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Quilting Sutures, Scarpa Fascia Preservation, and Meta-Analyses of Seroma Rates after Abdominoplasty

Swanson, Eric MD

Plastic and Reconstructive Surgery – Global Open: July 2017 - Volume 5 - Issue 7 - p e1429
doi: 10.1097/GOX.0000000000001429
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United States

From the Swanson Center, Leawood, Kans.

Disclosure: The author has no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the author.

Eric Swanson, MD, Swanson Center, 11413 Ash Street, Leawood, KS 66211, 931 663-1030, E-mail: eswanson@swansoncenter.com

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Sir:

Three recently published meta-analyses compare seroma rates after abdominoplasty.1–3 Two studies find in favor of quilting sutures1,3 and both studies evaluating Scarpa fascia preservation find it beneficial.1,2 An earlier meta-analysis of tissue adhesives (surprisingly) found no significant reduction in seroma rates.4 Is it time for plastic surgeons to adopt quilting sutures and preserve the Scarpa fascia?

Systematic reviews are notoriously difficult in plastic surgery because of confounding variables—the surgeon, method, body mass index, tissue resection weight, liposuction, diagnostic method (eg, clinical or ultrasound), compression garments, drains, and tissue adhesives. Publication bias is a problem.1

In support of their meta-analysis, Seretis et al.2 comment, “The methodology overcomes the insufficient study power of several RCTs [randomized controlled trials] to measure more than one endpoint due to small sample sizes and obviates the methodological flaws of retrospective studies or case series.” In truth, no amount of statistical rigor can compensate for flaws in the constituent studies.5 Nasr et al.4 acknowledge the heterogeneity of data and risk of bias. Despite limiting their analysis to randomized trials, these investigators found inadequate study quality.4

Ardehali and Fiorentino1 believe that preservation of Scarpa fascia involves “leaving a thin layer of subscarpa fascia fatty tissue on the abdominal wall.” Leaving a thin layer of areolar tissue on the abdominal wall is a traditional method used by most plastic surgeons; it is not the same as Scarpa fascia preservation, which typically leaves a thick layer of tissue (depending on patient weight of course) on the abdominal wall that includes the Scarpa fascia and subscarpal fat (Fig. 1).5,6 Importantly, both meta-analyses evaluating Scarpa fascia preservation1,2 included a level 1 study by Costa-Ferreira et al.7 Ordinarily, one might consider the findings of such a high-level study almost irrefutable. However, a confounder undermined the conclusion. In the group treated with Scarpa fascia preservation, an avulsion technique was used.7 Flap elevation in the control group was performed using electrodissection.7

Fig. 1

Fig. 1

Only 1 meta-analysis compares dissection methods—scalpel versus electrodissection2 but omitted a large comparative study by Rousseau et al.8 (possibly because the keywords “abdominoplasty” and “seromas” do not appear in the title). In their comparison of 327 patients treated with scalpel dissection versus 320 patients treated with electrodissection, Rousseau et al.8 report significantly more seromas after electrodissection. Similarly, Valença-Filipe et al.9 report no seromas in 39 scalpel dissections versus 15 seromas in 80 patients (18.8 %) treated with electrodissection. Both studies document a significant reduction in drain output and time to drain removal after scalpel dissection.8,9 The meta-data yield a significant seroma risk reduction using scalpel dissection (P < 0.01).10

Tourani et al.,11 in their cadaveric study, conclude that Scarpa fascia preservation would not preserve the lower abdominal lymphatic collectors. Scarpa fascia preservation does have a downside; the abdomen is not quite as flat because of the preserved fatty tissue (Fig. 1).5,6

Quilting (also called progressive tension) sutures add about 23 minutes of operating time and may cause dimpling.3 Seromas may still develop. Among patients treated with quilting sutures, the overall seroma rate reported in Ardehali and Fiorentino’s1 meta-analysis was 5.8 % (15/260), similar to the rate associated with scalpel dissection and no quilting sutures (5.4 %).5 Quilting sutures may be technically difficult to perform if the patient is placed in a jackknife position during surgery so as to maximize flap mobility (Fig. 1) and keep the scar within the panty line.5

Seroma fluid resembles an inflammatory exudate,12 as opposed to a transudate from lymphatic obstruction. Total protein, lactate dehydrogenase, cholesterol levels, and neutrophil percentage are higher in seromas than in lymphatic fluid.12 Although a limited dissection is believed to improve circulation and reduce complications, a controlled evaluation of abdominoplasty flap perfusion using laser fluorescence imaging found no advantage over a traditional dissection.6 A reduced seroma rate may be related to less electrodissection and therefore less tissue injury, rather than preservation of perforators and the Scarpa fascia.6

Electrodissection was introduced decades ago to reduce bleeding. However, a superwet infusion containing 1:500,000 epinephrine causes potent vasoconstriction, reducing blood loss from abdominoplasty to an average of 290 cc when the procedure is combined with liposuction.13 The evidence supports a reduction in seroma rates by using scalpel dissection and avoiding a need for quilting sutures.

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REFERENCES

1. Ardehali B, Fiorentino F. A meta-analysis of the effects of abdominoplasty modifications on the incidence of postoperative seroma. Aesthet Surg J. 2017. May 6, 2017 [Epub ahead of print].
2. Seretis K, Goulis D, Demiri EC, et al. Prevention of seroma formation following abdominoplasty: a systematic review and meta-analysis. Aesthet Surg J. 2017;37:316–323.
3. Jabbour S, Awaida C, Mhawej R, et al. Does the addition of progressive tension sutures to drains reduce seroma incidence after abdominoplasty? A systematic review and meta-analysis. Aesthet Surg J. 2017;37:440–447.
4. Nasr MW, Jabbour SF, Mhawej RI, et al. Effect of tissue adhesives on seroma incidence after abdominoplasty: A systematic review and meta-analysis. Aesthet Surg J. 2016;36:450–458.
5. Swanson E. Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination. Plast Reconstr Surg Glob Open. 2013;1:e32.
6. Swanson E. Comparison of limited and full dissection abdominoplasty using laser fluorescence imaging to evaluate perfusion of the abdominal skin. Plast Reconstr Surg. 2015;136:31e–43e.
7. Costa-Ferreira A, Rebelo M, Silva A, et al. Scarpa fascia preservation during abdominoplasty: randomized clinical study of efficacy and safety. Plast Reconstr Surg. 2013;131:644–651.
8. Rousseau P, Vincent H, Potier B, et al. Diathermocoagulation in cutting mode and large flap dissection. Plast Reconstr Surg. 2011;127:2093–2098.
9. Valença-Filipe, Martins A, Silva Á, et al. A prospective study on scalpel versus diathermocoagulation (coagulation mode). Plast Reconstr Surg Glob Open. 2015;3:e299.
10. Calculation for the chi-square test. Available at http://www.quantpsy.org/chisq/chisq.htm. Accessed May 7, 2017.
11. Tourani SS, Taylor GI, Ashton MW. Scarpa fascia preservation in abdominoplasty: does it preserve the lymphatics? Plast Reconstr Surg. 2015;136:258–262.
12. Prado A, Andrades P. Composition of postabdominoplasty seroma. Aesthetic Plast Surg. 2007;31:514–518.
13. Swanson E. Prospective study of lidocaine, bupivacaine and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg. 2012;130:702–722; discussion 723–725.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.