DRAINLESS ABDOMINOPLASTY

Dr Medha Bhave Lasercosmesis, Thane Param Hospital and ICU, Thane 25 years in practice

Dr Medha Bhave is MCh – Plastic and Reconstructive Surgery, DNB – Plastic Surgery, MS - General Surgery, DNB – General Surgery, and MBBS. She began her practice as a plastic surgeon in Thane in 1996. Her passion being aesthetic surgery, with a thesis on liposuction, she started doing liposuctions and tummy tucks. In 1999, she started her own aesthetic clinic in Thane and a hospital in 2004. She is the Founder Secretary of Association of Aesthetic plastic Surgeons (Mumbai, Thane, Navi Mumbai), and has been the National Secretary – Indian Association of Aesthetic plastic Surgeons. She was awarded Visiting Professorship with Association of Plastic Surgeons of India in 2019.

Know more from Dr Bhave about drainless abdominoplasty:

How do you identify a good candidate for drainless abdominoplasty? What would be your frequently asked questions to the patients?

Patients with abdominal skin laxity; abdominal protrusion that flattens when the patient lies down; abdominal overhang with or without fat deposits; or who have had a twin delivery; midline hernia; umbilical hernia; incisional hernia; and in selected cases, post-operative scars on the abdomen causing contour defects, are good candidates for drainless abdominoplasty.

My frequently asked questions would include that on number of deliveries; route of delivery; if there is any swelling in the umbilicus or in the midline; if the patient experiences backache, knee pain or difficulty in breathing; existing diet and exercise pattern; co-morbid conditions such as diabetes, hypertension, asthma; any allergy, surgery, accident or wound healing issues; and the purpose of the surgery and expectations (especially about stretch marks and flattening or contouring).

How can best results be derived from this procedure? Tell us about the surgical technique adopted by you?

Basically, an abdominoplasty begins with a thorough liposuction of upper abdomen, flanks and mostly back. It essentially then proceeds with a horizontal incision along the crease between anterior superior iliac spines. The skin-fat envelope is lifted off the abdominal muscles, the umbilicus is scored and left attached to the muscles. The muscles are then plicated vertically and sometimes horizontally for waist shaping. Then extra skin is removed, ptotic vulva is lifted and drains are kept to drain the possible fluid accumulation. The wound is closed after bringing the umbilicus back up in the correct position.

There are various ways to do away with the drains as they are painful, irritating and restrict mobility. Mobility is important in avoiding stagnation of blood in the calf veins, which leads to Deep Vein Thrombosis (DVT). I use surgical techniques to do away with these troublesome drains without compromising on the aesthetic outcome and extent of surgery. I can also repair a hernia, with or without any mesh, and still avoid drains. The essential steps involve: using moderate fluid injection for the initial liposuction; perfect control of bleeding; leaving fat and thin membranous layer of superficial fascia on the muscles so that the skin sticks to muscles like a Velcro; washing the wound to remove all loose fat and clots; stitching with deep bytes and barbed  sutures; and keeping the pressure garment for four days. A special procedure, what I refer to as toilet liposuction, is done to clear the fluid accumulated in liposuction tunnels.

How long is the recovery and what is the post-treatment care involved?

There is no shortcut to recovery in abdominoplasty. The tucked muscles need six months of care. The initial rest period is for 15 days during which patients can move around and take care of themselves but should not do household work. Many women who work from home can definitely work on the computer for a few hours. After the sutures are removed (if any, I tend to use good multilayer closure of the wound and tape for the skin nowadays), one can commute, and start with simple chores. Lifting heavy weights is not allowed for six months. Supporting abdomen while coughing and wearing belt/garment is essential for six months. Any activity that increases pressure in the abdomen like straining for stools and urine, yoga, and aerobics should be avoided. The patient can undertake regular walking as an exercise routine for six months.

What is the advantage of drainless abdominoplasty vs the regular abdominoplasty?

The most important advantage of drainless abdominoplasty is avoidance of cumbersome and painful drains. This facilitates early mobilisation of the patient. Also, there are some papers to suggest that drains are not useful and can irritate tissues, stimulate fluid formation in the tissues and can break or migrate inside. Some colleagues also noticed that when drains are left for a long time, the drainage does not stop. Such a situation could be confusing to manage for the doctor and a reason for anxiety for both.

Picture: Case one as mentioned by Dr Medha Bhave; Courtesy: Lasercosmesis

Any contraindications involved that a doctor should be aware off?

If too much infiltration is used, an energy-based device like VASER is used for liposuction, or there is continuous oozing of blood, it may be safer to leave drains for 48 hours. But if proper history is taken and tests are done to rule out conditions that cause bleeding, the situation does not arise. Meticulous and minimally traumatic technique is the primary requirement to go drainless. Recently, I have done drainless abdominoplasty using an energy-based radiofrequency device called Bodytite. We need to work on techniques to do a drainless procedure while using VASER as well.Toilet liposuction may prove useful for the same.

In cases where the patient has hernia, liposuction should be done after the hernia is tackled.

Most important contraindication for abdominoplasty is when there is too much intra-abdominal fat or compromised respiration. Abdominoplasty reduces volume of the abdominal cavity and pushes the diaphragm up causing lung congestion and sometimes collapse. This must be avoided by careful pre-operative studies.

Tell us about one of your a challenging as well as successful case studies for this treatment?

In one case, a body builder woman unable to make it to the numero uno position in a Mrs state pageant due to post-delivery fat deposits finally won the title post abdominoplasty. The fat hid her abdominal packs, and with abdominoplasty, she could remove all the fat and lax skin revealing the true muscles she had painstakingly built. I had to give her taut skin and minimal scar concealable in a bikini. It feels great to help someone achieve their dream.

In a second case, a professional woman who had twin delivery via C-section faced social issues as the abdominal contour gave illusion of perpetual pregnancy. She thrived in her chosen field post abdominoplasty after achieving even midline depression and lateral highlights, which are hall marks of medium definition abdominoplasty. Her stamina as well as frequency of micturition improved due to better emptying of bladder after muscle plication.