868 Hernia (2021) 25:863–870 13 neo-umbilicus in a man. There were no rehospitalizations, and ten patients had soft tissue revisions as office procedures for improved aesthetics. One patient complained of localized abdominal wall pain at 6 months after surgery that resolved with physical therapy. One patient underwent retightening of her abdominal wall after a mesh abdominoplasty. The tentative diagnosis for this patient was new stretching of the abdominal wall lateral to the semilunar lines. A recent report documented the aesthetics of this procedure for female patients [17]. Patients with severe rectus diastasis have worse preoperative aesthetic scores than do patients with milder diastasis who are undergoing suture plication. Both groups have similar improvements in aesthetic scores, but the suture plication group starts with improved aesthetics and remains aesthetically more pleasing than the mesh group as judged by four blinded observers. Discussion Surgical repair of rectus diastasis requires that the circumference of the abdominal wall be decreased in the axial plane. This requires the forceful placement of tension by the sutures on the tissues across the mesh to narrow the distance between the semilunar lines. While a suture plication of the linea alba is successful for mild or even moderate diastasis for patients with compliant post-partum abdominal walls, this may not be true for severe rectus diastasis or for patients (such as men) with high tensile demands on their tissues. The greater the tension required to achieve a meaningful correction, the greater the tendency for a standard suture-only plication to pull-through, resulting in a surgical failure over time. The anterior rectus fascia (which is necessary for suture plication techniques) is itself stretched and possibly prone to suture pull-through. Level one data for hernia repair exists that sutures under tension fail more often than do meshes that can distribute forces and provide a scar scaffold for healing. Our procedure employs transfascial sutures and a narrow mesh to anatomically decrease the circumference of the abdominal wall and simultaneously narrow the rectus muscles, but without folding or plicating the rectus muscles inwards that is associated with all suture plication techniques. These sutures are under high tension, and it requires forceful pulling to tighten the musculature. This tension is tolerated, however, because it is distributed amongst many points of fixation. This mesh abdominoplasty procedure is performed using long incisions for visualization as well as for the ability to resect and tighten skin. It stands to reason that the greater the circumference decrease in the abdominal wall, the more that skin will become redundant. These patients all have paid money out of pocket to achieve a more youthful abdominal wall, and muscle tightening alone with a residual loose skin envelope often does not suffice. Scars are left within the underwear line in women, and occasionally in the most severe cases in the aesthetic subunit of the vertical midline. The latter approach tightens the flanks for improved contours. The 0% SSO in this series is lower than the SSO senior author’s series in suture plication standard abdominoplasties [17]. One explanation for this observation is that the soft tissues have improved healing when on top of a stable abdominal wall platform. The well-fixed nature of the mesh may be significantly protective against deep hematomas and fluid collections. The deep position of the mesh, maintenance of tissue blood flow, use of the PlasmaBlade, drains, antibiotic irrigants, and blunt dissection all contribute to this low SSO. The procedure described in this manuscript is quite different from the use of a minimally fixed retromuscular mesh that does not emphasize tension placed across Fig. 7 Preoperative view of female patient undergoing mesh abdominoplasty through a transverse incision Fig. 8 Post-operative 1 year view of female patient who underwent a mesh abdominoplasty through a transverse incision | The Surgical Technologist | MAY 2022 214
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