Abdominoplasty and seroma: A prospective randomised study comparing scalpel and handheld electrocautery dissection

Decreasing Seroma Incidence Following Abdominoplasty: A Systematic Review and Meta-Analysis of High-Quality Evidence

Background

Seroma formation is the most common complication of abdominoplasties. Many preventive interventions have been proposed, but none have been recognized as a definitive solution, partly due to varying levels of evidence (LOE) in the literature.

Objectives

We aimed to analyze seroma prevention methods supported by high-level evidence.

Methods

The PubMed database was queried through August 2023. Primary articles of interest included randomized controlled trials (RCTs), prospective comparative studies, and meta-analyses of these studies. The LOE for each article was determined according to the American Society of Plastic Surgeons Rating Scale. The "seroma occurrence ratio," or ratio of seroma events in the interventional group to respective control group, was calculated to compare incidence rates between techniques.

Results

Twenty articles and 9 categories of techniques were analyzed. Study designs included 10 RCTs, 2 prospective cohort studies, 7 prospective comparative studies, and 1 retrospective randomized study. The use of progressive-tension and quilting sutures had the most data supporting a statistically significant reduction in seroma (occurrence ratio 0.306, P < .001). Tissue adhesives and preservation of Scarpa's fascia were also well reinforced (0.375, P < .01 and 0.229, P < .011, respectively), while increasing the number of drains was not (P = .7576). Meta-analysis demonstrated that compared with 2 drains alone, alternative techniques were more effective at reducing seroma occurrence (pooled risk ratio 0.33, 95% CI, 0.11-0.99).

Conclusions

This review highlights multiple seroma prevention techniques for abdominoplasty investigated in recent high-quality literature. We suggest future randomized comparative studies of the various seroma prevention methods to fully ascertain their efficacy following abdominoplasty.

Level of Evidence 1

Bioglass/ceria nanoparticle hybrids for the treatment of seroma: a comparative long-term study in rats

Background: Seroma formation is a common postoperative complication. Fibrin-based glues are typically employed in an attempt to seal the cavity. Recently, the first nanoparticle (NP)-based treatment approaches have emerged. Nanoparticle dispersions can be used as tissue glues, capitalizing on a phenomenon known as 'nanobridging'. In this process, macromolecules such as proteins physically adsorb onto the NP surface, leading to macroscopic adhesion. Although significant early seroma reduction has been shown, little is known about long-term efficacy of NPs. The aim of this study was to assess the long-term effects of NPs in reducing seroma formation, and to understand their underlying mechanism. Methods: Seroma was surgically induced bilaterally in 20 Lewis rats. On postoperative day (POD) 7, seromas were aspirated on both sides. In 10 rats, one side was treated with NPs, while the contralateral side received only NP carrier solution. In the other 10 rats, one side was treated with fibrin glue, while the other was left untreated. Seroma fluid, blood and tissue samples were obtained at defined time points. Biochemical, histopathological and immunohistochemical assessments were made. Results: NP-treated sides showed no macroscopically visible seroma formation after application on POD 7, in stark contrast to the fibrin-treated sides, where 60% of the rats had seromas on POD 14, and 50% on POD 21. At the endpoint (POD 42), sides treated with nanoparticles (NPs) exhibited significant macroscopic differences compared to other groups, including the absence of a cavity, and increased fibrous adhesions. Histologically, there were more macrophage groupings and collagen type 1 (COL1) deposits in the superficial capsule on NP-treated sides. Conclusion: NPs not only significantly reduced early manifestations of seroma and demonstrated an anti-inflammatory response, but they also led to increased adhesion formation over the long term, suggesting a decreased risk of seroma recurrence. These findings highlight both the adhesive properties of NPs and their potential for clinical therapy.

Postbariatric Abdominoplasty: A Comparative Study on Scarpa Fascia Preservation Versus Classical Technique

BACKGROUND

Abdominoplasties performed with Scarpa Fascia preservation, improve recovery and reduce complications, particularly seroma. Bariatric patients who experience massive weight loss frequently seek body contouring procedures and represent a high-risk group. This study aimed to evaluate the effects of abdominoplasty with Scarpa Fascia preservation versus the classical technique in a bariatric population.

METHODS

A retrospective observational cohort study was performed between March 2015 and March 2021 in 65 postbariatric patients who underwent a classic full abdominoplasty (group A, N = 25) or a similar procedure except for the preservation of Scarpa fascia (group B, N = 40). Total and daily drain output, time until drain removal, long drainers (≥ 6 days), length of hospital stay, emergency department visit, readmission to the hospital, reoperation, local and systemic complications were the outcomes evaluated.

RESULTS

Group B had a 3-day reduction in time until drain removal (p < 0.001), a 62.6% reduction of total drain output (p < 0.001) and a 3-day reduction in the length of the hospital stay (p < 0.001). Long drainers (≥ 6 days) were highly reduced (from 56.0% in group A to 7.5% in group B) (p < 0.001). There was a lower incidence of liquid collections in group B, with a 66.7% reduction in seroma incidence.

CONCLUSIONS

Abdominoplasty with Scarpa Fascia preservation improves recovery by reducing drain output, allowing earlier drain removal and reducing long periods with suction drains. It also reduces hospital stay and seroma incidence. This technique modifies the high-risk postbariatric patient in such a major way that he behaves like a nonbariatric.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparing the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery

Background

Due to the sensitivity of the surgical site and a higher probability of injury, the use of a scalpel and electrocautery to create an incision in the spine is discussed. In this study, we will compare the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery.

Materials and methods

This study was conducted in Iran as a randomized controlled trial with double-blinding (1,401). Sixty candidates for spine surgery were randomly divided into two groups of 30 using electrocautery (A) and a scalpel (B) based on available sampling. The VAS scale was used to assess postoperative pain. The duration of the incision and intraoperative blood loss were recorded. The infection and fluid secretions were determined using the Southampton scoring scale. Utilizing the Manchester scar scale, the wound healing status was evaluated. The SPSS version 16 software was used for data analysis (t-test, Mann-Whitney U, ANOVA).

Results

The electrocautery group had substantially lower bleeding, pain, and wound healing rates than the scalpel group (P > 0.05). However, the electrocautery group had significantly longer surgical times, more secretions, and a higher infection rate than the scalpel group (P > 0.05). In terms of demographic and clinical characteristics, there was no significant difference between the two groups (P < 0.05).

Conclusion

Electrocautery reduces postoperative hemorrhage and, potentially, postoperative pain in patients. However, as the duration of surgery increases, so does the duration of anesthesia, and patient safety decreases. Additionally, the risk of infection increases in the electrocautery group compared to the scalpel group, and the rate of wound healing decreases.

Clinical Trial Registration

https://www.irct.ir/, identifier (IRCT20230222057496N1).

Clinical Evaluation of 310 Abdominoplasties and Measurement of Scar Level

BACKGROUND

Most published studies on abdominoplasty focus on methods to reduce the risk of seromas. These methods include limited dissection (lipoabdominoplasty), quilting sutures, and preservation of the Scarpa fascia. Quantitative evaluation of the aesthetic result has been lacking.

METHODS

A retrospective study was undertaken of all patients undergoing abdominoplasty in the author's practice from 2016 to 2022. A full abdominoplasty was performed, usually with liposuction (87%). All patients were treated under total intravenous anesthesia without paralysis or prone positioning. A single closed suction drain was removed 3 or 4 days after surgery. All procedures were performed as outpatients. Ultrasound surveillance was used to detect any deep venous thromboses. No patient received chemoprophylaxis. The operating table was flexed, often to 90°. Deep fascial anchoring sutures were used to attach the Scarpa fascia of the flap to the deep muscle fascia. Measurements of the scar level were made at intervals after surgery up to 1 year.

RESULTS

Three hundred ten patients were evaluated, including 300 women. The mean follow-up time was 1 year. The overall complication rate, which included minor scar deformities, was 35.8%. Five deep venous thromboses were detected. There were no hematomas. Fifteen patients (4.8%) developed seromas that were successfully treated by aspiration. The mean vertical scar level 1 month after surgery was 9.9 cm (range, 6.1-12.9 cm). There was no significant change in scar level at subsequent follow-up times up to 1 year. By comparison, the scar level in published studies ranged from 8.6 to 14.1 cm.

DISCUSSION

Avoidance of electrodissection reduces tissue trauma that causes seromas. Flexed patient positioning during surgery and deep fascial anchoring sutures are effective in keeping the scar low. By avoiding chemoprophylaxis, hematomas can be avoided. Limiting the dissection (lipoabdominoplasty), preserving the Scarpa fascia, and adding quilting (progressive tension) sutures are unnecessary.

CONCLUSIONS

Total intravenous anesthesia offers important safety advantages. Avoiding electrodissection is effective in keeping seroma rates at a tolerable level (5%), and the scar low and more easily concealed. Alternative methods present disadvantages that may contribute to a suboptimal aesthetic result and require additional operating time.

Monopolar electrocautery versus sharp dissection in the neck dissection: a retrospective study

The cold scalpel/scissors (CS) and the monopolar electrocautery (ME) are still the most commonly used instruments for neck dissection in head and neck oncology. However, a direct comparison of these techniques does not exist. This study aims to compare these techniques concerning blood loss, the decline of hemoglobin levels, and surgery duration. Data on 200 patients who received tumor resection, neck dissection and either a radial forearm free flap (RFFF)or a primary closure (PC) were examined retrospectively. The patients were divided according to the performed defect closure (RFFF or PC) and the main instrument usedfor the beck dissection (Group 1: RFFF and ME, Group 2: RFFF and CS, Group 3: PC and ME Group 4: PC and CS). The intraoperative blood loss, decline of hemoglobin values and surgery duration were analyzed and compared between the corresponding groups. The patients where the ME was used lost on average 409.93 ml (group 1 vs. 2) and 242.4 ml (group 3 vs. 4) less blood. The median decrease in the hemoglobin levels was by 1.01 g/dL (group 1 vs. 2) and 0.85 g/dL (group 3 vs. 4) lower for the ME. The median surgery duration was by 102 min (group 1 vs. 2) and 83 min (group 3 vs. 4) shorterfor the ME. All differences were statistically significant. Traditional scalpel and scissors used for neck dissection lead to significantly higher blood loss and longer operation time than the monopolar electrocautery.

"Spin" in Plastic Surgery Randomized Controlled Trials with Statistically Nonsignificant Primary Outcomes: A Systematic Review

BACKGROUND

"Spin" refers to a manipulation of language that implies benefit for an intervention when none may exist. Randomized controlled trials (RCTs) in other fields have been demonstrated to employ spin, which can mislead clinicians to use ineffective or unsafe interventions. This study's objective was to determine the strategies, severity, and extent of spin in plastic surgery RCTs with nonsignificant primary outcomes.

METHODS

A literature search of the top 15 plastic surgery journals using MEDLINE was performed (2000 through 2020). Parallel 1:1 RCTs with a clearly identified primary outcome showing statistically nonsignificant results ( P > 0.05) were included. Screening, data extraction, and spin analysis were performed by two independent reviewers. The spin analysis was then independently assessed in duplicate by two plastic surgery residents with graduate-level training in clinical epidemiology.

RESULTS

From 3497 studies identified, 92 RCTs were included in this study. Spin strategies were identified in 78 RCTs (85%), including 64 abstracts (70%) and 77 main texts (84%). Severity of spin was rated moderate or high in 43 abstract conclusions (47%) and 42 main text conclusions (46%). The most identified spin strategy in the abstract was claiming equivalence for statistically nonsignificant results (26%); in the main text, focusing on another objective (24%).

CONCLUSIONS

This study suggests that 85% of statistically nonsignificant RCTs in plastic surgery employ spin. Readers of plastic surgery research should be aware of strategies, whether intentional or unintentional, used to manipulate language in reports of statistically nonsignificant RCTs when applying research findings to clinical practice.

Comparing Seroma Formation at the Deep Inferior Epigastric Perforator, Transverse Musculocutaneous Gracilis, and Superior Gluteal Artery Perforator Flap Donor Sites after Microsurgical Breast Reconstruction

Background  Seroma formation is the most common donor site complication following autologous breast reconstruction, along with hematoma. Seroma may lead to patient discomfort and may prolong hospital stay or delay adjuvant treatment. The aim of this study was to compare seroma rates between the deep inferior epigastric perforator (DIEP), transverse musculocutaneous gracilis (TMG), and superior gluteal artery perforator (SGAP) donor sites. Methods  The authors conducted a retrospective single-center cohort study consisting of chart review of all patients who underwent microsurgical breast reconstruction from April 2018 to June 2020. The primary outcome studied was frequency of seroma formation at the different donor sites. The secondary outcome evaluated potential prognostic properties associated with seroma formation. Third, the number of donor site seroma evacuations was compared between the three donor sites. Results  Overall, 242 breast reconstructions were performed in 189 patients. Demographic data were found statistically comparable between the three flap cohorts, except for body mass index (BMI). Frequency of seroma formation was highest at the SGAP donor site (75.0%), followed by the TMG (65.0%), and DIEP (28.6%) donor sites. No association was found between seroma formation and BMI, age at surgery, smoking status, diabetes mellitus, neoadjuvant chemotherapy, or DIEP laterality. The mean number of seroma evacuations was significantly higher in the SGAP and the TMG group compared with the DIEP group. Conclusion  This study provides a single center's experience regarding seroma formation at the donor site after microsurgical breast reconstruction. The observed rate of donor site seroma formation was comparably high, especially in the TMG and SGAP group, necessitating an adaption of the surgical protocol.

The role of tranexamic acid in breast and body contouring surgery: a review of the literature

Background: Postoperative seroma and haematoma are two of the most common complications follow-ing large surface area surgeries. A review of the literature was performed to evaluate evidence for the use of tranexamic acid in reducing postoperative seroma and haematoma formation in breast surgery and body contouring surgery. Methods A literature search was performed using MEDLINE, the Cochrane Database of Systematic Review, the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Ef-fect (DARE) and PubMed in English from 1 Jan 1990–30 Mar 2020. The search terms ‘TXA’, ‘breast reduction’, ‘mammaplasty’, ‘breast implants’, ‘breast implantation’, ‘breast reconstruction’, ‘mastectomy’, ‘tissue ex-pansion’, ‘body contouring’, ‘breast’ and ‘abdominoplasty’ were used alone and in combination. Results: A total of six articles were found including three randomised controlled trials, two cohort studies and one retrospective study. Two ongoing trials were found on The Cochrane Central Register of Con-trolled Trials (CENTRAL). No systematic reviews were found. Conclusion: Literature surrounding the use of TXA in breast and body contouring surgery is sparse com-pared to what is available in other surgical sub-specialties. The literature available shows promising results with the use of TXA in controlling haematoma, drain output and seroma formation in breast surgery and body contouring surgery with minimal morbidity in these patient groups.

The Global Prevalence of Seroma After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoplasty is one of the most common cosmetic surgeries performed worldwide. Seroma is also the most common local complication associated with abdominoplasty, which increases care costs, reduces patient satisfaction, and has serious complications for patients. Results of previous studies report different levels of seroma prevalence after abdominoplasty. The aim of this study is to standardize the statistics of the prevalence of seroma after abdominoplasty using meta-analysis.

METHODS

In this systematic review and meta-analysis study, data from studies conducted on the global prevalence of seroma after abdominoplasty was extracted using the keywords "Prevalence, Epidemiology, Complications, Abdominoplasty, Seroma, and Lipo abdominoplasty" in the databases of Science, Scientific Information Database, MagIran, Embase, Scopus, PubMed, Web of Science, and Google Scholar search engine without time limit until October 2020. The random-effects model was used to analyze the eligible studies, and the heterogeneity of the studies was investigated with the I² index. Data analysis was performed using Comprehensive Meta-Analysis software (Version 2).

RESULTS

In reviewing 143 studies (five studies related to Asia, 55 studies related to Europe, three studies related to Africa, and 80 studies related to the Americas) with a total sample size of 27834 individuals, the global prevalence of seroma after abdominoplasty was obtained as 10.9% (95% CI: 9.3-3.6.6%) and the highest prevalence of seroma was related to the Europe continent with 12.8% (95% CI: 10.15-3.9%). The results from meta-regression showed a declining trend in the global prevalence of seroma after abdominoplasty with an increase in the sample size, age of study participants, and the year of study (p < 0.05).

CONCLUSIONS

This study shows that the prevalence of seroma after abdominoplasty is high globally. Therefore, physicians and specialists must consider its importance and take the controlling and treatment measures seriously.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Effect of quilting on seroma formation in mastectomies: A meta-analysis

BACKGROUND

Seroma is the most common complication following mastectomy and can require several days of drainage and lead to delayed wound healing, longer hospital stays, and an increased financial and emotional burden. Seroma formation is not well understood and but there is good evidence that closing the dead space via quilting can help reduce seroma formation. This study assessed randomized controlled trials and reviewed current literature to elucidate if there is a strong association between quilting sutures and seroma formation.

METHODS

A systematic search of 5 databases using search terms similar to "seroma", "quilting", "flap fixation", "random", and "mastectomy". Data was extracted and Medcalc software used to perform a meta-analysis of the primary outcome: incidence of seroma formation, as well as secondary outcomes: volume and duration of drainage.

RESULTS

Eleven randomized controlled trials with 2009 patients were included. Quilting with sutures greatly reduced the incidence of seroma formation compared with conventional closure (p < 0.001, RR 0.367 [95% CI 0.25, 0.539]; I² = 63.56%) as well as duration of drainage (p = 0.015, SMD -1.657, SE 0.680 [95% CI -2.991, -0.324]; 8 studies, n = 1578; I² = 98.98%). Quilting did not significantly affect volume of drainage.

CONCLUSIONS

Quilting was found to be associated with lower seroma rates. Future studies should investigate the use of quilting in combination with other preventative techniques to search for a synergistic method that will further improve patient care.

LigaSure Impact™ reduces complications after abdominoplasty in weight loss patients

PURPOSE

Bariatric surgery is on the rise worldwide. With the desired weight loss after bariatric surgery, patients frequently develop massive skin flaps resulting in the need of abdominoplasty. In these patients, this surgical technique is frequently associated with perioperative complications. Strategies to minimize complications are sought after. The objective of our study was to compare two different dissection techniques and their impact on postoperative outcome.

METHODS

We included 66 patients in our study who underwent abdominoplasty after massive weight loss following bariatric surgery. In group 1, abdominoplasty was performed using the conventional technique of diathermia (n = 20). In group 2, abdominoplasty was performed using LigaSure Impact™ (n = 46). The duration of the surgical procedure and perioperative complications were recorded as primary endpoints. Secondary endpoints were length of hospital stay and assessment of additional risk factors.

RESULTS

Baseline characteristics were comparable between groups. The duration of surgery was significantly shorter in group 2. Postoperative complications were significantly less frequent in group 2 (p = 0.0035). Additional risk factors, e.g., smoking and diabetes mellitus, were not associated with increased rates of perioperative complications.

CONCLUSIONS

The choice of technical device for dissection in abdominoplasty alone will not guarantee minimized complication rates. Yet, the utilization of LigaSure Impact™ in refined surgical techniques may facilitate reduced rates of complications, especially wound infections, and a shortened duration of surgery.

Local Triamcinolone Treatment Affects Inflammatory Response in Seroma Exudate of Abdominoplasty Patients: A Randomized Controlled Trial

BACKGROUND

As the leading complication of abdominoplasty, seroma formation might represent an inflammatory process in response to surgical trauma. This prospective randomized trial investigated whether local administration of the antiinflammatory agent triamcinolone could prevent seroma accumulation.

METHODS

Weekly and cumulative seroma volumes were compared between the study groups A, B, and C over a 4-week follow-up (group A, with drain, without triamcinolone; group B, without drain, without triamcinolone; group C, without drain, with triamcinolone). Aspirated seroma samples were analyzed by enzyme-linked immunosorbent assay for selective inflammatory mediators.

RESULTS

Triamcinolone significantly reduced cumulative seroma volume (n = 60; mA 845 ± SDA 578 ml, mC 236 ± SDC 381 ml, p = 0.001). The most accentuated suppressive effect of triamcinolone was observed shortly after the treatment (week 1) (mA1 616 ± SDA1 457 ml, mB1 153 ± SDB1 161 ml, mC1 22 ± SDC1 44 ml, pA1/C1 < 0.001, pB1/C1 = 0.014). Local triamcinolone administration resulted in a differential concentration of interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9 (week 1) in seroma exudate as measured by enzyme-linked immunosorbent assay (mIL-6A1 1239 ± SDA1 59 pg/ml, mIL-6C1 848 ± SDC1 80 pg/ml, p < 0.001; mMMP-9A1 2343 ± SDA1 484 pg/ml, mMMP-9C1 376 ± SDC1 120 pg/ml, p = 0.001).

CONCLUSIONS

Local administration of 80 mg of triamcinolone reduced postabdominoplasty seroma accumulation significantly. Under triamcinolone treatment, suppressed levels of IL-6 and MMP-9 in seroma fluid were observed. Notably, inflammatory marker suppression correlated clinically with a decrease in seroma accumulation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Dissection Technique for Abdominoplasty With Scarpa Fascia Preservation: Comparative Study on Avulsion Technique Versus Diathermocoagulation

BACKGROUND

Many strategies have been developed to lower the high complication rate associated with a full abdominoplasty. The dissection technique may have a role to achieve this goal.

OBJECTIVES

The present study compared 2 different dissection techniques to perform a full abdominoplasty with Scarpa fascia preservation: avulsion technique and electrodissection.

METHODS

A retrospective observational cohort study was performed in 2 health institutions from January 2005 to January 2019. A total of 251 patients were involved: 122 patients submitted to abdominoplasty employing the avulsion technique (Group A) and 129 with diathermocoagulation (coagulation mode) (Group B). The latter was further divided into group B1 (57 patients with device settings according to surgeon's preferences) and B2 (72 patients with a specific regulation aiming at minimal tissue damage). Several variables were analyzed: population characteristics, time of hospital stay, time to drain removal, total and daily drain output, emergency department visits, readmission, reoperation, and local and systemic complications.

RESULTS

The general characteristics of both groups did not statistically significantly differ except for previous abdominal surgery. The diathermocoagulation group had a significantly lower length of hospital stay and time to drain removal. Moreover, these advantages were maximized when electrocautery was conducted with a specific low-voltage setting as significant differences were found. The other outcomes were identical.

CONCLUSIONS

Limiting the extension of electrodissection with the avulsion technique did not present any advantage. Utilizing diathermocoagulation (coagulation mode) during a full abdominoplasty with Scarpa fascia preservation, especially when it is aimed at minimal tissue damage, reduces patients' time with drains.

LEVEL OF EVIDENCE: 3

Health technology assessment through the six sigma approach in abdominoplasty: Scalpel vs electrosurgery

Abdominoplasty is a surgical procedure conducted to reduce excess abdominal skin and fat and improve body contouring. Despite being commonly performed, it is associated with a risk of complications such as infection, seroma, haematoma and wound dehiscence. To reduce the incidence of complications, different methods are used to create the abdominal flap, i.e., incision with a scalpel or electrosurgery. In this study, health technology assessment (HTA) using the Six Sigma methodology was conducted to compare these incision techniques in patients undergoing abdominoplasty. Two consecutively enroled groups of patients (33 in the scalpel group and 35 in the electrosurgery group) who underwent surgery at a single institution, the University of Campania "Luigi Vanvitelli", were analysed using the drain output as the main outcome for comparison of the incision techniques. While no difference was found regarding haematoma or seroma formation (no cases in either group), the main results also indicate a greater drain output (p-value<0.001) and a greater incidence of dehiscence (p-value=0.056) in patients whose incisions were made through electrosurgery. The combination of HTA and the Six Sigma methodology was useful to prove the possible advantages of creating skin incisions with a scalpel in full abdominoplasty, particularly a significant reduction in the total drain output and a reduction in wound healing problems, namely, wound dehiscence, when compared with electrosurgery, despite considering two limited and heterogeneous groups.

[Abdominoplasties: Do we still need to drain in 2021?]

OBJECTIVE

The purpose of this study was to consider the use of drainage when performing an abdominoplasty with regards to postoperative complications for two groups of patients.

PATIENTS AND METHOD

From January 1st 2017 to December 31th 2019, 215 patients underwent an abdominoplasty in our institution. In this retrospective, comparative, single institution study, patients were divided into two groups: "drainage" D (n=162) when suction completed abdominoplasty, "no drainage" ND (n=53) when suction didn't completed abdominoplasty. Early and distant complications were retrieved for each group and compared.

RESULTS

There was no significant difference between the two groups concerning the occurrence of seroma postoperatively (8% of patients in group D and 11.3% of patients in group AD). The drainage group D experienced more seroma's punctures (2,3± 1,0) and the mean of punctured fluid was higher (386,5ml±350,4ml) compared to the no drainage group ND (1,3+- 0,5 number of punctures with a mean punctured fluid of 165,8mL± 224,2mL). The mean hospital stay was shorter for group ND (2,9± 1,8 days) than for group D (4,4+- 1,7 days), P<0,0001.

CONCLUSION

Performing an abdominoplasty with quilting suture but drainless doesn't seem to increase postoperative complications statistically. The authors recommend, under the guise of a quilting suture, not to systematically drain the abdominoplasties and to reserve this technique for patients at risk of complications (high BMI, significant weight loss and co-morbidities).

Mixed Metal Oxide Nanoparticle Formulations for the Treatment of Seroma

Seroma formation is a well-recognized postoperative complication for many plastic and general surgical procedures. Although various tissue adhesives and substances have been used in an effort to treat seroma formation, no therapies have been established clinically. Recently, the nano-bridging phenomenon has been introduced as a promising approach to achieve tissue adhesion and strong closure of deep skin wounds in rats. The present study seeks to assess the potential of nano-bridging beyond skin wounds in a rat model of seroma. Seromas were induced in 20 Lewis rats through bilateral axillary lymphadenectomy, excision of the latissimus dorsi and cutaneous maximus muscles, and disruption of dermal lymphatics. On postoperative day (POD) 7, the seroma was aspirated on both sides. A bioactive nanoparticle (NP) suspension based on zinc-doped strontium-substituted bioglass/ceria nanoparticles (NP group) or fibrin glue (fibrin group) was injected into the right seroma cavity, while the left side was left untreated. On POD 14, the NP group showed complete remission (no seromas at all), while the fibrin group recorded a reduction of only 63% in the seroma fluid volume. The NPs exerted local anti-inflammatory and neo-angiogenic effects, without any detectable systemic changes. Moreover, the ceria levels recorded in the organs did not surpass the background level, indicating that the nanoparticles stayed at the site of application. This study is a promising first example demonstrating the ability of inorganic nanoparticle formulations to reduce seroma formation in a rat model, without any detectable systemic adverse effects. These results emphasize the potential of nanotechnological solutions in the therapeutic management of seroma in the clinical setting.

Robotic-assisted latissimus dorsi muscle flap for autologous chest reconstruction in poland syndrome

BACKGROUND

As chest reconstructions in Poland syndrome are performed for patients at young ages, patients are generally concerned about conspicuous scars. Meanwhile, a robotic-assisted latissimus dorsi (LD) muscle harvest with inconspicuous scars has been performed for autologous breast reconstruction. As our experience with robotic-assisted LD flap harvest has increased over the years, we have made improvements in surgical techniques to optimize results. The purpose of this study was to introduce and identify the role of the refined robotic-assisted LD muscle flap harvest technique in autologous chest reconstruction in patients with Poland syndrome.

METHODS

Autologous chest reconstruction using a robotic-assisted LD muscle flap harvest was performed for 21 patients with Poland syndrome. Subjective assessments were performed to evaluate improvement in chest deformity, patient satisfaction with overall outcomes, chest symmetry, and scars. Assessments by the operator and two independent evaluating investigators were carried out with patients' photographs. The complication rates and the time for robotic surgery were also evaluated.

RESULTS

At the last visit, the average patient grades for improvement in chest deformity, satisfaction with overall outcomes, chest symmetry, and scars were 4.80, 4.72, 4.18, and 4.87, respectively. Assessments by the operator and two independent evaluating investigators demonstrated that improvement in chest deformity was achieved in all patients. No serious complications such as flap loss were recorded for any patient. The time for robotic surgery markedly decreased as experience accumulated.

CONCLUSIONS

Surgical refinements for robotic-assisted LD flap harvest might be effective and reduce operative times for patients with Poland syndrome.

Evidence-Based Abdominoplasty Review With Body Contouring Algorithm

Abdominal contour deformities are an aesthetic challenge to the plastic surgeon. Patients present with diverse clinical histories, multiple comorbidities, and unique aesthetic demands. Weight loss, previous pregnancy, and aging are 3 principal indications for abdominoplasty. Bariatric surgery has increased demand for body contouring procedures. This heterogeneous patient cohort means a "one-size-fits-all" abdominoplasty is not appropriate. Precise evaluation, evidence-based decision-making, and artistic acumen are required while balancing patient goals with safe, realistic, and long-lasting aesthetic outcomes. This article reviews surgical options for abdominal body contouring, providing an evidence-based treatment algorithm for selecting the appropriate procedure for each patient to maximize clinical and patient reported outcomes.

Ligasure impact™might reduce blood loss, complications, and re-operation occurrence after abdominoplasty in massive-weight-loss patients: A Comparative Study

Background and Aims:

The most effective dissection technique for raising the flap in abdominoplasty is still controversial, particularly in high-risk massive-weight-loss patients. LigaSure Impact™vessel-sealing system (Medtronic, Dublin, Ireland) is an energy device commonly used among different surgical specialties to reduce morbidity and implement outcomes. The aim of this study was to investigate the effectiveness of LigaSure Impact in abdominoplasty compared with the conventional techniques, diathermia.

Material and Methods:

Patients underwent primary abdominoplasty after massive weight loss at a single center from 1 January 2008 to 31 May 2015 and were retrospectively reviewed. A total of 94 patients eligible for the study were divided into two groups on basis of the dissection technique: LigaSure Impact group (29 patients) and the conventional technique group (65 patients). Total intraoperative blood loss was the primary endpoint. Duration of the operation, perioperative complications and re-operation were recorded as secondary endpoints.

Results:

Baseline characteristics were well balanced between the groups. Significant differences were found in intraoperative blood loss favoring LigaSure Impact group (259.6 ± 198.8 mL vs 377.9 ± 190.0 mL, p = 0.004) and blood transfusion rates (13.8% vs 35.4%, p = 0.047). In contrast, operative time was significantly longer in LigaSure Impact group (168.6 ± 121.2 vs 179.7 ± 57.6 min, p = 0.005), while a tendency to shorter hospital stay was found in LigaSure Impact group (3.6 ± 1.1 days vs 4.6 ± 3.2 days, p = 0.081). Overall complications occurrence, Clavien–Dindo grade II (24.1% vs 55.4%) and grade III (13.8% vs 30.8%) complications were significantly lower in LigaSure Impact group (respectively, p = 0.005, p = 0.007, p = 0.016). Late (>30 days) re-operation rate was significantly lower in the LigaSure Impact group (6.9% vs 27.70%, p = 0.0028). Specific wound complications showed no significant difference.

Conclusion:

LigaSure Impact vessel-sealing system may be beneficial in improving abdominoplasty outcomes in massive-weight-loss patients because it might reduce blood loss, need for transfusions, complications, and re-operations.

Using quilting sutures in decreasing seroma formation after managing large ventral hernias: a comparative study

PURPOSE

The aim of this study was to evaluate using quilting sutures in a prospective randomized controlled manner the decrease in the incidence of seroma formation among patients subjected to ventral hernia repair.

METHODS

The study was a prospective randomized controlled study. 370 patients with large ventral hernias were randomly distributed among two groups. Group A (control group) included 180 patients in whom the repair was done without quilting sutures. Group B (quilting group) included 190 patients, all performed with quilting. Method of dissection was unified as far as possible. All cases had an attached closed suction drain that was removed after two successive days of output ≤ 50 cc. The output of the suction drain was recorded; accumulation of clinically detected seroma after 1, 2 and 4 weeks of removal of the drain was monitored.

RESULTS

There was no statistical difference between both groups as regards the demographic data and the hernia characteristics. There was significantly smaller amount of output of the drains in every day of the first five postoperative days as well as the total amount of the output before drain removal in favor of the quilting group. Drains were removed earlier in group B. The incidence of clinically detected seroma was less in group B as well.

CONCLUSIONS

Quilting sutures is an effective and easy technique to reduce post-ventral hernia seroma accumulation.

Can drains be avoided in lipo-abdominoplasty?

Context:

Seroma formation is a common complication after lipoabdominoplasty. Conventionally, drains have been placed to prevent seroma; however, there are problems with drains, namely, pain, compromised mobilisation, breakage, tissue irritation and infection. Strategies to prevent seroma, such as the use of glue or quilting sutures have all been attempted with variable and unpredictable benefit.

Aims:

The author extrapolated the experience with own liposuction protocols to lipoabdominoplasty and began doing away with drains from the year 2006 onwards unless absolutely indicated. Incidence of complications is evaluated here.

Settings and Design:

This retrospective study is the report of our experience with 204 lipoabdominoplasties performed since 2006 upto December 2016.

Subjects and Methods:

Consecutive abdominoplasty patients were evaluated for seroma formation, wound dehiscence till suture removal. Nuances of operative details that helped avoid drains were contemplated.

Results:

Only one patient who had drainless abdominoplasty had seroma formation and wound dehiscence.

Conclusions:

We found that (a) 'toilet liposuction', (a term the author would like to introduce) (b) multilayer wound closure without tension, (c) avoidance of gliding surfaces d) continuous use of pressure garment for 4 days post-operative and (e) reducing the amount of infiltration are the key factors in avoidance of collections and thus seroma formation. If such a technique is diligently followed, desired results are obtained; yet there is no need to insert drains in most patients. Reducing the need of drains permits early ambulation and better patient comfort without seroma and other complications.

Cutting electrocautery versus scalpel for surgical incisions: a systematic review and meta-analysis

BACKGROUND

Although cutting electrocautery can be superior to the scalpel in reducing blood loss and incisional time, several reports associated electrocautery with higher rates of wound infection, impaired healing, and worse cosmesis. We performed this systematic review and meta-analysis to compare cutting electrocautery versus scalpel for surgical incisions.

MATERIALS AND METHODS

We conducted a computerized literature search of five electronic databases and included all published original studies comparing cutting electrocautery and scalpel surgical incisions. Relevant data were extracted from eligible studies and pooled as odds ratios (ORs) or standardized mean difference (SMD) values in a meta-analysis model, using RevMan and Comprehensive Meta-analysis software.

RESULTS

Forty-one studies (36 randomized trials, four observational, and one quasirandom study) were included in the pooled analysis (6422 participants). Compared with the scalpel incision, cutting electrocautery resulted in significantly less blood loss (SMD = -1.16, 95% CI [-1.60 to -0.72]), shorter incisional (SMD = -0.63, 95% CI [-0.96 to -0.29]) and operative times (SMD = -0.59, 95% CI [-1.12 to -0.05]), and lower pain scores (SMD = -0.91, 95% CI [-1.27 to -0.55]) with no significant differences in terms of wound infection rates (OR = 0.92, 95% CI [0.74-1.15]) or overall subjective scar score (SMD = -0.49, 95% CI [-1.72 to 0.75]).

CONCLUSIONS

Surgical incision using electrocautery can be quicker with less blood loss and postoperative pain scores than the scalpel incision. No statistically significant difference was found between both techniques in terms of postoperative wound complications, hospital stay duration, and wound cosmetic characteristics. Therefore, we recommend routine use of cutting electrocautery for surgical incisions.

Managing Complications in Abdominoplasty: A Literature Review

Background

Abdominoplasty, with or without liposuction, is among the most frequently performed aesthetic procedures. Its main objective is to improve the body contour by means of excising redundant skin and fat tissue. Although abdominoplasty is considered a safe procedure with high satisfaction rates, intraoperative and postoperative complications can become a challenge for the surgical team. The aim of this article is to offer a synopsis of the most common complications arising after abdominoplasty, along with evidence-based guidelines about how to prevent and treat them.

Methods

A systematic MEDLINE search strategy was designed using appropriate Medical Subject Headings (MeSH) terms, and references were scanned for further relevant articles.

Results

According to the published case series, local complications are considerably more common than complications with systemic repercussions. Approximately 10% to 20% of patients suffer a local complication following abdominoplasty, while fewer than 1% suffer a systemic complication. Prevention and management strategies are critically discussed for complications including seroma, haematoma, infection, skin necrosis, suture extrusions, hypertrophic scars, neurological symptoms, umbilical anomalies, deep venous thrombosis and pulmonary thromboembolism, respiratory distress, and death.

Conclusions

The complications of abdominoplasty vary in severity and in the impact they have on the aesthetic outcomes. Recommendations for prevention and management are based on various levels of evidence, with a risk of observer bias. However, most complications can be treated appropriately following the current standards, with satisfactory results.

Scalpel versus electrosurgery for major abdominal incisions

BACKGROUND

Scalpels or electrosurgery can be used to make abdominal incisions. The potential benefits of electrosurgery may include reduced blood loss, dry and rapid separation of tissue, and reduced risk of cutting injury to surgeons. Postsurgery risks possibly associated with electrosurgery may include poor wound healing and complications such as surgical site infection.

OBJECTIVES

To assess the effects of electrosurgery compared with scalpel for major abdominal incisions.

SEARCH METHODS

The first version of this review included studies published up to February 2012. In October 2016, for this first update, we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, EBSCO CINAHL Plus, and the registry for ongoing trials (www.clinicaltrials.gov). We did not apply date or language restrictions.

SELECTION CRITERIA

Studies considered in this analysis were randomised controlled trials (RCTs) that compared electrosurgery to scalpel for creating abdominal incisions during major open abdominal surgery. Incisions could be any orientation (vertical, oblique, or transverse) and surgical setting (elective or emergency). Electrosurgical incisions were made through major layers of the abdominal wall, including subcutaneous tissue and the musculoaponeurosis (a sheet of connective tissue that attaches muscles), regardless of the technique used to incise the skin and peritoneum. Scalpel incisions were made through major layers of abdominal wall including skin, subcutaneous tissue, and musculoaponeurosis, regardless of the technique used to incise the abdominal peritoneum. Primary outcomes analysed were wound infection, time to wound healing, and wound dehiscence. Secondary outcomes were postoperative pain, wound incision time, wound-related blood loss, and adhesion or scar formation.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out study selection, data extraction, and risk of bias assessment. When necessary, we contacted trial authors for missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data, and mean differences (MD) and 95% CI for continuous data.

MAIN RESULTS

The updated search found seven additional RCTs making a total of 16 included studies (2769 participants). All studies compared electrosurgery to scalpel and were considered in one comparison. Eleven studies, analysing 2178 participants, reported on wound infection. There was no clear difference in wound infections between electrosurgery and scalpel (7.7% for electrosurgery versus 7.4% for scalpel; RR 1.07, 95% CI 0.74 to 1.54; low-certainty evidence downgraded for risk of bias and serious imprecision). None of the included studies reported time to wound healing.It is uncertain whether electrosurgery decreases wound dehiscence compared to scalpel (2.7% for electrosurgery versus 2.4% for scalpel; RR 1.21, 95% CI 0.58 to 2.50; 1064 participants; 6 studies; very low-certainty evidence downgraded for risk of bias and very serious imprecision).There was no clinically important difference in incision time between electrosurgery and scalpel (MD -45.74 seconds, 95% CI -88.41 to -3.07; 325 participants; 4 studies; moderate-certainty evidence downgraded for serious imprecision). There was no clear difference in incision time per wound area between electrosurgery and scalpel (MD -0.58 seconds/cm2, 95% CI -1.26 to 0.09; 282 participants; 3 studies; low-certainty evidence downgraded for very serious imprecision).There was no clinically important difference in mean blood loss between electrosurgery and scalpel (MD -20.10 mL, 95% CI -28.16 to -12.05; 241 participants; 3 studies; moderate-certainty evidence downgraded for serious imprecision). Two studies reported on mean wound-related blood loss per wound area; however, we were unable to pool the studies due to considerable heterogeneity. It was uncertain whether electrosurgery decreased wound-related blood loss per wound area. We could not reach a conclusion on the effects of the two interventions on pain and appearance of scars for various reasons such as small number of studies, insufficient data, the presence of conflicting data, and different measurement methods.

AUTHORS' CONCLUSIONS

The certainty of evidence was moderate to very low due to risk of bias and imprecise results. Low-certainty evidence shows no clear difference in wound infection between the scalpel and electrosurgery. There is a need for more research to determine the relative effectiveness of scalpel compared with electrosurgery for major abdominal incisions.

Efficacy and Safety of Scarpa Fascia Preservation During Abdominoplasty: A Systematic Review and Meta-analysis

INTRODUCTION

Scarpa fascia preservation might be a promising approach to reduce seroma and other complications after abdominoplasty. However, the results remained controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of scarpa fascia preservation in patients with abdominoplasty.

METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials and clinical controlled trials assessing the effect of scarpa fascia preservation versus control (without scarpa fascia) during abdominoplasty were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were seroma and hematoma/bleeding. Meta-analysis was performed using random-effect model.

RESULTS

Four studies involving 630 patients were included in the meta-analysis. Overall, compared with the control group, scarpa fascia preservation was associated with a significant reduced seroma (OR 0.16; 95% CI 0.06-0.43; P = 0.0004), time until drain removal (std. mean difference = -0.92; 95% CI -1.31 to -0.54; P<0.00001;), drain output (std. mean difference = -0.92; 95% CI -1.38 to -0.45; P = 0.0001), and hospital stay (std. mean difference = -0.93; 95% CI -1.48 to -0.39; P = 0.0008), but it failed to alter hematoma/bleeding (OR 0.46; 95% CI 0.09-2.38; P = 0.36), infection (OR 0.38; 95% CI 0.11-1.25; P = 0.11), and suture rupture (OR 0.67; 95% CI 0.12-3.73; P = 0.65) in patients with abdominoplasty.

CONCLUSIONS

Scarpa fascia preservation was associated with a significant decreased seroma, time until drain removal, drain output, and hospital stay, but could not change hematoma/bleeding, infection and suture rupture following abdominoplasty. Scarpa fascia preservation should be recommended during abdominoplasty.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prevention of Seroma Formation Following Abdominoplasty: A Systematic Review and Meta-Analysis

Background

With seroma formation being the most common complication of abdominoplasty, multiple surgical strategies have been proposed to lower the seroma rate, yet their effectiveness is unclear.

Objectives

The objective of this systematic review and meta-analysis was to comprehensively summarize and quantify the effects of preventive surgical measures for seroma in patients undergoing abdominoplasty.

Methods

A predetermined protocol was used. An electronic search in MEDLINE, Scopus, the Cochrane Library, and CENTRAL electronic databases was conducted from inception to June 2016. This search was supplemented by a review of reference lists of potentially eligible studies and a manual search of key journals in the field of plastic surgery. Eligible studies were prospective controlled studies, which investigated prevention of seroma formation and reported on seroma rate. Secondary outcomes were rate of hematoma, wound dehiscence, infection, reoperation and hospital readmission, time to drain removal, total drain output, and length of hospital stay.

Results

The meta-analysis included nine studies with 664 abdominoplasty patients. Seroma rate was 7.5% in the prevention group and 19.5% in the control group with the odds ratio (95% confidence interval) being 0.26 (0.10-0.67), P = .006, favoring the prevention group. Similar results were also revealed for infection rate, time to drain removal, and length of hospital stay. Subgroup analysis showed that preservation of Scarpa's fascia, tissue adhesives and, possibly, progressive tension sutures reduce, independently, seroma formation.

Conclusions

This meta-analysis provides strong evidence that the use of certain preventive measures during abdominoplasty, compared to conventional procedure, reduces seroma formation.

Level of Evidence 2