Purpose: In 2007, abdominoplasties represented the fourth most common surgical procedure performed by plastic surgeons across the United States. Many authors have identified seroma as the most frequent complication, with rates ranging from 4.0% to 17.5%. Surgeons have adopted various technical modifications when performing abdominoplasties with the intention of reducing seroma formation. The following abstract serves as a comparative review of the technical modifications utilized by six plastic surgeons when performing an abdominoplasty.
Methods: A retrospective review of all consecutive patients who underwent an abdominoplasty over an 11 year period were reviewed. All surgeries were performed individually by the six plastic surgeons, with little variation in each surgeon’s operative technique over the past decade. Each surgeon’s patient cohort, operative technique and post-operative complications were compared with particular focus on factors affecting seroma formation.
Results: The 1008 study patients underwent either a full or mini abdominoplasty (93.2% vs. 6.8%, respectively) with an associated total complication rate of 32.6%. The most common complication was seroma formation occurring in 155 patients (15.4%). Interventions included aspiration in the office (95.4%), image guided aspiration (9.0%), and operative drainage (5.8%). The average amount aspirated was 190 mL (10 mL - 2250 mL) with an average of two (1-8) aspirations per seroma. Risk factors for seroma formation included male sex (p <0.001) and morbid obesity (p=0.043). Liposuction of the flanks and the abdominal flap at the time of abdominoplasty was associated with a higher seroma rate (p=0.003). The use of tumescence without subsequent liposuction resulted in a lower seroma rate (p=0.049). Those patients who had a seroma were more likely to undergo a revision (p=0.003). The six surgeons were compared showing a relatively homogenous patient cohort, although the techniques varied. Compared to the rest of the surgeons, surgeon A had a significantly higher seroma rate (26.7%). Surgeon A’s technique included frequent abdominal flap liposuction of zone I and II and the use of bovie at high settings to aggressively undermine up to the costal margin, with maintenance of a layer of sub-scarpal tissue on the anterior abdomen. Surgeon E, who had a significantly lower seroma rate compared to the other surgeons, was much less aggressive with respect to undermining and resection, relying on lower bovie settings. Overall duration and number of drains, as well as method of dissection (bovie vs. sharp), showed no increase in seroma formation.

Discussion: Seroma formation following an abdominoplasty is the most frequent complication, resulting in significant morbidity. Numerous surgical modifications have been anecdotally proposed to reduce seroma rates. Liposuction of the flanks and abdomen in conjunction with increased generalized edema creates significant lymphatic disruption that leads to seroma formation. Aggressive undermining with higher bovie settings that increase thermal damage to surrounding lymphatic channels may also contribute significantly. In order to reduce seroma rates, surgeons should avoid aggressive liposuction and undermining, particularly in high risk patients.