Aesth Plast Surg DOI 10.

1007/s00266-011-9807-8

ORIGINAL ARTICLE

Suction Drains, Quilting Sutures, and Fibrin Sealant in the Prevention of Seroma Formation in Abdominoplasty: Which is the Best Strategy?
Marcos Eduardo Bercial Miguel Sabino Neto Jose Augusto Calil Luis Antonio Rossetto Lydia Masako Ferreira

Received: 26 June 2011 / Accepted: 24 July 2011 Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011

Abstract Background Seroma is the most common complication in abdominoplasty and abdominal ultrasound is one of the best noninvasive methods for diagnosing seroma formation. The aim of this study was to compare the use of suction drains, quilting sutures, and brin sealant in abdominoplasty to determine the best strategy to prevent seroma formation. Methods Forty-three female patients, aged 2066 years, nonsmokers, with Nahas type III deformities, and body mass index (BMI) ranging from 18.0 to 24.9 kg/m2, underwent abdominoplasty between March and October 2008 in a public hospital setting. The patients were randomly allocated to one of three treatment groups: DN group (n = 15), abdominoplasty with suction drains alone; QS group (n = 13), abdominoplasty with quilting suture between the subcutaneous tissue of the ap and musculoaponeurotic layer of the anterior abdominal wall; and FS group (n = 15), abdominoplasty with brin sealant. All patients underwent ultrasound examination on postoperative days 15 and 30 for detection of abdominal uid collections. Results The groups were homogeneous for age and BMI. There was a signicant reduction in seroma formation between postoperative days 15 and 30 in the three groups (DN group, P = 0.0003; QS group, P = 0.0011; and FS

group, P = 0.0003). Seroma formation was signicantly higher in the FS group (H = 6.04, P \ 0.05) compared with the DN and QS groups on postoperative day 15. Conclusion Seroma formation was signicantly lower in the DN and QS groups compared with the FS group on postoperative day 15. Keywords Seroma Fibrin sealant Drainage, Suction Abdominal wall Surgery

M. E. Bercial (&) M. Sabino Neto L. A. Rossetto L. M. Ferreira Division of Plastic Surgery, Department of Surgery, Universidade Federal de Sao Paulo (UNIFESP), Rua Napoleao de Barros 715, 4o. Andar, Sao Paulo, SP 04024-002, Brazil e-mail: bercial@hotmail.com J. A. Calil Plastic Surgery Unit, Hospital do Servidor Publico Municipal de Sao Paulo, Sao Paulo, Brazil

Abdominoplasty is one of the most commonly performed aesthetic procedures throughout the world [13], and seroma formation is its most common complication [3, 7, 12, 13]. Seroma is usually formed in the dead space between the fascia of the rectus abdominis muscle and abdominal ap after abdominoplasty [12]. Repeated aspirations may be required to treat seromas [12]. Untreated chronic seromas may lead to the formation of a capsule (pseudobursa) around the seroma, creating a secondary deformity [8, 20]. Baroudi and Ferreira [3] described the use of quilting sutures between the abdominal ap and the rectus abdominis sheath during abdominoplasty to prevent seroma formation. Good results have also been reported by other authors using this procedure [1214]. The placement of prophylactic drains [18] and use of brin sealant [5, 19] in abdominoplasty have been described as an attempt to reduce seroma formation after surgery, but the incidence of seroma has remained high. In those studies, seroma formation was detected by clinical examination and puncture and aspiration [5, 13, 14, 19] or by abdominal ultrasound [12, 17]. The aim of this study was to compare the three strategies for the prevention of seroma formation after abdominoplasty (suction drains, quilting sutures, and brin sealant) by measuring seroma volume using abdominal ultrasound

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at two time points (postoperative days 15 and 30). No study was found in the literature comparing these three strategies.

Materials and Methods The study was approved by the Research Ethics Committee of the Universidade Federal de Sao Paulo (UNIFESP), Brazil, and performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its succeeding revisions. Written informed consent was obtained from all patients prior to their inclusion in the study, and anonymity was assured. This was a prospective randomized trial conducted between March and October 2008. All patients were referred from the Plastic Surgery Outpatient Clinic of the Hospital do Servidor Publico Municipal de Sao Paulo. A convenience sample of 43 patients included women aged 2066 years who were nonsmokers, had Nahas type III deformities (excess skin and supra- and infraumbilical abdominal wall deformities) [11], had a body mass index (BMI) ranging from 18.0 to 24.9 kg/m2, were in good clinical condition, had been pregnant in the previous 12 months, had not undergone previous abdominal surgery and/or bariatric surgery, and expressed the desire to undergo abdominoplasty. They all signed the written informed consent. The patients were randomly assigned by lottery a few minutes before undergoing surgery to one of the three treatment groups: DN group (n = 15), abdominoplasty with suction drains; QS group (n = 13), abdominoplasty with quilting sutures between the subcutaneous tissue of the ap and musculoaponeurotic layer of the anterior abdominal wall, but without suction drains; and FS group (n = 15), abdominoplasty with brin sealant, but without suction drains. All patients received spinal anesthesia. A dermal-fat ap was detached from the musculoaponeurotic layer of the anterior abdominal wall using an electrocautery device. An incision was made in the suprapubic region and extended to the umbilical region, as previously marked, and the umbilicus was incised from the skin. The detachment of the dermal-fat ap extended laterally to the external oblique muscles, and superiorly from the supraumbilical region to the xiphoid process, through a tunnel 10.0 cm wide. Liposuction was not performed prior to the ap surgery. Patients with diastasis recti greater than 1.0 cm were treated by plication of the anterior rectus muscle, in a single plane, with interrupted cross-stitches using 2-0 monolament nylon sutures. In the DN group, a suction drain, 4.8 mm in diameter, was placed under the abdominal ap at the anterior midline and exteriorized 2 cm below the abdominoplasty scar.

In the QS group, 40 quilting sutures were placed per patient between the subcutaneous tissue of the ap and musculoaponeurotic layer of the anterior abdominal wall. Of the 40 quilting sutures, 10 were placed in the supraumbilical region, 10 in the right ank, 10 in the left ank, and 10 in the infraumbilical region. In the FS group, 4 ml of a human brin sealant (QUIXIL, OMRIX Biopharmaceuticals, Tel Aviv, Israel) was sprayed with compressed air (according to the manufacturers instructions) over the entire raw surface of the wound, depositing a 1-mm-thick lm before closure of the abdominal ap. The patients were instructed to rest for 1 day with the head of the bed raised to 45 and knees exed. On the rst postoperative day, normal diet was resumed, the indwelling bladder catheter was removed, and walking, exing forward, with supervision was encouraged. Patients were also instructed to wear compression stockings for 30 days and compression garments for 3 months postoperatively. Ultrasound examination was performed on all patients on postoperative days 15 and 30, by the same radiologist using the same ultrasound system (Nemio linear 812 MHz, Toshiba, Sao Paulo, Brazil). The same physician (rst author) was present at all ultrasound examinations ready to perform puncture and aspiration if seroma volume was greater than 20 ml. Statistical Analysis Data were analyzed using nonparametric tests. Changes in seroma volume between time points within groups were examined with the Wilcoxon test [16]. The KruskalWallis analysis of variance (ANOVA) [16] was used for comparisons between groups of the variables age, BMI, and percentage difference in seroma volume between the two time points (postoperative days 15 and 30). Percentage difference (D%) was calculated using the formula:   SV15 SV30 D% 100 SV15 where SV15 is seroma volume on postoperative day 15, and SV30 is seroma volume on postoperative day 30. All statistical tests were performed at a signicance level of 5% (P \ 0.05).

Results Statistical analysis showed that the groups were homogeneous for age (H = 2.36) and BMI (H = 0.35), as shown in Figs. 1 and 2, respectively. There were no signicant

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(DN: Z = 3.41, P = 0.0003; QS: Z = 3.06, P = 0.0011; FS: Z = 3.41, P = 0.0003). There was a signicant difference in seroma volume between the FS group and the DN and QS groups (seroma volume, FS [ DN and QS) on postoperative day 15 (H = 6.04, P \ 0.05). No signicant differences were found between groups in seroma volume on postoperative day 30 (H = 2.37) or in percentage difference in seroma volume between postoperative days 15 and 30 (H = 1.56), as shown in Table 1.

Discussion Seroma is the most common complication of abdominoplasty. According to retrospective studies, seroma occurs in 122% of abdominoplasties [24, 6, 13]. These rates are probably underestimated because seroma is considered a minor complication and therefore is underreported by patients. Prospective studies have reported seroma formation in 3842% of abdominoplasties [7, 10, 12]. Patients with previous abdominal scars, excess skin after pregnancy, high BMI, and large weight loss are at high risk to develop this complication [12]. The causes of seroma formation are still unclear. However, it seems that the thickness of the ap may result in hypertrophy of the lymphatic system, and that uid may accumulate in the dead space after surgical trauma [12]. Also, previous abdominal scars may serve as a mechanical barrier to the lymphatic system and retain extracellular uids, thus contributing to seroma formation [12]. Matarasso [9] emphasized the importance of minimizing the dead space immediately after closure of the surgical incision and during the following weeks (early and late postoperative periods) with the use of suction drains to prevent seroma formation. Baroudi and Ferreira [3] described the use of quilting sutures to prevent seroma. According to this technique, 3040 quilting sutures are placed between the abdominal ap and the rectus

Fig. 1 Age distribution of abdominoplasty patients in the three groups

Fig. 2 BMI distribution of abdominoplasty patients in the three groups

differences between groups in percentage difference in seroma volume between postoperative days 15 and 30. A signicant reduction in seroma volume was observed between postoperative days 15 and 30 in the three groups

Table 1 Seroma volume measured by ultrasound for the three groups at the two time points Group Postoperative day 15 Median Draina Quilting suturesb Fibrin sealant P value*
a b

Postoperative day 30 Maximum 190.4 49.2 295.0 N 15 13 15 Median 0.9 0.0 1.0 0.278 Minimum 0.0 0.0 0.0 Maximum 44.7 10.0 15.6 N 15 13 15 P value# 0.001 0.002 0.001

Minimum 1.1 0.1 6.2

13.9 16.1 53.6 0.049

Numbers in bold indicate statistical signicance Signicant difference between the DN and FS groups (P = 0.050) Signicant difference between the QS and FS groups (P = 0.020)
#

* KruskalWallis test;

Wilcoxon test

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abdominis sheath to reduce dead space and improve immobilization of the ap. Other authors also reported good results with the use of quilting sutures [1, 12, 13, 15]. Fibrin sealant has been used to facilitate hemostasis, reducing seroma formation in abdominoplasty [5, 19]. Seroma usually develops between postoperative days 10 and 20; therefore, the use of drains during the rst 24 h after surgery probably has no inuence on seroma formation. Drains used in the immediate postoperative period are effective in preventing hematoma but not seroma formation [4]. Small amounts of seroma are commonly resorbed by the body, without affecting the abdominoplasty outcome [21]. Untreated chronic seroma may lead to the formation of a capsule around the seroma, creating a deformity in the anterior region of the abdomen [8, 20]. Infection of the uid collection is another possible complication that may evolve to a secondary deformity [12]. In the postoperative period, repeated aspirations may be required for the treatment of seromas, causing discomfort to the patient [17]. Abdominal ultrasound has been used as a noninvasive method for the diagnosis of uid collections after abdominoplasty [9, 12, 17]. Although in the literature there is no well-dened volume of uid collection above which aspiration is required, in the present study, seroma volumes greater than 20 ml, which may be not detected clinically, were treated by ultrasound-guided ne-needle aspiration [12, 17]. On postoperative day 15, seroma volume was smaller in the QS group compared with the other groups, which is in agreement with the ndings of other studies [1, 3, 1215]. On the other hand, seroma volume was greater in the FS group than in the other two groups, in contrast with the results of Cruz-Korchin and Korchin [5] and Toman et al. [19]. The same amount of brin sealant used in those studies (4 ml) was used in the present study, although the brand was different. Patients at high risk of seroma formation should be considered for abdominoplasty with quilting sutures, even though the procedure prolongs operating time by about 30 min.

References
1. Andrades P, Prado A, Danilla S et al (2007) Progressive tension sutures in the prevention of postabdominoplasty seroma: a prospective, randomized, double-blind clinical trial. Plast Reconstr Surg 120:935946 2. Avelar J (1985) Fat suction versus abdominoplasty. Aesthet Plast Surg 9:265275 3. Baroudi R, Ferreira CA (1998) Seroma: how to avoid it and how to treat it. Aesthet Surg J 18:439441 4. Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau P, Mimoun M (2000) Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results. Plast Reconstr Surg 106:16141618 5. Cruz-Korchin N, Korchin L (2005) The use of brin sealant (Tisseel) in abdominoplasty. Plast Reconstr Surg 116:2325 6. Grazer FM, Goldwyn RM (1977) Abdominoplasty assessed by survey with emphasis on complications. Plast Reconstr Surg 59: 513517 7. Hafezi F, Nouhi AH (2002) Abdominoplasty and seroma. Ann Plast Surg 48:109110 8. Hay-Roe V (1991) Seroma after lipoplasty with abdominoplasty. Plast Reconstr Surg 87:997998 9. Matarasso A (1995) Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg 95:829836 10. Mohammad JA, Warnke PH, Stavraky W (1998) Ultrasound in the diagnosis and management of uid collection complications following abdominoplasty. Ann Plast Surg 41:498502 11. Nahas FX (2001) A pragmatic way to treat abdominal deformities based on skin and subcutaneous excess. Aesthet Plast Surg 25: 365371 12. Nahas FX, Ferreira LM, Ghelfond C (2007) Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg 119: 10601064 13. Pollock H, Pollock T (2000) Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg 105:25832586 14. Rios JL, Pollock T, Adams WP Jr (2003) Progressive tension sutures to prevent seroma formation after latissimus dorsi harvest. Plast Reconstr Surg 112:17791783 15. Rossetto LA, Garcia EB, Abla LF, Neto MS, Ferreira LM (2009) Quilting suture in the donor site of the transverse rectus abdominis musculocutaneous ap in breast reconstruction. Ann Plast Surg 62:240243 16. Siegel S, Castellan NJ Jr (2006) Estatstica nao parametrica para ciencias do comportamento, 2nd edn. Artmed, Porto Alegre 17. Stocchero IN (1993) Ultrasound and seromas. Plast Reconstr Surg 91:198 18. Titley OG, Spyrou GE, Fatah MF (1997) Preventing seroma in the latissimus dorsi ap donor site. Br J Plast Surg 50:106108 19. Toman N, Buschmann A, Muehlberger T (2007) Fibrin sealant and seroma formation following abdominoplasty. Chirurg 78: 531535 20. Zecha PJ, Missotten FE (1999) Pseudocyst formation after abdominoplastyextravasations of Morel-Lavallee. Br J Plast Surg 52:500502 21. Zimman AO, Butto CD, Ahualli PE (2001) Frequency of seroma in abdominal lipectomies. Plast Reconstr Surg 108:14491451

Conclusion Our results indicated that the use of quilting sutures is the best strategy for preventing seroma formation in abdominoplasty compared with the use of either suction drains or brin sealant.
Conict of interest The authors declare that they have no conicts of interest to disclose.

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