Why explant surgeries, tummy tucks and Liposuction cases don't need rains with Dr. Robert Whitfield

Welcome to this episode of the Drive. Yesterday we had a big discussion with one of our clients just about drains. And it was an interesting day. One of my clients brought their daughters in to discuss just what entails, you know, getting a breast reduction done now. It'll follow along. So I haven't used drains over the last number of years in breast surgery, which is not new. Drains have been not used in breast reduction surgery using a vertical technique and other techniques for quite a long period of time. And the premise is always the same, whether it's doing a reduction or if you're doing a tummy tuck, a drainless tummy tuck, you can look it up, you can ask ChatGPT about drainless tummy tuck, or you can type it into Google or Safari or Bing and learn about a drainless tummy tuck, which has been around for decades now. And so the issue behind all this is closing down the space left by removal of tissue or the elevation or lifting of tissues away from its underlying structure. If you think about a tummy tuck, we do this all the way up to the level of the lower portion of the rib margin, called the costal margin. And we do this using something called cautery. Cautery separates the tissue using energy heat. It also stops bleeding at the same time. So it's separating the tissue, it's creating what we call coagulation of the tissues. And then you have the surface of the abdominal flap, which is the back of the tissue, which is fatty, and you have the underlying surface of the anterior abdominal wall, which is white. And it's the fascia that covers all the muscles. So the six pack muscles, the oblique muscles, those are covered with this white tissue. And then in a tummy tuck, if someone needs repair of their rectus diastasis, then the muscles are re approximated by sewing the fascia which is covering the muscle together to close the gap. So that is then closed by placing sutures in a horizontal manner. So across from right to left from the top of the pocket down in rows to help eliminate the space. And then because this really would drain inferior to the groin and the pubic area, there's not a lot of other avenues. The flank can accommodate drainage of fluid as well. And then this is a typically a hip bone to hip bone incision from what's called the anterior iliac spine to anterior iliac spine. And it's curved down towards the pubic area and around to the other side, it's closed. And you can do that as a drainless tummy tuck. So conversely when we're doing breast surgery and we're say using the technique most commonly used, which is a circle vertical technique that allows you to take tissue out of the. Mostly the inferior lateral, so kind of towards the side where people have like side boob fullness in the armpit, and then up towards the apex in a C shape. And that's basically then removed. The tissues are closed down. The suturing then is around the circle, which is the nibular complex, and then vertically reapproximating what they call the pillars. And then management of the bottom of the breast can be done via a number of technique. You can defat the area, you can use liposuction in the area, you can use scissors to thin the area. You're just removing it. So that tissue does it perform what's called a standing cone or a dog ear and sticks out? If it does, it's something that can be taken care of in the office of the local at a later time. So that's done without a drain. And that's called a breast reduction. It's a very common procedure. So if we go back to somebody who's had an implant, average implant, you know, typically we'll say is around 300 cc's a gram weight. A cup size of tissue is around roughly 200 grams. Several studies have been published regarding breast reductions, and they go by grams. So we'll say cup size, like I said, is 200 grams. And then as you go up and up, you get closer and closer and are doing larger and larger reductions. And you're creating more and more space by the larger reduction. Or when we're doing an explant, you create a larger amount of space because of the volume of the implant. And then where is the implant? There are slightly different pockets because implants can be above and, and below the muscle. So obviously that's a difference. When we're doing a reduction, we don't change anything to do with the muscle at all. So we're all above the muscle. So in that setting, if we're, say, doing a removal of an implant that's above the muscle, just like we're doing a reduction that's above the muscle and we don't drain it, how do we guarantee that no fluid accumulates in the pump? Well, typically we always wrap patients, and we wrap patients to compress the area, and then the compression decreases the amount of available space for fluid to accumulate. Every time anybody has an injury, whether it's from surgery or trauma, say you twisted your ankle, it swells. So fluid Accumulates in the tissues, and if there's more fluid than the body can absorbed, then you'll get a collection. So one of the really nice ways that we work to help reduce the need for any drain tubes in our patients at the time of surgery is a little bit more involved. And we'll start with the story of how we stopped using drains. This patient of mine who requested. Requested that we do a fat transfer at the same time of their explant. And so I had done a number of explant surgeries and had always done the fat transfer secondarily. This is many, many years ago at this point. The patient didn't have any symptoms, just didn't want to have implants anymore, which is becoming a more common theme. Implants in some patients, they got them when they were younger, and now they just don't align with their belief system or how they want to live. So this patient asked me to do a simultaneous fat transfer. So we did their. Ultimately did their explant surgery and perform their fat transfer, which went very well. And at that point, many years ago, I had used a drain to drain the space. So the patient had an explant and a lift and a fat transfer. So they had all the normal things we did at that point for an explant, and they were wrapped and they had drains in. And because we added a fat transfer, they now had had liposuct their abdomen of their bra, fat area, of their flank area, and they were wearing a compression garment that was commonly used after liposuction. So that became a practice where we were doing our best to, you know, help the patients get through all those different types of treatments that were performed during the procedure. And many times, either through the inframammary fold, which is the fold underneath the breast, or actually through a breast pocket. It was pretty common in plastic surgery. Instructionally. You would see it done through some of the masters in plastic surgery, different videos accompanying different textbooks. You would see it at your meetings when you were learning and doing, you know, basically what kind of options were available to contour. And when you're sculpting, especially the lateral borders, the inferior borders, performing what's called always like equals of the fat, say, liposuction, things that are pretty common practices. So we were doing a lot of contouring, and with the level of contouring, it was, you know, well understood that the fluid was going to drain from superior to inferior or from the top of the body to the lower part of the body because of gravity. And that's always the case. Everything wants to go downward. If you put, for instance, a lot of fluid in the abdomen, in the subcutaneous tissues, underneath the skin, in the fatty layer, perform liposuction on the abdomen, all the fluid you put in there, especially towards the top, is going to have to descend and much of it is going to descend downward. It's going to cause swelling in the pubic area. So for men, when they undergo liposuction of the abdomen, they're going to get a lot of scrotal swelling. For women, when they go and have liposuction of the abdomen, they're going to get swelling in the pubic area. It can also descend and cause labial swelling, which it gets everybody concerned, but it's all going to get reabsorbed. Sometimes the liposuction garments, because they have cutouts for the genital area, can make this seem worse than it is. Creates a lot of concern. So many times right after surgery, if there's more swelling, it's more. Or you will remove the liposuction garment and have them use leggings and other lymphatic wear to help avoid this short term issue. But that's a different discussion. So the fluid has to go down and out. So using this well known premise, you can connect the breast pocket through the subcutaneous tissues of the abdomen. And that's a pretty common practice. The reason that it works so well is the actual continuity of the breast pocket to the anterior abdominal wall is easy because you're looking right at it. And when we do see that view, we want to make sure that we're trying to do it in a manner that is going to be easy for the fluid to get out. And if, if we're doing liposuction, for instance, so say I'm going to thin the higher anterior abdominal wall and I may or may not have already done the flank area, which makes it easier. And the patient wants more contouring of the side, maybe they have more fullness there. There's different areas. Some people have more of a bra fat area than others. So in the position when the patient's on their stomach in the prone position, if we're doing REM of the kind of love handle, lower back, mid back area, we'll approach all that and, and create a series of channels via liposuction. And this is with, on the device, on suction, we'll remove the fat, say especially if we're going to do a fat transfer. So we start the prone position, we make an incision at the top of basically the butt cheeks over the sacrum. It's hidden by wearing any type of underwear or even a thong. And then you can fill that area with fluid. And then once you've got the fat extracted, we use a fat transfer cannula system from Wells Johnson. And you close that, turn the patient over and put them in the supine position. And then we'll just say we're going to take the fat from the abdomen. We'll put the fluid in. I usually go through the umbilical area. We'll add that volume to all the quadrants like of the abdomen as a four square. So, you know, upper and lower on the right and upper and lower on the left. And we'll begin to remove the fat after the fluids been distributed and the epinephrine's had time to work, remove the fat. So now you have a lot of avenues for fluid to move around from the top of the abdomen to the bottom of the abdomen. And we perform the explant procedure. When the pocket's been, you know, completely cleansed out, all the tissue has been removed. We've rinsed it several times. We'll connect those by adding more fluid in the fatty layer from the breast pocket to the abdominal layer. And then you connect these two. You can do it with liposuction if you're going to remove fat, contour it. You can do it without liposuction if you are just creating more of a drainage opportunity. And so, so it makes sense from an anatomy standpoint. And then we'll close all of our cases and we wrap each patient. So if we're just doing a standard case with no fat transfer, we're going to wrap and compress the upper two thirds of the breast and really try to get more of that fluid to drain out of the bottom. And then the day after, after this is done, patients come to our office and get lymphatic massage with Flopresso, which is a great device out of New Zealand. It really allows for really effective lymphatic drainage. And so we say the same things about lymphatic drainage are if you just follow the concept, like if we're putting fluid in the body anywhere, it has to come out. And I like to share that if having liposuction performed, which is performed hundreds of thousands of times a day around the world, it's done predominantly under local. And so these and I, so that everybody understands this, liters of fluid get put in to the tissues. This expands the tissues so that Then the surgeon who is removing the fats has room to work. It's a very safe, an effective tool. Like I said, it's done under local because use a combination of local anesthesia, saline solution, and epinephrine. But during all those cases, patients don't have drains placed, so there may be several liters of fluid placed. You obviously don't get all the fluid out that you place into the body. You can't. It's not possible. So then where does the fluid go? I mean, if you put six liters in and you only got two liters out, that's four extra liters of fluid. And conceptually, nobody puts a drain in to get those four extra liters of fluid out. That's what the lymphatic system of your body does in terms of absorbing that fluid, returning that fluid to your. Your normal mechanisms of filtration, and then you're ultimately going to pee it out. You know, your body has the best filtration system, the most efficient filtration system ever. So flu goes in once again, it's going to get absorbed, and then it's going to get excreted, which is basically through the combination of absorption and lymphatic system filtration and excretion through the kidneys. So that's how we avoid using drains and have for many, many years. It all makes perfect sen. There's, there's nothing cryptic about it. And drains don't prevent bleeding, and they don't prevent any seromas.