Content uploaded by Jamil Ahmad
Author content
All content in this area was uploaded by Jamil Ahmad on Sep 29, 2018
Content may be subject to copyright.
Body Contouring
Aesthetic Surgery Journal
2017, Vol 37(4) 428–439
© 2017 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sjw241
www.aestheticsurgeryjournal.com
Featured Operative Technique
Drainless Abdominoplasty Using Barbed
Progressive Tension Sutures
Kathryn V. Isaac, MD; Frank Lista, MD; Mark P. McIsaac, MD; and
Jamil Ahmad, MD
Abstract
We describe our current technique of drainless abdominoplasty using barbed progressive tension sutures. The perioperative management and detailed
steps of procedure are outlined, including indications for concomitantly performing liposuction and repair of diastasis of the rectus abdominis muscles.
This approach reliably improves abdominal contour, minimizes complications, and is straightforward to learn and perform.
Editorial Decision date: September 20, 2016.
Abdominoplasty aims to correct abdominal contour defor-
mities. The technique has evolved from a purely excisional
procedure to excision combined with liposuction to further
enhance the aesthetic result.1-15
A frequently reported complication following abdom-
inoplasty is seroma. The reported incidence ranging
from 1% to 57%13,16-20 with an average incidence of
10%.21 Complications secondary to seroma formation
include wound dehiscence, skin necrosis, infection, and
capsule formation necessitating reoperation. Numerous
risk factors have been suggested for seroma formation.
Some potential etiologic include dead space resulting
from undermined areas, shearing forces between the
abdominoplasty flap and the smooth surface of the
deep fascia, higher weight of resected tissue, dissection
of lymphatics, and release of inflammatory mediators
postoperatively.21-30 A multitude of strategies have been
proposed to decrease the incidence of seroma includ-
ing using drains, limited undermining, preservation
of sub-Scarpal fat on the deep fascia, avoiding lipo-
suction, avoiding the use of electrocautery, and use of
tissue glues.23,24,31,32 More recently, use of progressive
tension sutures has been described to prevent seroma
formation.33,34
Since 2009, we have performed drainless abdomino-
plasty using barbed progressive tension sutures. In this
article, we describe our current technique for abdomino-
plasty along with indications for concomitantly performing
liposuction or repair of diastasis of the rectus abdominis
muscles. The guiding principles on the Declaration of
Helsinki were strictly applied and adhered to in this study.
The straightforward and safe approach presented in this
article consistently improves abdominal contour while
minimizing complications.
Dr Issac is a Resident, and Drs Lista and Ahmad are Assistant
Professors, Division of Plastic and Reconstructive Surgery,
Department of Surgery, University of Toronto, Toronto, Ontario,
Canada, and Dr Lista is Breast Section Co-editor for Aesthetic Surgery
Journal (ASJ) and Dr Ahmad is My Way Section Editor for ASJ. Dr
McIsaac is a Resident, Division of Internal Medicine, Department of
Medicine, University of Saskatchewan, Saskatoon, Saskatchewan,
Canada.
Corresponding Author:
Dr Jamil Ahmad, The Plastic Surgery Clinic, 1421 Hurontario Street,
Mississauga, Ontario, Canada L5G 3H5.
E-mail: drahmad@theplasticsurgeryclinic.com
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
Table1. Operative Sequence for Drainless Abdominoplasty Using Barbed
Progressive Tension Sutures
Step Details
1 Marking
2 Infiltration
3 Liposuction (if indicated)
4 Umbilical dissection
5 Infraumbilical dissection with sub-Scarpal fat preservation
6 Supraumbilical dissection
7Excision of sub-Scarpal fat where diastasis recti repair will be performed (if
indicated)
8Diastasis recti repair with two layered, continuous barbed suture (if indicated)
9 Marking and excision of excess skin
10 Marking and incision of new position for the umbilicus
11 Creating midline definition
12 Local anesthesia infiltration and insertion of pain pump catheters
13 Barbed progressive tension sutures
14 Barbed three-point suspension sutures of the lower abdominal incision
15 Closure of lower abdominal incision and inset of umbilicus
16 Application of dressings and abdominal binder
Isaac et al 429
PATIENT SELECTION AND PREOPERATIVE
ASSESSMENT
Patients presenting for abdominoplasty have a combina-
tion of several anatomical deformities:
1) Abdominal skin excess.
2) Abdominal subcutaneous fatty excess.
3) Diastasis of the rectus abdominis muscles and laxity of
the musculoaponeurotic layer of the abdominal wall.
4) Poor umbilical shape and/or malposition.
5) Mons pubis ptosis.
6) Abdominal wall hernia.
During the initial consultation, physical exam focuses
on identifying which of the aforementioned anatomical
deformities are present and these will dictate the technical
details required for abdominoplasty.
Patients must be nonsmokers. Patients must have
a stable weight over a 6-month period preceding sur-
gery and have a body mass index (BMI) of less than
35 kg/m2. In some patients following massive weight
loss, the BMI may be more than 35 kg/m2 if they have
lost a significant amount of weight and their weight has
plateaued.
SURGICAL TECHNIQUE
The operative sequence for drainless abdominoplasty is
reviewed in Table 1. A detailed video demonstrating the pro-
cedure may be viewed in Video 1 (available as Supplementary
Material at www.aestheticsurgeryjournal.com).
Preoperative Preparation
In the preoperative room, our warming protocol is started
and continued throughout surgery and while in the
recovery room.35 One hour prior to surgery, the patient
is premedicated with oral gabapentin 600 mg (Pfizer,
Kirkland, Quebec, Canada), celecoxib 200 mg (Pfizer,
Kirkland, Quebec, Canada), acetaminaphen 1000 mg
(Johnson & Johnson, Markham, Ontario, Canada), and
ondansetron hydrochloride dehydrate 8 mg (Novartis
Pharmaceuticals Canada Inc., Dorval, Quebec, Canada)
to reduce intraoperative opioid requirements and postop-
erative nausea and vomiting. All patients receive lower
extremity compression stockings and sequential com-
pression devices. Venous thromboembolism (VTE) risk
stratification is performed for each patient and prophy-
laxis is instituted according to the assessment of expos-
ing and predisposing risk factors.36 Chemoprophylaxis
for VTE risk reduction is planned for patients with very
high risk for VTE (Caprini/Davison risk assessment
model score >5 or abdominoplasty combined with
another surgery of estimated duration over 45 min-
utes). Chemoprophylaxis with subcutaneous dalteparin
sodium 5000 IU (Pfizer, Kirkland, Quebec, Canada) is
commenced the morning of postoperative day 1 and
continued for a total of 14 days.
Markings
Preoperative markings are made with the patient stand-
ing. The midline of the abdomen is marked from the
xiphoid to the pubic symphysis. The inferior abdominal
incision is marked starting in the midline. Superiorly
directed traction is placed on the lower abdominal skin
so that the mons pubis is on maximal stretch while the
inferior abdominal incision is marked 6 to 7 cm above
clitoral hood or base of the penis. This will address lax-
ity of the mons pubis while preventing an excessively
high scar. The central aspect of the inferior abdominal
incision is marked as a horizontal line with the skin
on maximal stretch to the medial aspect of the inguinal
crease. The inferior abdominal incision is then gently
curved superiorly to parallel to the inguinal ligament
towards a point, typically 2 to 3 cm, inferior to the
anterior superior iliac spine with the skin on maximal
stretch. We prefer to maintain a final scar that is very
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
430 Aesthetic Surgery Journal 37(4)
low on the abdomen so that it can be hidden with most
styles of underwear and bathing suits. In cases where it
may be impossible to excise the skin to a point superior
to the umbilicus, we keep the scar inferior and plan for
an inverted T-shaped scar instead of marking the patient
so that the scar ends more superiorly on the abdomen
(Figure 1).
The estimated superior extent of the resection is also
marked. This will serve as a reference line to ensure sym-
metrical scar location when the superior extent of the
resection is remarked intraoperatively after the elevation
of the abdominoplasty flap is completed. The estimated
superior incision is usually located just superior to the
umbilicus in the midline and gently curves inferiorly to
meet the inferior abdominal markings.
The inferior abdominal incision marking is extended
laterally beyond the estimated area of resection to allow
for intraoperative extension of the skin resection to prevent
dog-ear formation, if necessary (Figure 2).
The areas for liposuction are also marked preoperatively.
Positioning
The patient is positioned supine with the upper extremi-
ties abducted to 90 degrees at the shoulders. At the begin-
ning of the procedure, the operating table is adjusted so
that the patient is extended at the waist to approximately
20 degrees from neutral to make the abdominal wall taut.
This may help to prevent intraabdominal injury during
infiltration and liposuction.
Infiltration
The abdomen is infiltrated with a solution of 1L of lactated
Ringer’s with 1 mL of 1:10,000 epinephrine. If liposuction
is required, infiltration of the upper and lateral abdomen
is performed first to allow time for vasoconstriction. Use
of infiltration helps to decrease blood loss. Additionally,
the fluid may help to dissipate heat from electrocautery
used during the dissection limiting thermal damage that
can contribute to seroma formation.
Liposuction (if Indicated)
In patients with excess fatty tissue in the supraumbilical
skin and lateral abdominal skin, liposuction is performed
to enhance abdominal contour. Power-assisted liposuction
(Microaire Surgical Instruments, Charlottesville, VA) is
performed in the central and lateral upper abdomen with
a 4 mm cannula. Liposuction is performed in the middle
and deep thirds of the subcutaneous tissue, aspirating adi-
pose tissue both superficial and deep to Scarpa’s fascia.
Liposuction of the skin that will be excised is unnecessary.
Figure 1. This 51-year-old woman had abdominoplasty
approximately 20 years prior to presentation for secondary
abdominoplasty. Note the high position of the lower
abdominal scar.
Figure 2. Preoperative markings are made in the standing
position. (A) The inferior abdominal incision is marked
starting in the midline with superiorly directed traction so
that the mons pubis is on maximal stretch. The inferior
abdominal incision is marked 6 to 7 cm above the clitoral
hood. (B) The inferior abdominal incision marking is
extended laterally beyond the estimated area of resection to
allow for intraoperative extension of the skin resection, if
required, to prevent dog-ear formation. (C) The estimated
superior extent of the resection is also marked and this will
serve as a reference line to ensure symmetrical scar location
when the superior extent of the resection is remarked
intraoperatively after the elevation of the abdominoplasty
flap. (D) If indicated, the areas for liposuction are marked.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
Isaac et al 431
Dissection and Elevation of
Abdominoplasty Flap
The umbilicus is incised with a no.11 blade in an oval
shape superiorly and inverted V-shape inferiorly. The
umbilical stalk is separated from the surrounding subcu-
taneous tissues down to the deep fascia. The umbilical
stalk should not be skeletonized to ensure adequate blood
supply.
The lower abdominal incision is performed through the
skin and Scarpa’s fascia. The abdominoplasty flap is incised
in the midline from the umbilicus to the lower abdominal
incision to facilitate exposure during flap elevation. The
abdominoplasty flap is elevated just deep to Scarpa’s fascia,
leaving sub-Scarpal fat on the abdominal deep fascia in the
infraumbilical area (Figure 3). In the infraumbilical area,
the width of the undermined area extends the entire length
of the lower abdominal incision. Superior to the level of the
umbilicus, the dissection is continued on the abdominal
deep fascia and the extent of the dissection is limited to
the linea semilunaris laterally. This preserves blood supply
to the abdominoplasty flap and limits the amount of dead
space in the supraumbilical area (Figure 4).
Diastasis Recti Repair with Continuous
Barbed Suture (if Indicated)
After elevation of the abdominoplasty flap, the abdomi-
nal fascia is inspected and if diastasis recti is present then
repair is performed. If a hernia is present, this should be
repaired prior to diastasis recti repair.
Diastasis recti will present as an increased distance
between the medial edges of the rectus abdominis mus-
cles; typically greater than 2 cm at the widest point. The
goal of repair is reapproximating the medial edges of the
rectus abdominis muscles in the midline. The planned
width of the repair is marked with ink as a fusiform shape
along the medial edges of rectus abdominis muscles from
xiphoid to pubic symphysis (Figure 5). In the infraum-
bilical region, the sub-Scarpal fat is resected off of the
abdominal deep fascia located between the medial edges
of rectus abdominis muscles. This ensures fascia to fas-
cia approximation without fatty tissue interposed within
the repair. The repair is performed with #2 polydioxanone
(PDO) Stratafix (Johnson & Johnson, Markham, Ontario,
Canada). This is a bidirectional barbed suture. Prior to
using the barbed suture, it is immersed in a chlorhexidine
solution and kept on a sterile glove package. When using
barbed suture, contact of the suture with the skin, drapes,
and any other material with fibers should be avoided.
This will prevent contamination of the suture with debris
which can cause extrusion and infection.37 The suture is
passed through the fascia in the midline just inferior to the
xiphoid. A two layered diastasis recti repair is performed
using each arm of the bidirectional suture. The first arm is
passed as a continuous, horizontal mattress suture from
the xiphoid to the pubic symphysis. The suture should
pass within the fascia and spanning sutures should be
avoided. At the level of the umbilicus, the suture is passed
around on one side within the fascia and then the contin-
uous, horizontal mattress suture is performed again infe-
rior to the umbilicus to the pubic symphysis. The suture
is then continued back in a superior direction to lock it
in place. The second arm of the bidirectional suture is
passed as the second layer of the diastasis recti repair from
the xiphoid to the pubic symphysis. The suture should be
passed on the same side of the umbilicus that the first arm
was passed to avoid strangulation (Figure 6).
Figure 4. Dissection of abdominal flaps with preservation
of sub-Scarpal fat only in the region below umbilicus. Above
the umbilicus, the region of dissection is limited to the
lateral edges of the rectus abdominis muscles and the depth
is just superficial to the musculoaponeurotic plane.
Figure 3. Infraumbilical dissection with preservation of sub-
Scarpal fat. Elevation of the abdominoplasty flap is just deep
to Scarpa’s fascia (indicated by the asterisk).
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
432 Aesthetic Surgery Journal 37(4)
Marking and Excision of Excess Skin
The operating table is adjusted so that the patient is
flexed to approximately 135 degrees at the waist. The
abdominoplasty flap is split in the midline until the
appropriate degree of tension is achieved in the midline.
A towel clip is used to temporarily secure the abdomino-
plasty flap to the skin of the lower abdominal incision
in the midline. The lateral tissue in the abdominoplasty
flap is redraped medially to prevent formation of dog ears
laterally. Using a Lockwood flap demarcator (Accurate
Surgical & Scientific Instruments Corporation, Westbury,
NY), the position of the lower abdominoplasty incision
is transposed and marked along the abdominoplasty
flap. To ensure symmetry, the newly marked superior
extent of skin excess is compared with the preoperative
markings and the contralateral side. The resection of the
excess skin is performed perpendicular to the skin sur-
face through the subcutaneous tissue. If there is excess
sub-Scarpal fat, this can be excised from the distal aspect
of the abdominoplasty flap.
Creating Midline Definition
Superficial to the linea alba, there is a midline, fibrous
condensation of the subcutaneous tissues. To create a
defined midline, this fibrous condensation is intermit-
tently scored from the superior extent of the undermin-
ing to superior to the new position of the umbilicus.
Electrocautery is used to create partial thickness scores
of this fibrous condensation every 1 to 2 cm along the
midline (Figure 7). Disrupting this fibrous condensation
allows effacement of the subcutaneous tissue resulting in
a midline depression.
Marking and Incision of New Position for
the Umbilicus
The new position of the umbilicus is marked in the midline
by putting superiorly directed traction of the umbilicus and
transposing the location of the umbilicus to the skin surface.
This is typically about 2 cm superior to the level of the iliac
crest. An inverted V-shaped incision is made with a no.11
blade scalpel and the fat deep to the incision is excised to
create a depression for the umbilicus. An inverted V inci-
sion is preferred as this results in superior hooding. The
inferiorly based skin flap created by the inverted V-shaped
incision will be inset into the split in the inferior aspect of
the umbilicus in a tongue-and-groove manner. This creates
a pleasing umbilical contour while helping to avoid circum-
ferential scar contracture of the umbilicus.
Local Anesthesia Infiltration and
Insertion of Pain Pump Catheters
To provide optimal postoperative pain management,
20 mL of 0.25% marcaine are injected into the abdomi-
nal fascia. Two marcaine pain pump catheters (Alpha 200
Figure 5. (A) Photographed and (B) illustrated planned
width of diastasis recti repair with barbed suture plication.
Denuding the fascia of sub-Scarpal fat in the area for rectus
diastasis repair. Removal of this tissue is necessary to ensure
edge-to-edge approximation of fascia during the barbed
suture plication.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
Isaac et al 433
Infusion Pump, Advanced Infusion, San Dimas, CA) are
inserted deep to the anterior rectus sheath for continuous
infusion of marcaine, postoperatively. The pain pump is
loaded with 80 mL of 0.5% marcaine mixed with 32 mL of
0.9% sodium chloride solution. It is administered at a rate
of 4 mL/hour for 12 hours total.
Barbed Progressive Tension Sutures
Progressive tension sutures are used to fixate the abdom-
inoplasty flap to the abdominal deep fascia to help pre-
vent seroma formation by obliteration of dead space and
preventing shearing of the abdominoplasty flap from the
abdominal deep fascia.
The planned location of the first barbed progressive ten-
sion suture is marked with ink as a longitudinal line over
the lateral aspects of each rectus abdominis muscles from
the xiphoid to the mons pubis and continued laterally to the
lateral extent of the lower abdominal incision (Figure 8). The
lateral extensions curve superiorly and then inferiorly so the
suture ends up halfway between the lower abdominal inci-
sion and the superior extent of undermining. The second
barbed progressive tension suture is marked along the lower
abdominal incision and is described later. Progressive ten-
sion sutures are performed using 0 PDO Stratafix.
When performing the progressive tension suture, the
suture should be passed through Scarpa’s fascia in the
abdominoplasty flap and the abdominal deep fascia to
have adequate purchase. The suture should not be placed
superficially in the abdominoplasty flap as this will
result in dimpling of the skin that will not resolve with
time (Figure 9). Careful placement of the barbed suture
through Scarpa’s fascia is critical to avoid dimpling of
the skin. The first suture is placed at the superior extent
of undermining in the midline. Each arm of the bidirec-
tional suture is continued in an inferior direction to the
right and the left of the midline to close the dead space
in the paramedian area. The suture should pass within
the tissues and spanning sutures should be avoided. It is
important to reassess where each suture should be placed
by redraping the abdominoplasty flap onto the abdominal
fascia after each suture pass. During the vertical com-
ponent of the first progressive tension suture, between
the xiphoid and mons pubis, the sutures are placed more
medially on abdominoplasty flap and more laterally on
the abdominal deep fascia to appropriately redrape the
flap and prevent skin bulging in the midline, thereby
creating a smoother contour. During the horizontal com-
ponent of the first progressive tension suture, along the
lower abdominal incision, the sutures are placed more
laterally on abdominoplasty flap and more medially on
Figure 7. (A) Intermittent scoring of the fibrous condensation in the midline with cautery creates a concavity which
accentuates (B) midline definition.
Figure 6. Plication of the fascia is performed with a two
layer continuous #2 PDO Stratafix barbed suture.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
434 Aesthetic Surgery Journal 37(4)
the abdominal deep fascia to appropriately redrape the
lateral abdominal skin and help prevent dog ear forma-
tion at the lateral extent of the lower abdominal incision.
Provisionally closing the lower abdominal incision with
towel clips will help to ensure appropriate redraping of
the abdominal skin while performing progressive ten-
sion sutures in the lower abdomen. The towel clips are
intermittently removed and replaced as the progressive
tension suture is performed medial to lateral to ensure
precise insetting of the lower abdominal flap.
Barbed Three-Point Suspension Sutures
of the Lower Abdominal Incision
The lower abdominal incision is closed with a 0 PDO
Stratafix, continuous three-point suture between Scarpa’s
fascia of the superior and inferior wound edges and the
deep fascia. The suture is started in the midline and per-
formed in a medial to lateral direction bilaterally. Ensuring
that Scarpa’s fascia is secured with each pass of the suture
is especially important to ensure correction of mons pubis
ptosis. Additionally, closure with this long absorbing
suture will prevent scar widening and migration.
Closure
The skin is reapproximated with 3-0 Vicryl (Johnson &
Johnson, Markham, Ontario, Canada) interrupted, inverted
deep dermal sutures followed by a continuous, horizontal
mattress deep dermal suture. Staples are used on the skin.
The umbilicus is inset with 4-0 Monocryl Plus (Johnson
& Johnson, Markham, Ontario, Canada) interrupted,
inverted deep dermal sutures followed by a continuous,
intradermal suture. The continuous suture should not be
pulled tight or this will lead to circumferential scar con-
tracture of the umbilicus (Figure 10).
Application of Dressings and
Abdominal Binder
The pain pump is secured and activated. The incisions are
dressed with petroleum gauze and ABD pads (Medline,
Figure 8. (A) Photographed and (B) illustrated marking of the abdominal musculoaponeurotic layer where the progressive
tension sutures will be performed for obliteration of dead space and inset of abdominal flaps.
Figure 9. (A) Photographed and (B) illustrated progressive tension suturing between the abdominal musculoaponeurotic layer
and Scarpa’s fascia.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
Isaac et al 435
Mundelein, IL). An abdominal binder is placed over the
dressings.
Postoperative Care
The multimodal postoperative oral analgesia regime continues
with celecoxib 200 mg once daily for five days, and oxycodone
hydrochloride 5 mg/acetaminophen 325 mg (Bristol-Myers
Squibb, Montreal, Quebec, Canada) one to two tablets every
four to six hours as needed. Most patients are encouraged to
discontinue narcotic pain medicine within one week following
surgery. Additionally, ondansetron hydrochloride dehydrate
8 mg three times daily is continued for one day following sur-
gery to prevent postoperative nausea and vomiting and docu-
sate sodium 100 mg (Apotek, Toronto, Ontario, Canada) twice
daily is continued while taking any narcotic pain medicine.
Patients take Arnica montana 12C (Boiron, Saint-Bruno-de-
Montarville, Quebec, Canada) five pellets three times daily for
10 days to help with ecchymosis and swelling.
All abdominoplasty surgeries alone or in combina-
tion with other procedures are performed as ambulatory
surgery. Typically, the patient ambulates with assistance
within one hour after completion of surgery.
Routine follow-up is scheduled at 1 day, 6 days, 2
weeks, 4 weeks, 6 weeks, 3 months, and 1 year after sur-
gery. During the postoperative day 1 visit, the dressings are
changed and the Marcaine pain pumps are removed. The
abdominal binder is discontinued and a compression gar-
ment is placed and worn at all times except during show-
ers for 6 weeks postoperatively. Patients are encouraged to
shower once daily starting postoperative day 2 and apply
antibiotic ointment to the incisions three times daily. At
the postoperative day 6 visit, the staples are removed and
SteriStrips (3M, St. Paul, MN) are applied. Patients begin
massaging the abdomen to help with edema and desensi-
tization. Silicone treatment of the scars is started once the
incisions have completely healed, typically between 2 to
4 weeks postoperatively, and continued for 4 to 6 months
after surgery. Patients typically resume normal activity at
2 weeks postoperatively and strenuous activity at 6 weeks
postoperatively.
CLINICAL EXPERIENCE
Patient Demographics and Procedural
Characteristics
This technique for drainless abdominoplasty has been
performed by one of the senior authors (F.L.) since 2009.
However, it was during 2011 when the second senior
author (J.A.) joined the practice and we began to exam-
ine outcomes. We performed a retrospective chart review
of all abdominoplasty surgery performed by the senior
surgeons (F.L. and J.A.) with our technique for drain-
less abdominoplasty using barbed progressive tension
sutures.
Between September 2011 and October 2015, 502 patients
underwent abdominoplasty (Figures 11 and 12). The mean
age was 41 years (range, 18-70 years) and 488 patients
(97.2%) were female. The mean BMI was 25.4 kg/m2
(range, 17.1–40.9 kg/m2). Liposuction was performed in
232 cases (46.2%) while repair of the diastasis recti was
performed in 393 cases (78.3%). Two hundred and thir-
ty-seven patients (47.2%) had abdominoplasty combined
with another procedure.
Complications
The most common complication was seroma experienced
by 20 patients (4.0%). All were treated with percutane-
ous needle aspiration every 3 to 7 days in clinic until
they resolved; none required reoperation. Seromas were
most commonly detected in the infraumbilical region
around the 2-week postoperative visit. A range of 1 to 4
percutaneous aspirations every 3 to 7 days were required
for resolution of the seromas (Video 2, available as
Supplementary Material at www.aestheticsurgeryjournal.
com). The number of aspirations required for resolution
did not appear to correlate with the volume of seroma on
initial detection.
Infection occurred in 4 patients (0.8%). Hematoma
occurred in 1 patient (0.2%) and this required reoperation
for drainage. Interestingly, the size of the hematoma was
limited by the surrounding progressive tension sutures
which restricted the potential space and acted to tampon-
ade the bleeding. One patient (0.2%), who underwent
abdominoplasty in combination with breast augmenta-
tion-mastopexy, experienced a pulmonary embolism that
occurred on postoperative day 11. This was treated and did
not result in any long-term sequelae. No persistent dim-
pling of the abdominal flap was noted by the surgeons nor
the patients.
Figure 10. Appearance of abdomen after final wound closure.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
436 Aesthetic Surgery Journal 37(4)
DISCUSSION
The etiology of seroma formation following abdomino-
plasty is multifactorial. In our technique for drainless
abdominoplasty, multiple strategies are employed to
reduce this complication. Highlighted strategies include
preservation of sub-Scarpal fat, limited undermining
of the abdominal flap, and barbed progressive ten-
sion sutures. Preservation of sub-Scarpal fat may help
obliteration of dead space and help adherence of the
abdominal flap to the musculoaponeurotic abdominal
wall. The limited undermining is necessary for preser-
vation of vascular supply of the abdominal flap allow-
ing liposuction, if indicated, to be safely combined with
abdominoplasty. Additionally, the limited undermining
limits dead space.
Performing progressive tension sutures is a critical
step in our drainless abdominoplasty technique. This
strategy aims to reduce seroma formation through
obliteration of dead space and prevention of shearing
A B
CD
EF
Figure 11. (A, C, E) Preoperative and (B, D, F) 6-month postoperative photographs of a 52-year-old woman who underwent
drainless abdominoplasty using barbed progressive tension sutures. Her BMI is 25 kg/m2. She had liposuction and rectus
diastasis repair. Her surgery is shown in Video 1.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
Isaac et al 437
between the abdominoplasty flap and musculoapo-
neurotic abdominal wall. The suture used is a PDO
Stratafix and was specifically chosen to allow for an
expeditious and reliable closure. The presence and
bidirectionality of the barbs in the PDO Stratafix
suture facilitate execution and speed of the maneuver
by maintaining the tension of the suture in the tissue
as it is progressively placed interfascial or between
the fascial and subcutaneous tissues. This absorb-
able Polydioxanone suture is essentially absorbed
between 180 and 220 days, which is nearly double
the length of time the suture is retained compared to
other available absorbable barbed sutures composed
of polyglycolide-polycaprolactone.38
Several techniques using barbed sutures have been
described for progressive tension sutures during abdomino-
plasty. Warner and Gutowski39 described using Quill barbed
suture (Angiotech Pharmaceuticals, Inc., Vancouver, British
Columbia, Canada) for progressive tension sutures. They
examined the time taken to perform progressive tension
B
CD
EF
A
Figure 12. (A, C, E) Preoperative and (B, D, F) 3-year postoperative photographs of a 45-year-old woman underwent drainless
abdominoplasty using barbed progressive tension sutures. Her BMI is 26 kg/m2. She had liposuction and rectus diastasis repair.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
438 Aesthetic Surgery Journal 37(4)
sutures with Quill barbed suture and found that the use
of barbed suture decreased the time taken to perform this
aspect of abdominoplasty compared with interrupted pro-
gressive tension sutures. With their technique, they place
multiple vertically oriented rows of progressive tension
barbed sutures. They did not go into detail on the amount of
undermining of the abdominoplasty flap or if there was any
preservation of the sub-Scarpal fat, which may also help to
decrease seroma formation. Additionally, they did not use
a three-point barbed suture closing along inferior incision.
Rosen40 compared the effect of using Quill barbed
sutures without drains to non-barbed sutures with drains
for abdominoplasty closure on operative time, closure
cost, and complications. There was no seroma in the
barbed suture group and 1 seroma in non-barbed suture
group. This article focused on a comparative analysis
between the two groups and not on the other technical
aspects which may also contribute to decreasing seroma
formation.
In this article, we have attempted to describe all of the
technical strategies that may contribute to reducing the
incidence of clinically significant seroma formation. The
major strategies in our abdominoplasty technique includ-
ing sub-Scarpal preservation of fat, limited undermining
of the abdominal flap, and progressive tension sutures to
close dead space.
CONCLUSIONS
Based on our series, this is a safe, reliable drainless abdom-
inoplasty technique utilizing barbed progressive tension
sutures. It consistently improves abdominal contour while
minimizing complications.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
REFERENCES
1. Ramirez OM. Abdominoplasty and abdominal wall reha-
bilitation: a comprehensive approach. Plast Reconstr Surg.
2000;105(1):425-435.
2. Matarasso A, Matarasso DM, Matarasso EJ.
Abdominoplasty: classic principles and technique. Clin
Plast Surg. 2014;41(4):655-672.
3. Saldanha OR, Pinto EB, Matos WN Jr, Lucon RL,
Magalhães F, Bello EM. Lipoabdominoplasty without un-
dermining. Aesthet Surg J. 2001;21(6):518-526.
4. Saldanha OR, Federico R, Daher PF, et al. Lipoabdominoplasty.
Plast Reconstr Surg. 2009;124(3):934-942.
5. Saldanha OR, Azevedo SF, Delboni PS, Saldanha Filho
OR, Saldanha CB, Uribe LH. Lipoabdominoplasty:
the Saldanha technique. Clin Plast Surg.
2010;37(3):469-481.
6. Saldanha OR, Salles AG, Ferreira MC, et al. Aesthetic
evaluation of lipoabdominoplasty in overweight patients.
Plast Reconstr Surg. 2013;132(5):1103-1112.
7. Roostaeian J, Harris R, Farkas JP, Barton FE, Kenkel JM.
Comparison of limited-undermining lipoabdominoplasty
and traditional abdominoplasty using laser fluorescence
imaging. Aesthet Surg J. 2014;34(5):741-747.
8. Epstein S, Epstein MA, Gutowski KA. Lipoabdominoplasty
without drains or progressive tension sutures: an analysis of
100 consecutive patients. Aesthet Surg J. 2015;35(4):434-440.
9. Graf R, de Araujo LR, Rippel R, Neto LG, Pace DT, Cruz
GA. Lipoabdominoplasty: liposuction with reduced un-
dermining and traditional abdominal skin flap resection.
Aesthetic Plast Surg. 2006;30(1):1-8.
10. Swanson E. Prospective outcome study of 360 patients
treated with liposuction, lipoabdominoplasty, and abdom-
inoplasty. Plast Reconstr Surg. 2012;129(4):965-978.
11. Swanson E. Prospective clinical study of 551 cases of
liposuction and abdominoplasty performed individu-
ally and in combination. Plast Reconstr Surg Glob Open.
2013;1(5):e32.
12. Heller JB, Teng E, Knoll BI, Persing J. Outcome analysis of
combined lipoabdominoplasty versus conventional abdom-
inoplasty. Plast Reconstr Surg. 2008;121(5):1821-1829.
13. Weiler J, Taggart P, Khoobehi K. A case for the safety and
efficacy of lipoabdominoplasty: a single surgeon retro-
spective review of 173 consecutive cases. Aesthet Surg J.
2010;30(5):702-713.
14. Levesque AY, Daniels MA, Polynice A. Outpatient lipo-
abdominoplasty: review of the literature and practi-
cal considerations for safe practice. Aesthet Surg J.
2013;33(7):1021-1029.
15. Samra S, Sawh-Martinez R, Barry O, Persing JA.
Complication rates of lipoabdominoplasty versus tradi-
tional abdominoplasty in high-risk patients. Plast Reconstr
Surg. 2010;125(2):683-690.
16. Hensel JM, Lehman JA Jr, Tantri MP, Parker MG, Wagner
DS, Topham NS. An outcomes analysis and satisfaction
survey of 199 consecutive abdominoplasties. Ann Plast
Surg. 2001;46(4):357-363.
17. Floros C, Davis PK. Complications and long-term results
following abdominoplasty: a retrospective study. Br J
Plast Surg. 1991;44(3):190-194.
18. Alderman AK, Collins ED, Streu R, et al. Benchmarking
outcomes in plastic surgery: national complication rates
for abdominoplasty and breast augmentation. Plast
Reconstr Surg. 2009;124:2127-2133.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018
Isaac et al 439
19. Trussler AP, Kurkjian TJ, Hatef DA, Farkas JP, Rohrich
RJ. Refinements in abdominoplasty: a critical outcomes
analysis over a 20-year period. Plast Reconstr Surg.
2010;126(3):1063-1074.
20. Stevens WG, Repta R, Pacella SJ, et al. Safe and con-
sistent outcomes of successfully combining breast sur-
gery and abdominoplasty: an update. Aesthet Surg J.
2009;29(2):129-134.
21. Di Martino M, Nahas FX, Kimura AK, Sallum N, Ferreira
LM. Natural evolution of seroma in abdominoplasty. Plast
Reconstr Surg. 2015;135(4):691e-698e.
22. Araco A, Gravante G, Araco F, Sorge R, Cervelli V.
Postoperative seromas after abdominoplasty: a retrospec-
tive analysis of 494 patients and possible risk factors.
Plast Reconstr Surg. 2009;123(4):158e-159e.
23. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture
prevent seroma in abdominoplasty? Plast Reconstr Surg.
2007;119:1060-1064.
24. Borile G, Pavelecini M, Dreher R, Chem E, Chem RC.
The use of suction drains in abdominal dermolipec-
tomy: a randomized clinical trial. Plast Reconstr Surg.
2008;121(4):228e-229e.
25. Kulber DA, Bacilious N, Peters ED, Gayle LB, Hoffman
L. The use of fibrin sealant in the prevention of seromas.
Plast Reconstr Surg. 1997;99(3):842-849.
26. Mabrouk AA, Helal HA, Al Mekkawy SF, Mahmoud
NA, Abdel-Salam AM. Fibrin sealant and lipoabdomino-
plasty in obese grade 1 and 2 patients. Arch Plast Surg.
2013;40(5):621-626.
27. Yilmaz KB, Dogan L, Nalbant H, et al. Comparing scalpel,
electrocautery and ultrasonic dissector effects: the impact
on wound complications and pro-inflammatory cytokine
levels in wound fluid from mastectomy patients. J Breast
Cancer. 2011;14(1):58-63.
28. Sforza M, Husein R, Andjelkov K, Rozental-Fernandes
PC, Zaccheddu R, Jovanovic M. Use of quilting sutures
during abdominoplasty to prevent seroma formation: are
they really effective? Aesthet Surg J. 2015;35(5):574-580.
29. Najera RM, Asheld W, Sayeed SM, Glickman LT.
Comparison of seroma formation following abdomino-
plasty with or without liposuction. Plast Reconstr Surg.
2011;127(1):417-422.
30. Grigoryants V, Baroni A. Effectiveness of wound closure
with V-Loc 90 sutures in lipoabdominoplasty patients.
Aesthet Surg J. 2013;33(1):97-101.
31. Nahas FX, di Martino M, Ferreira LM. Fibrin glue as a
substitute for quilting suture in abdominoplasty. Plast
Reconstr Surg. 2012;129(1):212e-213e.
32. Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap
elevation in a more superficial plane: decreasing the
need for drains. Plast Reconstr Surg. 2010;125(2):677-682.
33. Pollock TA, Pollock H. No-drain abdominoplasty
with progressive tension sutures. Clin Plast Surg.
2010;37(3):515-524.
34. Pollock TA, Pollock H. Progressive tension sutures in
abdominoplasty: a review of 597 consecutive cases.
Aesthet Surg J. 2012;32(6):729-742.
35. Lista F, Doherty CD, Backstein RM, Ahmad J. The impact
of perioperative warming in an outpatient aesthetic sur-
gery setting. Aesthet Surg J. 2012;32(5):613-620.
36. Somogyi RB, Ahmad J, Shih JG, Lista F. Venous throm-
boembolism in abdominoplasty: a comprehensive
approach to lower procedural risk. Aesthet Surg J.
2012;32(3):322-329.
37. Cortez R, Lazcano E, Miller T, et al. Barbed sutures and
wound complications in plastic surgery: an analysis of
outcomes. Aesthet Surg J. 2015;35(2):178-188.
38. Matarasso A, Moya AP. Barbed sutures in body surgery.
Aesthet Surg J 2013;33(3S):57S-71S.
39. Warner JP, Gutowski KA. Abdominoplasty with progres-
sive tension closure using a barbed suture technique.
Aesthet Surg J. 2009;29(3):221-225.
40. Rosen AD. Use of absorbable running barbed suture
and progressive tension technique in abdomi-
noplasty: a novel approach. Plast Reconstr Surg.
2010;125(3):1024-1027.
Downloaded from https://academic.oup.com/asj/article-abstract/37/4/428/3020321 by guest on 29 September 2018