No Drain Tummy Tuck by Plastic Surgery Associates of Santa Rosa
About The No-Drain Tummy Tuck
This 55-year-old mother of two would like to get rid of the vertical scar after her C-section and improve her abdominal contour. Markings are made with a level. The no drain abdominoplasty uses progressive tension sutures as described by Doctors Harlan and Todd Pollock in this 2000 PRS article. Begin as with any full abdominoplasty by incising the umbilicus and elevating the abdominal flap. The lower abdomen should be widely undermined and the epigastrium should be undermined sufficiently to allow skin redraping after muscle plication. Plication techniques vary. Here, after the muscle edges are marked, an 0 PDS on a CT-1 needle is used as a running suture above and below the umbilicus.
For pain relief, 0.25% Marcaine with epinephrine is injected into the muscles deep to the fascia. EXPAREL is an alternative. Facilitate incremental flap advancement, flex the table aggressively, 30 to 45 degrees. Progressive tension sutures or PTS are the foundation for no drain abdominoplasty. The absence of drains means improved infection rates and post-op pain. It also reduces seroma and hematoma rates, improves flap advancement and distal perfusion, and reduced wound closure tension contributes to better scars. The suture used is a 2-0 Vicryl on an SH pop-off needle. Depending on the size of the patient, two to four sutures advance the superior flap and one to two are placed on either side of the umbilicus. Then, after insetting of the umbilicus, 8 to 12 sutures advance the lower flap. To place a PTS, the assistant advances the flap and the surgeon grabs Scarpa's fascia with the needle and sews the flap under tension to the muscle fascia. The difference between PTS and quilting sutures is quilting sutures close dead space, but unlike PTS, they don't advance the flap or distribute tension.
There are many ways to inset the umbilicus. Here, marks are made on the flap overlying the umbilical stalk in the shape of a circle with a 1.5 cm diameter. After injecting with local anesthesia, the plug of skin and fat is excised and the umbilical stalk is retrieved and inset with 4-0 buried Monocryl sutures. Later, closure will be completed with a 5-0 plain subcuticular. Progressive tension sutures can leave shallow dimples that typically resolve within six weeks. Sutures leaving deep dimples are too close to the skin and should be removed and redone right away. To remove the redundant tissue, approximate the flap in the midline and mark a straight line from each lateral corner to the midline. Adjust for major dog ears and save minor adjustments for the end. Inject local and excise.
To close, approximate Scarpa's with leftover 2-0 Vicryl pop-offs or 3-0 Vicryl. Then approximate the skin edges with deep dermal buried 4-0 Monocryls and for best dermal perfusion, use staples. Remove them by six or seven days to promote best scarring. After addressing dog ears, place a soft dressing. If a compression garment is used, make sure it doesn't impede venous return. The best part, no drains.