864 Hernia (2021) 25:863–870 13 scar scaffold that ensures that the tissue approximation will remain durable no matter the forces applied. If incisional hernia repair and rectus diastasis repair are so similar, why is suture plication so common and meshes used so infrequently for linea alba stretching? Suture plication is commonly performed in patients with compliant abdomens, and so the deforming forces perhaps are not as strong. Suture plication is effective in most cases of diastasis, with low complication and recurrence rates [5]. However, there are many women with severe rectus diastasis from repeated pregnancies and twin gestations. There are patients with high demands on their torso for work or sports that request repair of rectus diastasis. There are patients with elevated body mass indices (BMI) where the suture tensions for repair are increased. Finally, what should be done for rectus diastasis and suboptimal cosmetics in men? Most of the studies on rectus diastasis suture plication and recurrence rates focus on women and not men, with a recent study enrolling 87 women but only 2 men [6]. Should the standard suture plication principles created for low demand women with mild to moderate rectus diastasis be applied to these cases? There is a reluctance of surgeons to use mesh, perhaps fearing the combination of open surgery with large pieces of foreign material. Furthermore, reviews on complex revision abdominoplasty do not even mention the word mesh [7]. Alternatives to a standard Pitanguy abdominoplasty [8] include minimally invasive techniques for linea alba plication and/or mesh placement for rectus diastasis. While appropriate for patients without skin excess, some have found that these minimally invasive techniques without additional skin resection can lead to unacceptable complication rates [9]. To fill the knowledge gap on the surgical outcomes of the use of mesh for aesthetic abdominoplasty, we report our experience. This is a follow-up and larger report of the senior author, who has published on the outcomes of mesh abdominoplasty with a 6% surgical site occurrence rate and no clinical recurrences in 32 male and female patients with both incisional hernias and rectus diastasis [10]. Methods A chart review of all patients undergoing aesthetic abdominal wall surgery using mesh between 2007 and 2018 performed by the senior author (G.D.) was conducted for this retrospective cohort study. Inclusion criteria were patients who had a narrow well-fixed retrorectus mesh to repair their abdominal wall defect, did not have an incisional hernia or require intra-abdominal dissection, and had aesthetic skin removal (that the patient paid for) as part of the procedure. The indications for surgery were for aesthetics, treatment of small ventral hernias, midline abdominal pain, and/or improved core function. The identified patients’ charts were analyzed for patients’ demographics, clinical characteristics, and for post-operative outcomes. Extracted clinical characteristics were history of smoking or diabetes, body mass index (BMI), and width of rectus diastasis. The primary endpoint was surgical site occurrence (SSO) at any time after surgery. We defined SSO by the Ventral Hernia Working Group definition of a deep wound infection, a wound dehiscence, a seroma, or the development of an enterocutaneous fistula within 30 days of the procedure [11]. Secondary endpoints included the return to the operating room for any reason, non-surgical complications, readmission, post-operative recovery as assessed by the number of clinic visits within 6 months, superficial surgical site infection not requiring an incision and drainage, recurrence/persistence of abdominal wall laxity, and soft tissue revision rates. This study was approved by the Northwestern University Institutional Review Board. Patient evaluation and decision‑making After a thorough general history and physical examination as well as a focused abdominal wall examination, a decision is taken as to the appropriateness of a mesh repair of rectus diastasis. All candidates must be able to undergo a 2–3 h procedure, expect a post-operative hospitalization for pain, and are willing to undergo a 3–6 week recovery phase. All patients are told that they can have severe complications, including chronic pain, deep vein thrombosis, pulmonary emboli, and death. Exclusion criteria include BMI greater than 35, poor cardiac or pulmonary status that would prevent walking up several flights of stairs or the inability to lie flat, and bleeding disorders. Smoking was a relative contraindication. Decision-making is analog and not digital, meaning that there are numerous factors that lead both the patient to desire surgery and the surgeon to offer a mesh repair as opposed to a suture plication of the linea alba (Table 1). Patients who undergo mesh repairs are good surgical candidates with moderate to severe rectus diastasis with a generalized loss of abdominal wall tone between their semilunar lines, and have high demand on their torso for physical activity. As the loss of abdominal tone between the semilunar lines is a summation of both rectus diastasis and rectus muscle widening, there is no minimum width of rectus diastasis for patients to be treated with this technique. However, most patients have rectus diastasis greater than 4 cm in transverse dimension. Surgical technique Skin abdominoplasty Standard incision in the majority of females Skin handling for the low transverse incision is done in the style of Pitanguy. An incision is made 6–7 cm cephalad | The Surgical Technologist | MAY 2022 210
RkJQdWJsaXNoZXIy MTExMDc1