Post Operative Swelling Stages

In my previous blog post about post operative tummy tuck swelling I talked about how the blood supply is disrupted to different degrees using the two different types of tummy tuck techniques (standard vs. Lockwood). In summary, the more skin that is elevated and separated from the muscle layer, the more blood supply disruption you have. On this post we will address swelling of the tissues after tummy tuck and why compression garments following surgery are important to reduce swelling.

The body is made mostly of water, and there is a constant fluid leakage from the tissues balanced by reuptake of fluid into the lymphatic drainage system. When the lymphatic system is impaired, we get fluid accumulations. The fluid can accumulate between the tissues as interstitial fluid (like a soaked sponge), or outside of the tissues as a seroma (like a sac of fluid). It can also accumulate at some distance from the operative site, usually the upper thighs or legs.

The drawing above illustrates the various types of fluid accumulation following surgery. As you move from left to right on the illustration you have increasing swelling to result in these conditions:

normal skin ——> normal swelling ———- > seroma———>

Fluid accumulation can happen early on in the postoperative period. When the body is in the acute healing phase it produces a lot of fluid. There are also a lot of tissues cut by the surgery, so there is leakage from those areas. The lymphatic channels themselves, which are used for drainage of the fluid, are cut and interrupted, so drainage of the fluids is impaired. This is to be expected. Since we know that there will be fluid accumulation after surgery, plastic surgeons prepare for this by utilizing drains during the post operative period.

Swelling can also happen after the acute healing phase is over, during the prolonged healing phase. The long incision line across the lower abdomen interrupts a lot of lymphatic channels. Since drainage of the lymphatics goes from the extremities to the heart, the incision path blocks drainage until lymphatic channels get reestablished. This can take weeks or months. The swelling is manifested as swelling in the upper thighs, and in some cases in the lower legs. The abdominal skin flap can stay swollen due to lymphatic blockage weeks after surgery. This type of swelling requires compression, because swollen tissues themselves can cause more scarring.

Control of swelling starts with surgical planning. As was described in my earlier post describing the Lockwood technique of tummy tuck, the less you separate the tissues the better. This is because there is less empty space for fluid to accumulate, less tissue from which fluid leaks, more intact lymphatics to drain fluid, and tissues can heal faster. I prefer the Lockwood technique because separates less tissues than the standard technique After surgery, compression is very important. It prevents fluid leakage from the tissues, and once it occurs, the pressure forces it back into whatever drainage channels are available (drains or lymphatics). Tissues heal better and faster when there is minimal swelling.

The type of compression is important. Too much compression at a given point can stop blood flow and cause tissue death. Too little, and fluid accumulates. In my opinion abdominal binders (wrap around type) are inadequate because they shift and the shearing from it can disrupt the healing of the abdominal flap to the muscle underneath. Secondly, they can obstruct flow from the extremities back to the heart. This is why some people with abdominal binders can have swelling in the upper thighs.

To control swelling, I only use medical grade compression garments that go from the rib cage to just above the knees, with shoulder straps to prevent creases. The compression is uniform so there is not too much pressure in any one site. The compression in the thighs prevents any fluid buildup in the upper thighs and legs. In addition, in areas where I have separated a lot of tissue I put some foam pads to apply gentle extra pressure and prevent seromas. The compression garments are left continuously for two weeks (except for taking showers or baths), and during the day for another two weeks. This is a month of wearing garments. It is important to wear the garment for this entire period so that you are compressed during both periods of fluid accumulation, the acute (immediately following surgery) and prolonged healing phases (2-4 weeks out).

In summary, my experience has been that post operative swelling can be easily controlled with:

1) the appropriate surgical design (Lockwood technique)

2) prompt and prolonged compression with medical grade compression garments

Ricardo L Rodriguez, MD