Drainless Day-procedure Abdominoplasty: Reduced Pain and Fewer Complications in 210 Consecutive Cases

Abstract

Background:

Traditional abdominoplasty commonly involves drains, inpatient admission, and significant postoperative discomfort, which increases aftercare demands and delays return to normal activity. Despite technical refinements, many surgeons continue to rely on these long-standing practices. Modern techniques incorporating tissue fixation sutures (TFSs) and regional anesthesia now allow abdominoplasty to be performed as a drainless day procedure with reduced pain and fewer complications.

Methods:

A retrospective review was conducted of 210 consecutive lipoabdominoplasties performed by a single surgeon between 2017 and 2024. All cases used a defined TFS configuration consisting of 1 vertical row above and 3 horizontal rows below the umbilicus to obliterate dead space and minimize shear forces. Bilateral transversus abdominis plane blocks were routinely administered before closure. All procedures were performed under general anesthesia in a private hospital, with discharge occurring 2–4 hours postoperatively.

Results:

Ninety-nine procedures (47.1%) were standalone lipoabdominoplasties, and 111 (52.9%) were combined with other procedures, most commonly breast surgery. The overall complication rate was low: 1 seroma (0.5%) and 1 deep venous thrombosis (0.5%). Postoperative pain was effectively managed with oral analgesia, and most patients resumed light activity within 1 week.

Conclusions:

Abdominoplasty can be safely performed as a day procedure without drains using a reproducible TFS configuration and routine transversus abdominis plan blocks. This approach adds minimal operative time, reduces pain, lowers complication rates, and challenges entrenched norms regarding drainage and hospitalization in abdominoplasty.

Takeaways

Question: Can abdominoplasty be performed safely as a day surgery without drains while reducing pain and complications?

Findings: In 210 consecutive lipoabdominoplasties, a reproducible technique using tissue fixation sutures (1 vertical row above and 3 horizontal rows below the umbilicus) plus transversus abdominis plane blocks allowed all patients to be discharged within hours. Complications were rare (0.5% seroma, 0.5% deep vein thrombosis), pain was well controlled, and most resumed activity within 1 week.

Meaning: Abdominoplasty no longer requires drains or hospitalization; this reproducible technique offers patients a safer, less painful recovery.

INTRODUCTION

Abdominoplasty has traditionally been performed according to a standard paradigm involving wide supraumbilical undermining to the costal margin, avoidance of liposuction to preserve flap vascularity, routine use of drains, and a prolonged hospital stay. These conventions, taught across the United States, the United Kingdom, Australia, and elsewhere, were historically intended to minimize complications such as seroma, yet contributed to significant postoperative pain, slow recovery, and extended inpatient care.

The evolution of the present technique began in 1995 with the high-lateral-tension abdominoplasty described by Lockwood,¹ which emphasized limited midline undermining to preserve perforators while permitting safe liposuction of the upper abdominal flap. This foundational shift enhanced contour and vascular safety and laid the groundwork for modern lipoabdominoplasty, as later formalized by Saldanha et al,^2,3 whose method has been increasingly adopted over the past 2 decades.⁴ Saldanha et al^2,3 described preserving the Scarpa fascia and the partial deep fat layer in the lower abdomen; however, similar to Cardenas-Camarena et al,⁵ the author found this step to be unnecessary.

Further refinement came with the adoption of internal suturing techniques to eliminate dead space. Quilting sutures described by Baroudi and Ferreira⁶ and progressive tension sutures (PTSs) described by Pollock and Pollock^7,8 demonstrated that internal tissue fixation reduced the incidence of seroma, thereby minimizing the need for drains. Initially, individual sutures were used in this protocol; over time, these were replaced with continuous barbed tissue fixation sutures (TFSs), offering faster placement, consistent tension distribution, and improved stabilization of tissue planes.

Pain control also advanced with the adoption of transversus abdominis plane (TAP) blocks,⁹ which reliably provided 24 hours of postoperative analgesia. With dead space effectively managed by TFSs and pain controlled with regional blocks and nonopioid medications, a progression from traditional abdominoplasty to drainless day-procedure abdominoplasty (DDA) became both feasible and safe. Although this is a single-surgeon experience, these findings may have implications for international standards, where drains and postoperative hospitalization remain prevalent.

PATIENTS AND METHODS

Between 2017 and 2024, 210 consecutive patients (205 female, 5 male) underwent lipoabdominoplasty without drains, performed by a single surgeon (M.L.) in a licensed private hospital under general anesthesia administered by a board-certified anesthesiologist. All patients who were suitable for traditional abdominoplasty were suitable for DDA. Patients with a body mass index greater than 32 kg/m² were counseled to lose weight before surgery, and individuals who smoked were required to abstain for a minimum of 4 weeks preoperatively. Mechanical venous thromboembolism (VTE) prophylaxis was routine; chemoprophylaxis was considered for patients with prior thromboembolism. Three patients with excessive central abdominal skin underwent a fleur-de-lis abdominoplasty, resulting in a vertical scar as well as a horizontal lower abdominal scar. All procedures were performed as day procedures, and patients were discharged within 2–4 hours of completion. Of the cases, 99 (47.1%) were standalone lipoabdominoplasties, whereas 111 (52.9%) were performed in combination with other procedures, most commonly breast surgery, brachioplasty, or facial procedures.

This retrospective quality assurance review complied with local governance requirements and did not require a formal human research ethics committee review. All patients provided written consent for the use of de-identified images.

Preoperative Marking

With the patient standing, a vertical midline line was drawn from the xiphoid process to the pubis. A curvilinear lower incision was marked from just lateral to the anterior superior iliac spine bilaterally, meeting at the midline above the pubis. A circular marking around the umbilicus and planned liposuction zones on the upper abdomen and flanks were outlined.

Anesthesia and Infiltration

Total intravenous anesthesia (TIVA) was used for all patients. After induction, the umbilicus was circumscribed down to the rectus fascia. Four stab incisions were made in the lower abdominal flap, and 1000 mL of infiltration solution (30 mL of 0.75% ropivacaine, 2 mL of 1:1000 epinephrine, 1 g of tranexamic acid, in normal saline) was administered across the abdomen.

Surgical Technique

Liposuction

Liberal liposuction of the upper abdominal flap, flanks, and lower abdomen was performed using a 4-mm power-assisted cannula (PAL, MicroAire).

Incision and Flap Elevation

A curvilinear incision was made from hip to hip down to the abdominal wall fascia. The abdominal flap was elevated using coagulation diathermy, preserving the umbilical stalk. Midline transection of the abdominal flap up to the umbilicus allowed improved retraction. Supraumbilical undermining was limited to 8–9 cm to permit rectus plication while preserving perforators.

Rectus Plication

The rectus diastasis was marked with midline and elliptical markings. A continuous, locking no. 1 nylon suture was used to plicate the rectus sheath from the xiphoid to the umbilicus and from the umbilicus to the pubis (Fig. 1).

Fig. 1.

Limited undermining above the umbilicus. A, Intraoperative view of limited undermining above the umbilicus with markings on the rectus fascia before rectus plication. B, Intraoperative view after rectus plication.

TFSs (Above Umbilicus)

To eliminate dead space, a continuous barbed suture (No.1 Stratafix, Ethicon) was used to approximate the superficial fascial system (SFS) to the abdominal wall fascia. A vertical unidirectional Stratafix suture was placed from the xiphoid to the umbilicus.

Umbilical Management

The umbilical stalk was shortened and fixed with interrupted 2-0 Vicryl sutures. After flap advancement and temporary fixation with a single suture to the pubis, the umbilicus was exteriorized via a vertical elliptical incision and sutured to the dermis with 4-0 Vicryl in 4 quadrants. Redundant lower abdominal skin was excised with a beveled excision to taper the subcutaneous fat.

TAP Block

TAP blocks were administered bilaterally through a fascial incision 5 cm above the anterior superior iliac spine. Each side received 20 mL of 0.5% bupivacaine with epinephrine. This provided effective analgesia for up to 24 hours postoperatively.

TFSs (Below Umbilicus)

Two additional rows of TFSs were placed horizontally below the umbilicus using double-ended barbed sutures, starting at the midline, advancing laterally to each wound edge, and returning centrally. A final third row of TFSs opposed the muscle fascia to the SFS of the upper abdominal flap to the SFS of the lower abdomen. (See Video 1 [online], which demonstrates the first horizontal row of TFSs.) (See Video 2 [online], which demonstrates the third horizontal row of TFSs.)

Video 1. This video demonstrates the first horizontal row of tissue fixation sutures using a continuous Stratafix suture.

Download video file ^{(67.1MB, mp4)}

Video 2. This video demonstrates the third horizontal row of tissue fixation sutures using a continuous Stratafix suture.

Download video file ^{(75.1MB, mp4)}

Fig. 2.

Diagram showing the placement of 1 vertical row and 3 horizontal rows of TFSs.

Closure

The incision was closed in 2 layers using interrupted 2-0 Vicryl and subcuticular 3-0 Monocryl. The umbilical skin was also closed with a 3-0 Monocryl subcuticular suture.

All sutures were absorbable. No drains were used. The incision was sealed with a skin adhesive dressing system (Prineo, Dermabond) and covered with absorbent pads and a compression garment. A simple gauze bolster was placed over the umbilicus.

Postoperative Protocol

Patients were monitored postoperatively until they were alert, mobilized, and had voided. Discharge occurred within 2–4 hours. Each patient received a prepacked Webster-pak of medications: modified-release paracetamol (1330 mg every 8 h), celecoxib (100 mg twice daily), and oral tapentadol (50–100 mg as needed). Prophylactic antibiotics (500 mg of cephalexin 4 times daily) were prescribed for 10 days. No routine pharmacological VTE prophylaxis was used; patients were instructed to mobilize early and regularly.

The compression garment was worn for 6 weeks. Patients were reviewed at 1–2 days, 1 week, 1 month, 3 months, and 12 months postoperatively.

RESULTS

A total of 210 patients (205 female, 5 male) underwent DDA between 2017 and 2024. Of these, 99 procedures (47.1%) were performed as standalone lipoabdominoplasties, and 111 procedures (52.9%) were combined with other procedures, most commonly breast procedures.

The average operative time for standalone lipoabdominoplasty was approximately 2 hours. When combined with a breast procedure, the total operative time was approximately 4 hours. No surgical assistant was used. All patients were discharged within 2–4 hours postoperatively. No drains were used in any case. Two significant complications occurred in the series.

A single seroma, detected by clinical examination alone, developed beneath the lower abdominal wound closure in a patient treated before the adoption of additional TFSs at the inferior flap. Following this event, a supplementary row of TFSs was introduced between the muscle fascia and the SFSs of both upper and lower flaps to fully obliterate dead space. No seromas have occurred since this modification.

One patient with a known history of deep vein thrombosis developed a postoperative deep vein thrombosis after a decision, made in consultation with her hematologist, to forego prophylactic anticoagulation. The event resolved without sequelae.

Pain was well controlled in most cases with scheduled modified-release paracetamol and celecoxib. Tapentadol was prescribed as needed, but many patients required little or no breakthrough analgesia.

A representative outcome is shown in Figure 3, demonstrating patient appearance preoperatively, at 2 days postoperatively, and at 12 months. Figures 4–6 demonstrate patient appearances preoperatively and 12 months postoperatively.

Fig. 3.

Pre- and postoperative views of a 38-year-old woman who underwent DDA. A, Preoperative view. B, Two-day postoperative view. C, Twelve-month postoperative view.

Fig. 4.

DDA—before and after. A–C, Preoperative views of a 37-year-old woman before DDA. D–F, Twelve-month postoperative views.

Fig. 6.

DDA combined with breast surgery—before and after. A, Preoperative view of a 42-year-old woman before DDA, implant removal, mastopexy, and fat transfer to the breast, all performed in the same procedure. B, Twelve-month postoperative view.

Fig. 5.

DDA—before and after. A–C, Preoperative views of a 45-year-old woman before DDA. D–F, Twelve-month postoperative views.

DISCUSSION

Traditional abdominoplasty, as taught through the 1980s and 1990s, typically involved wide undermining to the costal margin, avoidance of liposuction, routine placement of drains, and an inpatient stay of several days. This historical approach remains prevalent; recent data from the American Board of Plastic Surgery, as reported by Stein et al,¹⁰ indicate that 75% of surveyed US surgeons still avoid liposuction of the abdominal flap, 75% perform wide undermining, 89% use drains (for an average of 11 d), and 19% hospitalize their patients. These practices contribute to increased patient discomfort, prolonged recovery, and elevated complication rates, with reported global seroma rates as high as 12.8%.¹¹ In contrast, the present series reflects a deliberate evolution toward a modern, patient-centered model of abdominoplasty through 3 key paradigm shifts away from traditional abdominoplasty: (1) strategic liposuction with limited undermining, (2) elimination of dead space with no drains, and (3) pain control that enables safe same-day discharge.

Paradigm Shift 1: Liposuction With Limited Undermining

High-volume liposuction of the upper abdominal flap and flanks is enabled by limiting supraumbilical undermining to a narrow midline corridor—typically 8–9 cm—sufficient for rectus plication. This technique preserves critical perforators, reduces vascular risk, and allows for improved contouring in a single-stage procedure, thereby minimizing the need for secondary revisions. This principle was first introduced by Lockwood¹ and later formalized by Saldanha et al,^2,3 who was the first to comprehensively describe the technique of lipoabdominoplasty and has continued to refine his approach over more than 2 decades.⁴ Similarly, Cardenas-Camarena et al⁵ have been safely performing lipoabdominoplasty for more than 26 years and have changed little of their original protocol.

A comparable technique was described by Matarasso et al,¹² who also emphasized preservation of vascular supply but advised caution with tumescent infiltration and liposuction in the central abdominal zone. In contrast, the present experience is similar to that described by Graf et al,¹³ where with careful technique and limited undermining, aggressive central liposuction could be safely performed without compromising flap viability.

Paradigm Shift 2: Eliminating Dead Space Without Drains

A second key transition in the evolution of drainless abdominoplasty involved moving away from reliance on postoperative drains and focusing instead on the complete elimination of dead space through internal fascial fixation. Initially, this involved the placement of individual quilting sutures, following the principle established by Baroudi and Ferreira,⁶ who demonstrated reduced seroma rates through fascial approximation.

Bromley¹⁴ advocated the use of 11 PTSs in conjunction with drains, maintaining that drainage remained necessary. In contrast, an early iteration of the technique used approximately 20 individual quilting sutures and eliminated drains entirely. These sutures were placed in a vertical row above the umbilicus and 2 horizontal rows below the umbilicus. Although this was largely effective, 1 seroma occurred, prompting the addition of a transverse row of sutures beneath the lower abdominal incision. The addition of a third row of sutures below the umbilicus increased the total number of individual sutures to approximately 30. After this modification, no further seromas were observed.

This clinical outcome prompted a conceptual reassessment of the technique. Unlike traditional PTSs, which function by advancing the flap to reduce tension, TFSs serve primarily to stabilize tissue planes, obliterate dead space, and reduce shear forces. Although limited advancement may still occur, the 3 horizontal rows of sutures below the umbilicus primarily serve a stabilizing role. Therefore, in this context, the term TFS is proposed as a more accurate descriptor than PTS to reflect their biomechanical purpose in modern drainless abdominoplasty.

To improve efficiency and reproducibility, individual TFSs were later replaced with continuous barbed sutures (Stratafix), which provided consistent fixation and near complete obliteration of dead space with reduced operating time. Continuous barbed sutures for abdominoplasty were first described by Warner and Gutowski¹⁵ in 2009. In 2019, Rosen et al¹⁶ described their 10-year experience with their technique, which uses wide undermining followed by 5 rows of vertically placed barbed sutures, with the surgeon and assistant operating simultaneously.

Isaac et al¹⁷ described more limited undermining with 2 rows of vertical barbed PTSs from the xiphoid to the mons pubis. Two horizontal rows of sutures are placed along the lower abdominal incision, with 1 row comprising a continuous 3-point suspension suture between the Scarpa fascia of the superior and inferior wound edges and the deep fascia.

The continuous barbed sutures used by Warner and Gutowski,¹⁵ Gutowski and Warner,¹⁸ Rosen et al,¹⁶ and Isaac et al¹⁷ are configured primarily as vertical rows of PTSs. The stated purpose is to advance the abdominal flap while also reducing dead space and shear forces between the flap and abdominal wall fascia.

By contrast, this series used a different configuration: 1 vertical row above and 3 horizontal rows below the umbilicus (to the author’s knowledge, a configuration not previously described). This arrangement was designed primarily to stabilize tissue planes and obliterate dead space, thereby minimizing shear rather than advancing the flap. Accordingly, the sutures are more accurately described as TFSs rather than PTSs. The addition of 3 horizontal rows below the umbilicus represents a key technical distinction from previously published vertical-dominant methods and appears central to the elimination of seroma in this cohort.

Multiple studies have shown that the use of internal fixation sutures—whether individual or continuous—reduces seroma incidence from historical rates around 10%¹¹ to 2%–4%.^19–28 In the present cohort, the use of TFSs resulted in a seroma rate of just 0.5%, with a single event occurring early in the series before lower flap fixation using 3-point suspension sutures, similar to the technique described by Isaac et al,¹⁷ had been incorporated into the closure protocol.

Although quilting sutures in abdominoplasty have been used in South America for decades, there has been limited uptake of the technique in the United States, Europe, and Australia. When informally questioned as to why this is the case, most surgeons refer to the increased time for placing quilting or PTSs.²⁹ Patronella²⁷ found a 15-minute increase in operating time, and Jabbour et al²⁸ reported a 23–minute increase. In this cohort, the initial use of 30 individual quilting sutures added an extra 15 minutes of operating time. This time was reduced to 12 minutes when there was a change to continuous barbed sutures. The limited, rather than wide, undermining above the umbilicus reduces overall surgical time, so that the current operating time in this series for a lipoabdominoplasty at 2 hours is little different to the time taken for a traditional abdominoplasty by the same surgeon. No surgical assistant was used.

These results reinforce the original hypothesis by Baroudi and Ferreira,⁶ which suggests that seroma formation is driven primarily by unopposed shear forces between tissue planes, rather than the absence of drainage. By eliminating dead space and stabilizing those planes with tissue fixation, this technique prevents seroma, reduces pain, and facilitates safe same-day discharge without drains.

Paradigm Shift 3: Enhanced Analgesia to Enable Same-day Discharge

Although same-day discharge following abdominoplasty is gaining traction globally, many surgeons—particularly in Australia and parts of Europe—continue to admit patients for 1–3 days postoperatively. During this time, narcotic analgesia is commonly administered intravenously or intramuscularly, with gradual mobilization guided by pain levels and sedation. However, emerging evidence supports the use of regional anesthetic techniques to facilitate faster recovery and outpatient care.

In 2013, Morales et al³⁰ described the use of abdominal field blocks to improve pain control following abdominoplasty. Subsequent studies have demonstrated that regional techniques—particularly TAP blocks performed with liposomal bupivacaine (Exparel)—can significantly reduce postoperative opioid requirements.^31,32 Although access to liposomal bupivacaine is limited in Australia, this series used routine bilateral TAP blocks, under direct view by the surgeon, using standard bupivacaine with epinephrine, achieving effective analgesia lasting up to 24 hours.

This allowed patients to mobilize upright within hours of surgery and be discharged once alert, orally tolerant, and pain-free. Most were maintained on a regimen of modified-release paracetamol and a nonsteroidal anti-inflammatory (celecoxib), with oral opioids (tapentadol) reserved for breakthrough pain. Many patients required no opioids at all.

Return to sedentary activity typically occurred within 7–14 days, with many patients able to work from home within the first week. Importantly, early discharge was not associated with an increased risk of complications. Even when abdominoplasty was combined with breast surgery, operative times remained less than 4 hours, and patients were reliably discharged within 2–4 hours postoperatively—without the use of drains in either operative field.

A New Abdominoplasty Paradigm

This 210-case experience supports a contemporary abdominoplasty protocol that incorporates targeted liposuction, limited undermining, drain-free closure with TFSs, and multimodal analgesia. The result is a reproducible, efficient, and patient-friendly procedure performed safely as a day surgery.

This approach offers several advantages:

• Reduced postoperative pain and opioid use

• Minimal seroma formation

• Faster return to normal activity

• Elimination of inpatient stay and drain-related complications.

This DDA protocol offers a viable alternative to the traditional model—one that prioritizes recovery, outcomes, and patient satisfaction without compromising safety.

This study was limited by its retrospective design, single-surgeon experience, and absence of a contemporaneous control group. Patient selection and perioperative protocols may limit generalizability. Prospective, multicenter comparisons would better quantify the independent contribution of the TFSs and TAP blocks to outcomes.

CONCLUSIONS

Lipoabdominoplasty (DDA), whether performed alone or with adjunct procedures, can be safely completed as a day procedure without drains. The described protocol—using a reproducible TFS configuration (1 vertical row above and 3 horizontal rows below the umbilicus) together with bilateral TAP blocks—permits early discharge, minimizes seroma risk, and reduces postoperative pain. Although limited to a single-surgeon experience, the consistency across 210 consecutive cases strengthens the findings. This approach offers a patient-centered alternative to traditional abdominoplasty protocols, with no increase in operative time and a low complication rate.

The consistent success of this technique demonstrates that abdominoplasty no longer requires drains or hospitalization. Its adoption offers patients less pain, fewer complications, and faster recovery without added operative complexity.

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.