing of the tissue. This is not the surgeon's fault, but some patients just do not heal fast enough or put out too much fluid for the body to absorb. Best wishes,Pablo Prichard, MD

The most common complication after a tummy tuck is a fluid build-up known as seroma which typically is seen weeks after surgery. This occurs from the oozing of fluids from the cut edges of the tissues underneath the skin into the unhealed space that exists between it and the deeper abdominal muscles. A drain is traditionally used for prevention as it will pull this fluid off and collapse the 'roof''of the space down to the 'floor' of the space which can allow it to heal together. Once the space is removed by healing, there is no place for fluids to drain into and the fluid output stops and no build-up occurs. The value of the drain can be supplanted by quilting sutures which immediately bring the roof and the floor together and never having a significant place for fluids to go into from the beginning. This involves more time during to do and does increase cost slightly but it eliminates the need for drains and substantially lowers the risk of a fluid buildup.

I have been using this technique since 1998 and think it is a great addition to the procedure. Instead of using a drain to essentially suck an area closed (think of vacuum sealing food) the sutures sew the space together.  With either method there is a chance for seroma to form. Seroma is a fluid collection under the skin (think water balloon.)

In reviewing over a hundred of these many years ago we found that chance of seroma was no more than when using drains. As we have gotten even better with that suture we probably have even fewer now.

The other advantage is that it takes tension off of the skin incision, less tension usually means better scars.  Another name for the stich is progressive tension suture.

An abdominoplasty results in a lot of empty space between the abdominal muscles and the deeper fatty tissue connected to the skin. When this happens the body fills up space with fluid (that's why drains are so important).
As this heals the skin slowly reattach to the muscles below. Quilting sutures are designed to speed up this process and make the body have less empty space even though the surgery remains essentially the same. Since there is less "space" there is less drainage and the need for less time with a drain or no drain at all. There is one additional benefit in that there is less tension at the skin and the scar tends to be even better. Tension normally produces widened and uneven scars.
Given the opportunity, quilting sutures are a great addition to the tummy tuck procedure resulting in better outcomes and a quicker recovery.  The only downside is that the surgery takes a bit longer as we are adding an additional step in the process. Discuss this with your surgeon.

Hi.

As you can see from our video, we have only recently been using quilting sutures, and they are a  big advance. They eliminate the space under the skin where fluid can form (seroma). But we still do occasionally use a drain.

The quilting method in abdominoplasty utilizes a series of internal dissolving sutures that close down the space made by elevation of the skin. By closing down this space, a number of good things happen. the first is that it takes the tension off of the skin closure. The second is that there is limited space for fluids to accumulate, and there is less motion of the operated area, which may also decrease the fluid collection process. There are other things that can be done to decrease the likelihood of fluid collection, such as staying above the Scarpa's fascia in the lower abdominal dissection, thereby avoiding interruption of the lymphatics which run deep to this fascia. Tissue glues may help as well. 

Hope this helps!