Abdominoplasty repair for abdominal wall hernias

Concomitant Panniculectomy in Abdominal Wall Reconstruction: A Narrative Review Focusing on Obese Patients

The global prevalence of obesity continues to rise, contributing to an increased frequency of abdominal wall reconstruction procedures, particularly ventral hernia repairs, in individuals with elevated body mass indexes. Undertaking these operations in obese patients poses inherent challenges. This review focuses on the current literature in this area, with special attention to the impact of concomitant panniculectomy. Obese individuals undergoing abdominal wall reconstruction face elevated rates of wound healing complications and hernia recurrence. The inclusion of concurrent panniculectomy heightens the risk of surgical site occurrences but does not significantly influence hernia recurrence rates. While this combined approach can be executed in obese patients, caution is warranted, due to the higher risk of complications. Physicians should carefully balance and communicate the potential risks, especially regarding the increased likelihood of wound healing complications. Acknowledging these factors is crucial in shared decision making and ensuring optimal patient outcomes in the context of abdominal wall reconstruction and related procedures in the obese population.

Transfection of hypoxia-inducible factor-1α mRNA upregulates the expression of genes encoding angiogenic growth factors

Hypoxia-Inducible Factor-1α (HIF-1α) has presented a new direction for ischemic preconditioning of surgical flaps to promote their survival. In a previous study, we demonstrated the effectiveness of HIF-1a DNA plasmids in this application. In this study, to avoid complications associated with plasmid use, we sought to express HIF-1α through mRNA transfection and determine its biological activity by measuring the upregulation of downstream angiogenic genes. We transfected six different HIF-1a mRNAs-one predominant, three variant, and two novel mutant isoforms-into primary human dermal fibroblasts using Lipofectamine, and assessed mRNA levels using RT-qPCR. At all time points examined after transfection (3, 6, and 10 h), the levels of HIF-1α transcript were significantly higher in all HIF-1α transfected cells relative to the control (all p < 0.05, unpaired Student's T-test). Importantly, the expression of HIF-1α transcription response genes (VEGF, ANG-1, PGF, FLT1, and EDN1) was significantly higher in the cells transfected with all isoforms than with the control at six and/or ten hours post-transfection. All isoforms were transfected successfully into human fibroblast cells, resulting in the rapid upregulation of all five downstream angiogenic targets tested. These findings support the potential use of HIF-1α mRNA for protecting ischemic dermal flaps.

Outcomes of Ventral Hernia Repair After Orthotopic Liver Transplant Using Component Separation and Onlay Biologic Mesh

INTRODUCTION

The management of ventral hernias (VHs) after orthotopic liver transplant (OLT) can be uniquely challenging because of immunosuppression coupled with large laparotomy size that can compromise the quality of the abdominal wall. The component separation with multipoint suture onlay acellular dermis fixation technique has proven to be effective in high-risk abdominal wall reconstructions. The goal of this study was to elucidate the factors that affect safety and efficacy of VH repair in post-OLT patients.

METHODS

A retrospective review of 345 patients who underwent repair of VH with compartment separation and onlay acellular dermal matrix reinforcement from a single surgeon from 2012 to 2020 was conducted. Of these, 27 patients were identified with a history of OLT and were stratified based on whether the defect was a initial or recurrent hernia repair. The majority of patients had a standard chevron incision (70%). Data abstraction was performed for preoperative risk factors, hernia characteristics, surgical site complications, and postoperative course including hernia recurrence.

RESULTS

A majority of cases in the study period were initial hernia repairs (59%) with no significant differences in the patient demographics and size of VH defects (190 ± 112.69 cm 2 ). Comorbidities were similar between the groups with the exception of a significantly higher baseline creatinine levels and higher history of smoking in the recurrent hernia repair group ( P < 0.05). Of the 27 cases, there were no demonstrable hernia recurrences noted and an overall 11% complication rate. Univariate analysis noted a statistically significant difference in surgical site complication rate ( P = 0.017), with the initial hernia repair group having the lowest rate of surgical site complications.

CONCLUSIONS

In complex post-OLT patients with large VH, modified component separation with onlay acellular mesh was shown to have acceptable medium-term results. Further studies investigating the factors leading to postoperative complications are necessary to reduce recurrence in this evolving patient population.

Identifying the most attractive umbilical position - an eye tracking- and survey-based investigation

Abdominoplasty is a popular procedure in plastic surgery providing aesthetic, functional and psychological relief for patients suffering from excess abdominal tissue. Correct umbilical positioning is crucial for a successful aesthetic surgical outcome. This study aims to assess the most attractive position of the umbilicus by means of subjective and objective outcome measures. 58 Caucasian study participants with a mean age of 36.87 (15.6) years rated eight different umbilical positions. The various positions were determined based on the ratio of the distance between the xiphoid process and the umbilicus and the distance between the umbilicus and the infra-umbilical crease: 1:1, 1.25:1, 1.5:1, 1.75:1, 2:1, 2.5:1, 3:1 and 5.5:1. Semi-quantitative scoring of attractiveness based on a 5-point Likert scale and eye tracking analyses were utilized. The results revealed that the volunteers perceived as most attractive the ratio of 2:1 with 4.32 (out of possible 5.0). The ratio of 5.5:1 received the lowest rating with 1.8. The results of the objective eye tracking analyses confirmed the subjective rating as the 2:1 ratio was fixated last amongst all other displayed ratios with 1.85 s whereas the 5.5:1 ratio had the shortest interval between image display and first stable eye fixation with 0.94 s. The study confirms the concept of 'internal representation of beauty'. Abdominoplasty procedures could rely on this easy to perform ratio by dividing the distance into thirds and using the boundary between the inferior and middle third as a clinically reliable landmark.

Preconditioning of surgical pedicle flaps with DNA plasmid expressing hypoxia-inducible factor-1α (HIF-1α) promotes tissue viability

Ischemic necrosis of surgical flaps after reconstruction is a major clinical problem. Hypoxia-inducible factor-1α (HIF-1α) is considered the master regulator of the adaptive response to hypoxia. Among its many properties, it regulates the expression of genes encoding angiogenic growth factors, which have a short half-life in vivo. To achieve a continuous application of the therapeutic, we utilized DNA plasmid delivery. Transcription of the DNA plasmid confirmed by qRT-PCR showed significantly increased mRNA for HIF-1α in the transfected tissue compared to saline control tissue. Rats were preconditioned by injecting with either HIF-1α DNA plasmid or saline intradermally in the designated flap region on each flank. Seven days after preconditioning, each rat had two isolated pedicle flaps raised with a sterile silicone sheet implanted between the skin flap and muscle layer. The flaps preconditioned with HIF-1α DNA plasmid had significantly less necrotic area. Angiogenesis measured by CD31 staining showed a significant increase in the number of vessels per high powered field in the HIF-1α group (p < 0.05). Our findings offer a potential therapeutic strategy for significantly promoting the viability of surgical pedicle flaps by ischemic preconditioning with HIF-1α DNA plasmid.

[Multidisciplinary approach to surgical treatment of patients with superficial abdominal obesity]

OBJECTIVE

To analyze an effectiveness of laparoscopic surgery with simultaneous abdominoplasty in patients with superficial abdominal obesity.

MATERIAL AND METHODS

Laparoscopic abdominal, retroperitoneal and pelvic surgery with simultaneous abdominoplasty was performed in 25 patients with body mass index >40 kg/m².

RESULTS

Surgery time and intraoperative blood loss were significantly higher after simultaneous surgery (p<0.05). However, these differences did not influence postoperative period. Duration of analgesic therapy, activation of patients and length of hospital-stay, as well as overall postoperative morbidity were similar in both groups (p>0.05). Simultaneous abdominoplasty resulted significantly better quality of life according to almost all parameters (p<0.05).

CONCLUSION

According to certain indications, abdominoplasty is advisable as the first stage of simultaneous surgery in patients with large subcutaneous fat apron after bariatric surgery or in those with primary superficial abdominal obesity. The positive aspects of abdominoplasty are simplification of laparoscopic stage, reduced intra-abdominal pressure in postoperative period, excellent and good aesthetic effect and improved quality of life.

Simultaneous Ventral Hernia Repair and Panniculectomy: A Systematic Review and Meta-Analysis of Outcomes

BACKGROUND

Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases.360 METHODS:: The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data.

RESULTS

There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent.

CONCLUSIONS

SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.

The 4 Principles of Complex Abdominal Wall Reconstruction

Abdominal wall defects are some of the most common and challenging problems encountered by plastic surgeons. A high proportion of patients with abdominal wall defects have significant comorbidities and/or contamination, putting them at high risk for complications. In addition to advanced surgical skills and precise anatomical knowledge, the plastic surgeon needs strict discipline and medical acumen, to optimize patients before and after surgery. In this paper, we discuss the goals of abdominal wall reconstruction, and the 4 steps to successful surgery: preoperative patient selection/optimization, durable and dynamic reconstruction of the musculofascial layer, careful attention to the skin and subcutaneous tissue, and meticulous postoperative management.

Sublay or onlay incisional hernia repair along with abdominoplasty: which is better? Long-term results

PURPOSE

Estimation and comparison of results after incisional hernia repair (IHR) modo onlay or sublay with abdominoplasty in patients who lost the weight following Roux-en-Y Gastric Bypass (RYGB). Analysis and comparison of changes in quality of life (QL) of these patients prior to RYGB, before and after simultaneous IHR and abdominoplasty.

METHODS

Clinical analysis involved 40 patients with abdominal disfigurement (following RYGB and massive weight loss) after one-time IHR sublay method with abdominoplasty-group 1 or IHR onlay method with abdominoplasty-group 2. We evaluated postoperative results and long-term QL changes (DAS24, SF-36 scales).

RESULTS

We noted abnormal wound healing (2), pneumonia (3) and dysesthesia (3) in patients from group 1, and abnormal wound healing (2), seroma (2), pneumonia (2), and dysesthesia (4) in group 2. Quality of life was improved in the functional, esthetic and psychological aspects.

CONCLUSIONS

One stage incisional hernia repair by onlay as well as sublay method with abdominoplasty are safe surgical methods improving the functioning of patients after major weight loss following RYGB. Sublay hernia repair and abdominoplasty was connected with longer time of the: operation, drainage, analgesic agents use, time to mobilization and to full oral diet than the onlay method. Significant improvement of the quality of life was noted after every subsequent step of surgical treatment in both groups. Reduction of the risk of BMI re-growth after bariatric surgery is related to the need for constant, specialized care for these patients at every stage of follow-up after bariatric surgery.

Concomitant Abdominoplasty and Laparoscopic Umbilical Hernia Repair

BACKGROUND

Umbilical hernia is a common finding in patients undergoing abdominoplasty, especially those who are postpartum with rectus divarication. Concurrent surgical treatment of the umbilical hernia at abdominoplasty presents a "vascular challenge" due to the disruption of dermal blood supply to the umbilicus, leaving the stalk as the sole axis of perfusion. To date, there have been no surgical techniques described to adequately address large umbilical herniae during abdominoplasty.

OBJECTIVES

To present an effective and safe technique that can address large umbilical herniae during abdominoplasty.

METHODS

A prospective series of 10 consecutive patients, undergoing concurrent abdominoplasty and laparoscopic umbilical hernia repair between 2014 and 2017 were included in the study. All procedures were performed by the same general surgeon and plastic surgeon at the Macquarie University Hospital in North Ryde, NSW, Australia. Data were collected with approval of our ethics committee.

RESULTS

At 12-month follow up there were no instances of umbilical necrosis, wound complications, seroma, or recurrent hernia. The mean body mass index was 23.8 kg/m2 (range, 16.1-30.1 kg/m2). Rectus divarication ranged from 35 to 80 mm (mean, 53.5 mm). Umbilical hernia repair took a mean of 25.9 minutes to complete (range, 18-35 minutes).

CONCLUSIONS

We present a technique that avoids incision of the rectus fascia minimizes dissection of the umbilical stalk and is able to provide a gold standard hernia repair with mesh. This procedure is particularly suited to postpartum patients with large herniae (>3-4 cm diameter) and wide rectus divarication, where mesh repair with adequate overlap is the recommended treatment.

LEVEL OF EVIDENCE 4

Ultrasound-guided percutaneous microwave ablation vs. surgical resection for thoracoabdominal wall implants from hepatocellular carcinoma: intermediate-term results

OBJECTIVE

The aims of this study were to compare the clinical outcomes between ultrasound (US)-guided percutaneous microwave ablation (MWA) and surgical resection (SR) in patients with thoracoabdominal wall implants from hepatocellular carcinom (HCC) and to identify the prognostic factors associated with the two treatment methods.

MATERIALS AND METHODS

A total of 47 patients (mean age, 56.7 ± 15.9 years, range, 18-78 years; 34 men and 13 women) with 61 thoracoabdominal wall HCC seeding were included from April 2007 to May 2017. Twenty-five patients underwent US-guided MWA and 22 patients underwent SR. Survival, recurrence and liver function were compared between the two groups. Effect of changes in key parameters (i.e. overall survival (OS), disease-free survival (DFS) and local tumour reoccurrence-free (LTRF)) was statistically analysed with the log-rank test. Univariate and multivariate analyses were performed on several clinicopathological variables to identify factors affecting long-term outcome and recurrence.

RESULTS

The OS, DFS and LTRF after MWA were comparable to those of SR (p =0.493, p = 0.578 and p =0.270, respectively). Estimated 5-year overall survival rates were 63% after MWA and 48.1% after SR; for disease-free survival, estimated 5-year rates were 67.5% after MWA and 48.8% after SR; estimated 24-month LTRF rates were 71.3% after MWA and 87.8% after SR. The MWA group had less surgical time (p = <0.001), estimated blood loss (p = <0.001) and post-operative hospitalisation (p = 0.032) and cost (p = 0.015). Multivariate analysis showed remnant intrahepatic tumour (p =0.007), Child Pugh grade (p = 0.009) and metastasis (p= <0.001), were predictors for survival rate.

CONCLUSIONS

Ultrasound-guided percutaneous MWA is a safe and effective treatment method for metastatic HCC on the thoracoabdominal wall with similar outcomes to SR. Residual intrahepatic HCC, Child Pugh grade and distant metastasis are predictors for survival.

Does Abdominoplasty Add Morbidity to Incisional Hernia Repair? A Randomized Controlled Trial

Background Abdominoplasty is considered an operation linked to a considerable rate of morbidity. The convenience of simultaneously performing an incisional hernia repair and an abdominoplasty remains controversial. Methods A total of 111 patients were randomized prospectively to compare isolated incisional hernia repair and hernia repair when combined with abdominoplasty. Primary end points were in-hospital stay and early morbidity. Secondary end points were late morbidity, recurrences, and quality of life. Patients were followed-up for 24 months. Results Duration of the surgical procedure differed significantly between both groups (39 vs 85 minutes, P < .001) and postoperative hospital stay (2.5 vs 3.5 days; P < .001). No statistically significant differences in early or late morbidity between both groups were detected. The perceived quality of life for patients was higher in the combined surgery group (P < .001) that in the isolated hernia repair group. Conclusions Postoperative in-hospital stay and early and late morbidity do not differ significantly between isolated incisional hernia repair and simultaneous hernia repair with abdominoplasty, but associated abdominoplasty provides a higher quality of life when indicated.

Low incidence of complications using polyglactin 910 (Vicryl) mesh in breast reconstruction: A systematic review

BACKGROUND

Mastectomy and breast reconstruction are essential parts of the treatment of breast cancer. Acellular dermal matrices (ADMs) have been used for the reconstruction of the lower pole due to many advantages; however, its cost is seen as a major drawback in this era of concern for the allocation of health-care funds. Recently, polyglactin 910 (Vicryl; Ethicon, Somerville, NJ, USA) mesh has been published as an alternative. We assessed the published literature, in particular investigating for studies that compare Vicryl mesh with ADM.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Searched databases included Medline/PubMed, Cochrane Reviews, Embase, Web of Science, ClinicalTrials, and SCOPUS. Search criteria were as follows: (1) reporting of clinical data using Vicryl mesh in breast reconstruction, (2) reporting of original data, and (3) outcome of interest reported.

RESULTS

We retrieved 290 de-duplicated articles. After title and abstract screening, we dismissed 258 articles, and thus full text was reviewed for 32 articles; only three retrospective articles met inclusion criteria. The total population included 112 patients and 156 breasts. The reported incidence of complications was as follows: infection 2.6% (confidence interval (CI): 0.7-6.6%), reconstruction failure 3.2% (CI: 1.0-7%), and seroma 1.3% (CI: 0.2-4.6%). A seven- to 12-fold cost difference was reported. Follow-up length ranged from 1.2 to 3.6 years. No studies directly compared Vicryl mesh with ADM.

CONCLUSIONS

Although the evidence is limited, polyglactin 910 (Vicryl) mesh for immediate breast reconstruction appears to be a potentially safe, effective, and less expensive alternative to ADM. Prospective studies are needed to further compare mesh with ADM.

National Outcomes for Open Ventral Hernia Repair Techniques in Complex Abdominal Wall Reconstruction

Modern adjuncts to complex, open ventral hernia repair often include component separation (CS) and/or panniculectomy (PAN). This study examines nationwide data to determine how these techniques impact postoperative complications. The National Surgical Quality Improvement Program database was queried from 2005 to 2013 for inpatient, elective open ventral hernia repairs (OVHR). Cases were grouped by the need for and type of concomitant advancement flaps: OVHR alone (OVHRA), OVHR with CS, OVHR with panniculectomy (PAN), or both CS and PAN (BOTH). Multivariate regression to control for confounding factors was conducted. There were 58,845 OVHR: 51,494 OVHRA, 5,357 CS, 1,617 PAN, and 377 BOTH. Wound complications (OVHRA 8.2%, CS 12.8%, PAN 14.4%, BOTH 17.5%), general complications (15.2%, 24.9%, 25.2%, 31.6%), and major complications (6.9%, 11.4%, 7.2%, 13.5%) were different between groups ( P < 0.0001). There was no difference in mortality. Multivariate regression showed CS had higher odds of wound [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.5–2.0], general (OR 1.5, 95% CI: 1.3–1.8), and major complications (OR 2.1, 95%, CI: 1.8–2.4), and longer length of stay by 2.3 days. PAN had higher odds of wound (OR 1.5, 95%, CI: 1.3–1.8) and general complications (OR 1.7, 95% CI: 1.5–2.0). Both CS and PAN had higher odds of wound (OR 2.2,95%, CI: 1.5–3.2), general (OR 2.5, 95%, CI: 1.8–3.4), and major complications (OR 2.2, 95%CI: 1.4–3.4), and two days longer length of stay. In conclusion, patients undergoing OVHR that require CS or PAN have a higher independent risk of complications, which increases when the procedures are combined.

Concomitant sublay mesh repair of umbilical hernia and abdominoplasty

Concomitant mesh repair of large umbilical hernias and abdominoplasty pose a serious risk of devascularizing the umbilical stalk. A technique of placing mesh in a sublay manner, deep to the fascial defect, for an umbilical herniorrhaphy to avoid damage to the deep umbilical perforators during an abdominoplasty is described.

The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese

BACKGROUND

Because of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure.

METHODS

We performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m(2). The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up.

RESULTS

Mean patient age was 53 years (range 32-75 yr) with mean BMI of 46 kg/m(2) (range 41-60 kg/m(2)). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively.

CONCLUSION

The PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.

Unexpected encounter with painless endometriosis during abdominoplasty

Subcutaneous endometriomas are cystic lesions that are rarely described. During the course of abdominoplasty surgery, a "surprise" encounter with a cyst containing brown material brought up the possibility that an atypical incarcerated hernia was entered. Dissection revealed no connection between the cyst and the rectus fascia and subsequent pathologic evaluation revealed an endometrioma. This report describes the unusual encounter with a painless endometrioma during abdominoplasty.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ultrasound-guided microwave ablation for abdominal wall metastatic tumors: a preliminary study

AIM

To evaluate the feasibility, safety and efficacy of ultrasound-guided microwave (MW) ablation for abdominal wall metastatic tumors.

METHODS

From August 2007 to December 2010, a total of 11 patients with 23 abdominal wall nodules (diameter 2.59 cm ± 1.11 cm, range 1.3 cm to 5.0 cm) were treated with MW ablation. One antenna was inserted into the center of tumors less than 1.7 cm, and multiple antennae were inserted simultaneously into tumors 1.7 cm or larger. A 21 gauge thermocouple was inserted near important organs which required protection (such as bowel or gallbladder) for real-time temperature monitoring during MW ablation. Treatment outcome was observed by contrast-enhanced ultrasound and magnetic resonance imaging (MRI) [or computed tomography (CT)] during follow-up.

RESULTS

MW ablation was well tolerated by all patients. Six patients with 11 nodules had 1 thermocouple inserted near important organs for real-time temperature monitoring and the maximum temperature was 56 °C. Major complications included mild pain (54.5%), post-ablation fever (100%) and abdominal wall edema (25%). All 23 tumors (100%) in this group were completely ablated, and no residual tumor or local recurrence was observed at a median follow-up of 13 mo (range 1 to 32 mo). The ablation zone was well defined on contrast-enhanced imaging (contrast-enhanced CT, MRI and/or contrast-enhanced ultrasound) and gradually shrank with time.

CONCLUSION

Ultrasound-guided MW ablation may be a feasible, safe and effective treatment for abdominal wall metastatic tumors in selected patients.

Neoumbilicoplasty Is a Useful Adjuvant Procedure in Abdominoplasty

Background

Neoumbilicoplasties are indicated in congenital conditions associated with umbilical agenesis, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump and in surgical procedures for herniorrhaphy, as well as in the rare condition of umbilical endometriosis.

Objective

Neoumbilicoplasty is an adjuvant procedure that may be necessary during abdominoplasty with wide myofascial plication, or repair of concomitant hernias of the abdominal wall. The present article justifies sacrificing the umbilicus followed by neoumbilicoplasty in patients with significant wide myofascial plication or concomitant hernias of the abdominal wall.

Methods

Seventeen patients underwent a combination of abdominoplasty and wide (greater than 10 cm) vertical plication of the myofascial complex and required neoumbilicoplasty. The male to female ratio was 1:16; mean age was 44 years, mean weight 94.1 kg and mean height 160.2 cm. Characteristic body morphology included gross trunk obesity with a prominent anterior abdominal wall. The female patients were multiparous. Sacrificing the umbilici followed by neoumbilicoplasty was required in patients with umbilical hernias and patients who had divarication of the rectus abdominis muscles with short umbilical stumps.

Results

Nine patients had concomitant ventral hernias (52.94%) and eight patients had divarication of the rectus abdominis muscles with short umbilical stumps (47.05%). The mean perioperative myofascial plication distance was 15.41 cm and the gap closure required three to five rows of sutures.

Conclusion

Neoumbilicoplasty is a useful adjuvant procedure during abdominoplasty with wide myofascial plication or repair of concomitant hernias of the abdominal wall.

Repair of large complex recurrent incisional hernias with retromuscular mesh and panniculectomy

BACKGROUND

Recurrent incisional hernia repair is associated with high recurrence and wound complication rates.

METHODS

The clinical courses of patients who underwent recurrent incisional hernia repair via retromuscular mesh placement with concomitant panniculectomy at a university teaching hospital from 1999 to 2004 were reviewed retrospectively. Postoperative evaluation included a quality of life survey.

RESULTS

Forty-seven patients (13 male, 34 female) with an average body mass index of 34.4 kg/m2, an average midline hernia defect of 31.4 cm, and at least 1 and on average 2.5 previous repair attempts underwent hernia repair. Wound infections occurred in 4 patients (8%) and seromas requiring aspiration occurred in 1 patient (2%). Four patients (8%) had re-recurrences of their hernias. All patients rated the postoperative appearance of their abdomen as at least satisfactory.

CONCLUSIONS

Recurrent incisional hernia repair with a retromuscular mesh and panniculectomy has low recurrence and wound complication rates and excellent patient satisfaction.

Repair of Infected Abdominal Wall Hernias in Obese Patients Using Autologous Dermal Grafts for Reinforcement

BACKGROUND

Reconstruction of large, infected abdominal wall hernias in obese patients can be extremely challenging. A novel approach to abdominal wall reconstruction in a contaminated setting without the use of prosthetic materials is introduced.

METHODS

Two patients with massive abdominal wall hernias and infected mesh underwent removal of mesh and abdominal wall reconstruction with the component separation technique. Panniculectomy was performed and a dermal graft was obtained by defatting and deepithelializing the specimen. The dermal graft was then applied in an onlay fashion over the fascial closure or used to bridge a fascial gap.

RESULTS

One morbidly obese woman underwent reconstruction with onlay dermal graft reinforcement. She is hernia-free at 16 months. A second obese woman, with two enterocutaneous fistulae, had reconstruction with a dermal graft placed to bridge the midline fascial gap. She is hernia-free at 20 months.

CONCLUSIONS

Autologous reconstruction of abdominal wall hernias, in the setting of infected prosthetic material, provides an excellent opportunity for successful closure of the defect. Failure of component separation is most commonly due to fascial separations at the midline. Autologous dermal grafts provide an ideal reinforcement of these fascial edges in a contaminated environment.

Abdominal Contour Procedures: Evaluating the Options

Surgical science continues to increase the options available to an individual seeking an improved abdominal contour. Appropriately applied, abdominal-contouring procedures offer significant aesthetic improvements and result in a high level of patient satisfaction. Liposuction is one procedure in a continuum of techniques available for addressing abdominal contour, and it is the one with which patients are most familiar and most likely to request. Advising patients of the many available methods involves an understanding of the scope of each technique and an accurate assessment of individuals' anatomy and their expectations and perceptions of what a successful result represents. This article outlines the various surgical methods of abdominal contouring and fosters an understanding of how to select the appropriate procedure.