What surgical drains are for, and when they come out

Of everything explained before an abdominoplasty, the drain is what draws the alarmed look. A small tube coming out of the skin, ending in a bottle you have to carry around for a few days. The picture is worse than the experience, and it is worth explaining why.

What it removes, and from where

To take away the excess skin on the abdomen, that skin first has to be lifted off the muscles. When everything is closed again, there is a space between two surfaces that until that day were stuck together. And that space does not stay empty: the body fills it with fluid.

It is not blood and it is not pus. It is clear fluid, somewhere between pink and straw yellow, produced by any tissue that has just been handled. A perfect operation would produce it just the same.

The drain is a thin tube with small holes along the part that stays inside, connected to a container that holds a vacuum. While it is in place, that fluid comes out instead of collecting. This achieves two things: the skin can stick back down to the deeper layer, which is what healing requires, and no pressurised pocket forms underneath.

Why an abdominoplasty has them and a breast augmentation almost never does

The question nearly always arrives in the same tone: "my friend had implants and they didn't put any of that in her." That is true, and the reason is geometric.

In a breast augmentation a pocket is made to the exact size of the implant and the implant goes inside it. No space is left over. In an abdominoplasty a wide surface of skin and fat is lifted, from the pubis upwards, and when it is done that whole expanse has to stick back down again.

So the criterion is not "big surgery yes, small surgery no", but how much tissue was lifted. Liposuction does not lift layers, it only makes tunnels, and usually does not need them. A breast reduction may or may not have them. An abdominoplasty with muscle repair, nearly always.

What comes out is measured, which is why it is written down

The bottle has markings. Once a day, at the same hour, it is emptied and you note how much there was and what colour it was. If there are two, they are noted separately. That piece of paper — or the note on your phone, it makes no difference — is the information used to decide when they come out.

Normal progress goes down in both senses. The first day is the one with the most volume and the reddest colour; after that the amount falls and the colour clears towards pink and then to straw yellow.

There is no date marked on the calendar. They come out when the volume over twenty-four hours drops below a small figure — the order of magnitude is a few tens of millilitres a day — and stays there. In most abdominoplasties that happens within the first few days. In some it takes longer, and on its own that does not mean anything is wrong.

The drain does not produce the fluid: it removes it. Taking it out early speeds nothing up; it only changes where the fluid stays.

What removal feels like

This is the part everyone imagines as worse than it is. The stitch holding the tube to the skin is cut, you are asked to take a breath, and it is drawn out in one continuous movement. It takes a few seconds.

What almost every patient describes is not pain: it is strange. An internal tug, a sort of deep tickle travelling along the path of the tube, and then it is over. No anaesthetic is needed. What is left is an opening a few millimetres across that is covered and closes on its own.

There is a simple explanation for why it frightens more than it deserves: it is the only part of recovery you see go into the body and come back out.

Living with it for a few days

• No pulling. The bottle stays secured — to the garment, to a strap around the neck, to a belt — never hanging loose. Almost every scare comes from a tug while standing up or turning over in bed.
• Empty it the way you were shown and leave it holding a vacuum again. A bottle that is not suctioning is not draining.
• Write it down before you tip the contents away, not from memory the next day.
• Showering, only once you are cleared for it. While the drains are in, washing is done in parts, without wetting the area.
• Walk. Having drains in is no reason to stay in bed. You walk from the first hours, a little and often: that is what prevents thrombosis.
• Do not take it out at home, however little is coming out and however uncomfortable it is.

When to call without waiting for your appointment

• The volume goes up instead of down, or turns bright red again after having cleared.
• The fluid comes out cloudy or smelling bad.
• Fever.
• The skin around where the tube enters is red, hot and spreading.
• The drain suddenly stops producing fluid and at the same time the area swells or feels tight: it may be blocked.
• The tube comes out by itself, whole or in part.
• Pain that increases rather than decreases, swelling in one leg only, or difficulty breathing. That does not come from the drain, but it is the most urgent of all.

And if fluid gathers after they come out

It can happen, and it is worth knowing before it does. It is called a seroma: a pocket of fluid under the skin, in the area that was lifted. It feels like a soft region that shifts when you rest your hand on it, sometimes with a sense of heaviness, almost never painful.

It is usually dealt with by drawing the fluid off with a needle in the consulting room, and sometimes that has to be repeated. It is not a serious complication and it does not mean the surgery failed: it means the space took a little longer to close.

What does make a difference is saying so early. A seroma found and emptied in time resolves and that is the end of it. One that has been there for weeks can form a wall of its own, and then it needs considerably more than a needle.

What depends on you

Less than it seems, and all of it simple: keep the bottle secured, empty it and write it down, wear the garment as you were told, walk, and do not decide for yourself when the tube is no longer needed. The calendar is not set by the date: it is set by the paper where you note the millilitres.