865 Hernia (2021) 25:863–870 13 from the introitus, and the skin is elevated widely with cautery (Peak Plasmablade, Medtronic, Minneapolis MN) up to the umbilicus. The umbilical stalk is delivered from the abdominal flap, and the epigastric skin is dissected off of the stretched out abdominal wall predominantly with blunt dissection to leave the linea alba intact. Dissection first laterally and then moving to the midline helps the surgeon to remain in the proper plane. Above the umbilicus, the skin is elevated at least to the semilunar lines for placement of the mesh and for skin redraping. Conservative liposuction in the high epigastric area is performed when indicated. The low midline skin up to the umbilicus is incised for exposure. After placement of the mesh, the bed is placed into 45 degrees reflux, and the umbilical stalk skin is brought out through the abdominal skin flap. Two drains are placed, and the skin is closed with 3–0 polyglactin braided suture for the deep dermis and 4–0 monofilament polyglactin suture for the superficial dermis. The drains are removed when the drainage is less than 30 cc from each. Drains typically come out within one week. Other than a perioperative dose, no additional antibiotics are given. The tissues are irrigated with a dilute antibiotic solution during the procedure. Vertical incision in some females and all males While the best scar is one that can be easily hidden, it is also true that many patients with suboptimal cosmesis of the abdomen from rectus diastasis always wear shirts and would strongly consider a vertical incision if it would provide a better overall abdominal contour. In all surgeries with an aesthetic component, scars should be placed when possible between aesthetic subunits [12], and the subunit of the abdomen is in the vertical midline. Like the decision whether to use mesh or to perform a suture plication for abdominal wall tightening, the placement of the incision is a complex decision that encompasses many factors as detailed in Table 2. A minority of patients (six women and all of the men) had vertical skin incisions for their mesh abdominoplasty. These six patients either had pre-existing midline scars, prior abdominoplasty rendering a repeat procedure more difficult, surgery that required the removal of previously placed uncomfortable umbilical hernia mesh, or else had severely stretched epigastric skin that would be difficult to remove via a low transverse incision. All of the men had a vertical incision, as the scar is hidden by hair-bearing skin and the physical examination finding that men do not typically have excess skin in the hypogastric area. Additionally, vertical incisions allow for creation of an umbilicus using "pumpkin-teeth" flaps,[13] and the neo-umbilicus breaks up the vertical scar into an epigastric scar and a hypogastric scar. A short suprapubic transverse incision is typically required to prevent a dog-ear. The author prefers the vertical incision for the most severe cases of rectus diastasis over 8 cm wide and for men, as it provides for the best shape of Table 1 Decision-making for mesh repair of rectus diastasis versus suture plication Suture plication Well-fixed narrow mesh Mild rectus diastasis Severe rectus diastasis 2–3 cm of rectus diastasis 5 cm or greater rectus diastasis Localized abdominal wall stretching at linea alba Generalized abdominal wall stretching between semilunar lines Rectus muscles each about 6 cm wide Rectus muscles wider than 7–8 cm wide Good tone Floppy abdomen Female Male No scars Already has a vertical scar No weight loss Massive weight loss, or with elevated BMI (men) Low demand physical activity High demand Fear of mesh Acceptance of mesh Initial procedure Revision abdominoplasty Table 2 Decision-making for standard low transverse versus vertical incision Low transverse incision Vertical incision Women Men Hypogastric skin excess Epigastric skin excess No scars Pre-existing vertical scar No umbilical hernia Umbilical hernia Moderate rectus diastasis Severe rectus diastasis More skin elevation Less skin elevation Less risk adverse More risk adverse Short torso Long torso Prefers to walk straighter after surgery Always wears a shirt Massive weight loss Revision abdominoplasty Need to remove prior umbilical hernia mesh MAY 2022 | The Surgical Technologist | 211
RkJQdWJsaXNoZXIy MTExMDc1