A Novel Method of Fibula Flap In Situ Distraction Osteogenesis Prior to Flap Transfer.

BACKGROUND: The fibula flap is the workhorse for mandibular reconstruction, but fibula bone width is not ideal to match mandibular height. In this study, in situ widening of the fibula with distraction osteogenesis before transfer is evaluated as a solution. The authors present a proof of concept of this technique with a patient series, including one patient who has undergone subsequent orthognathic surgery of the reconstructed mandible. METHODS: A retrospective review of patients undergoing the authors' technique was performed. A longitudinal fibula osteotomy was made in situ and distraction was performed in the leg to widen the fibula. After distraction and consolidation periods, flaps were osteotomized and transferred to the mandible. RESULTS: This technique was applied to three patients (ages 9, 11, and 13 years) with Pruzansky III mandibular hypoplasia at the authors' institution over 15 years. In all cases, bony union was achieved. Mean surgical follow-up was 5 years. No significant morbidity occurred at the donor sites. Partial flap resorption was observed a number of years postoperatively in one patient. Temporomandibular joint ankylosis developed in one patient after closed treatment of an unrelated mandible fracture. A sinus tract developed in one patient, requiring débridement of a partial flap necrosis. One patient had orthognathic surgery, including osteotomy of the fibula. CONCLUSIONS: In situ fibula distraction osteogenesis is a novel technique to prelaminate a fibula flap before transfer to the mandible. This method allows for the reconstruction of challenging mandibular defects without compromising bone height, pedicle length, or the ability to perform orthognathic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Umbilicus Reconstruction with Bilateral Square "Pumpkin-Teeth" Advancement Flaps.

The creation of a neoumbilicus is a common challenge for plastic surgeons. The authors present their technique of umbilical reconstruction with bilateral square "pumpkin-teeth" advancement flaps. The technique described is applicable in both the setting of a vertical midline incision and when no midline incision is present (e.g., an abdominoplasty). The reconstruction has been performed in over 50 patients with a vertical midline incision and five patients without a midline incision. The only complications noted were persistent serous drainage in several patients with vertical incision and inadequate depth in one patient without a midline incision. This technique is quickly performed, and avoids small flaps, external incisions, and healing by secondary intention.

Implant Porosity and the Foreign Body Response.

The biocompatibility of prosthetic mesh is dependent on a number of physicochemical properties that ultimately incite an optimal foreign body response. The magnitude and character of the foreign body response directly affect the clinical success of the hernia repair, with too little scar resulting in bulge or hernia recurrence and too much scar causing mesh wrinkling and pain. Moreover, it is important to consider the effect of a sustained foreign body response and scar remodeling on the combined strength of the mesh-tissue construct over time. Understanding key elements that determine the foreign body response, such as implant porosity, surface area, and filament size, is critical to the performance of surgery. New absorbable materials introduce the additional variable of durability and persistence of the foreign body response after the foreign body itself has dissolved. In this review, we discuss the experimental and clinical literature relating the quality of the foreign body response to the physical attributes of implants in an effort to demystify prosthetic mesh selection.

Management of laparotomy wound dehiscence.

Many studies identify risk factors for dehiscence, but a paucity of data exist suggesting an optimal treatment strategy. This study examines repair of abdominal wound dehiscence, comparing closure and interposition of mesh. We conducted a retrospective review of 37 individuals who suffered a wound dehiscence after laparotomy. Outcomes of repairs with either primary closure or polyglactin mesh interposition were examined. Twenty-seven individuals underwent repair with primary closure. Twelve of these individuals suffered repeat wound dehiscence; 10 were treated with repeat fascial closure, 2 with polyglactin mesh interposition. Seven individuals initially underwent successful repair with polyglactin mesh interposition; all subsequently had their hernias repaired. Three patients had minor fascial separation managed nonoperatively. Primary closure is associated with a relatively high rate of recurrent wound dehiscence. Closure with polyglactin mesh interposition has a higher initial success rate, but necessitates additional surgeries for repair of the abdominal wall defect.

Reliable complex abdominal wall hernia repairs with a narrow, well-fixed retrorectus polypropylene mesh: A review of over 100 consecutive cases.

BACKGROUND: Our objective was to determine outcomes for complex ventral hernia repairs in a large cohort of patients utilizing an operative construct employing retrorectus placement of a narrow, macroporous polypropylene mesh with up to 45 suture fixation points for force distribution. No consensus exists on the optimal technique for repair of complex ventral hernias. Current trends emphasize large meshes with wide overlaps and minimal suture fixation, though reported complications and recurrence remain problematic. METHODS: A retrospective review was performed for all patients undergoing ventral hernia repair with retrorectus placement of midweight, uncoated, soft polypropylene mesh by a single surgeon (GAD) between the years of 2010 and 2015. Patient characteristics, operative history, operative data, and postoperative course were reviewed. RESULTS: A total of 101 patients with a mean age of 56 years and a mean body mass index of 29 m/kg2 (range 18-51 m/kg2) underwent hernia repair. Patients had a median of 3 prior abdominal operations (range 0-9), with 44 patients presenting with recurrent hernias. A total of 42 patients were Ventral Hernia Working Group grade 1, 40 grade 2, 17 grade 3, and 2 grade 4. There were no recurrences at a mean follow-up of almost 400 days for the 93 patients with long-term follow-up. The surgical site occurrence rate was 7.9% (3 surgical site infections, 2 seromas, 2 hematomas, and 4 instances of delayed wound healing in 8 patients). One patient required reoperation for hematoma drainage; 5 patients required readmission within 30 days. CONCLUSION: An operative construct employing a retrorectus placement of a narrow, macroporous polypropylene mesh with up to 45 suture fixation points for force distribution can achieve significantly better outcomes across a spectrum of Ventral Hernia Working Group grade, risk-stratified patients compared to rates reported in the literature for current strategies that employ wide meshes with minimal fixation.

Prospective repair of Ventral Hernia Working Group type 3 and 4 abdominal wall defects with condensed polytetrafluoroethylene (MotifMESH) mesh.

BACKGROUND: Treatment of clean-contaminated and contaminated ventral hernia defects remains controversial. Newer prosthetic materials may play an important role in these patients. METHODS: Ten patients with Ventral Hernia Working Group types 3 and 4 were prospectively enrolled and subsequently treated with direct supported repairs with condensed fenestrated polytetrafluoroethylene mesh. The primary outcome was hernia occurrence at 1 year after surgery. Secondary outcomes included surgical site infection, surgical site occurrence, medical complications, pain, and other patient-reported outcomes. RESULTS: There were no immediate postoperative infections and one minor postoperative hematoma treated in the office. One patient required delayed mesh removal 9 months after placement. Importantly, the mesh removal procedure was straightforward because of the material properties of the mesh. Of the 9 patients still with mesh, there were no hernia recurrences at the repair site with one full year of follow-up. CONCLUSION: Contaminated and clean-contaminated abdominal wall defects can be effectively and durably treated with condensed polytetrafluoroethylene mesh.

In vivo evaluation of a novel mesh suture design for abdominal wall closure.

BACKGROUND: The authors present a novel mesh suture design aimed at minimizing the early laparotomy dehiscence that drives ventral hernia formation. The authors hypothesized that modulation of the suture-tissue interface through use of a macroporous structure and increased aspect ratio (width-to-height ratio) would decrease the suture pull-through that leads to laparotomy dehiscence. METHODS: Incisional hernias were produced in 30 rats according to an established hernia model. The rat hernias were randomized to repair with either two 5-0 polypropylene sutures or two midweight polypropylene mesh sutures. Standardized photographs were taken before repair and 1 month after repair. Edge-detection software was used to define the border of the hernia defect and calculate the defect area. Histologic analysis was performed on all mesh suture specimens. RESULTS: Seventeen hernias were repaired with mesh sutures and 13 were repaired with conventional sutures. The mean area of the recurrent defects following repair with mesh suture was 177.8 ± 27.1 mm2, compared with 267.3 ± 34.1 mm2 following conventional suture repair. This correlated to a 57.4 percent reduction in defect area after mesh suture repair, compared with a 10.1 percent increase in defect area following conventional suture repair (p < 0.0007). None (zero of 34) of the mesh sutures pulled through the surrounding tissue, whereas 65 percent (17 of 26) of the conventional sutures demonstrated complete pull-through. Excellent fibrocollagenous ingrowth was observed in 13 of 17 mesh suture specimens. CONCLUSIONS: Mesh sutures better resisted suture pull-through than conventional polypropylene sutures. The design elements of mesh sutures may prevent early laparotomy dehiscence by more evenly distributing distracting forces at the suture-tissue interface and permitting tissue incorporation of the suture itself.

Repair of recurrent hernia after biologic mesh failure in abdominal wall reconstruction.

BACKGROUND: Biologic mesh is commonly used in abdominal wall reconstruction but may result in increased hernia recurrence. There are minimal data on repair of these recurrent hernias. METHODS: We conducted a retrospective chart review of 24 patients presenting to a single surgeon with recurrent ventral hernia, previously repaired with biologic mesh. RESULTS: Seventeen of 24 study patients underwent open repair, including 5 revisions of incomplete external oblique release. Mesh was polypropylene in 11 patients and fenestrated condensed polytetrafluoroethylene in 3 patients. In 1 patient, no mesh was used. In 2 patients, bridged biologic mesh was used because of risk of exposure. All biologic repairs have since recurred. Complications occurred in 3 of 15 prosthetic mesh patients and in all biologic mesh patients. CONCLUSIONS: Prior components release can be repeated if computed tomography scan reveals incomplete release. Recurrence is common after bridged biologic mesh repair. Conventional mesh can be used safely in many recurrent abdominal hernias after biologic mesh failure.

Routine use of bioprosthetic mesh is not necessary: a retrospective review of 100 consecutive cases of intra-abdominal midweight polypropylene mesh for ventral hernia repair.

BACKGROUND: The Ventral Hernia Working Group (VHWG) recently proposed a grading system to assist surgeons in selecting the appropriate mesh based on an individual patient's risk of developing a postoperative complication. The VHWG grading scale was used to evaluate the incidence of surgical-site complications in 100 consecutive midline ventral hernias repaired with uncoated mid-weight polypropylene mesh. METHODS: A retrospective review was conducted of 100 consecutive cases of midline ventral hernia repair using an intra-abdominal mesh underlay between July 2005 and May 2010. The median duration of follow-up was 23 months. RESULTS: Using the VHWG scale, 50 percent of cases were considered grade 2 ("Co-morbid") and 28 percent considered Grade 3 ("Potentially Contaminated"). The remaining cases were Grade 1 ("Low-risk"). Overall, there was a 5.6 percent rate of hernia recurrence, with a mean time to recurrence of 17 months. There were no enterocutaneous fistulae or infections requiring mesh removal. CONCLUSION: The use of uncoated mid-weight polypropylene mesh for reinforcement of midline ventral hernia repairs was not associated with increased rates of infection, fistula formation, or clinically significant adhesions. These findings challenge the recommendation by the VHWG to avoid synthetic repair material in patients with comorbidities or in "potentially contaminated" fields.

Abdominal wall reconstruction: lessons learned from 200 "components separation" procedures.

OBJECTIVES: To determine the efficacy and describe the evolution of the "components separation" technique for abdominal wall repair in 200 consecutive patients. DESIGN: Retrospective medical record review. SETTING: Northwestern Memorial Hospital, Chicago, Illinois. PATIENTS: Two hundred consecutive patients who underwent ventral hernia repair using the components separation technique. INTERVENTIONS: Biological and permanent meshes were used in select patients to augment the repair of the midline fascial closure but were not used as "bridging" materials. MAIN OUTCOME MEASURES: Hernia recurrence rates and major and minor complication rates for the overall series and for the different techniques. RESULTS: Primary components separation (n = 158) yielded a 22.8% recurrence rate. Closure of the midline tissues with augmentation of the repair using an acellular cadaveric dermis underlay (n = 18) had a 33.3% recurrence rate requiring a second operation, whereas intra-abdominal soft polypropylene mesh (n = 18) had 0% recurrence (P = .04). Elevated body mass index was a significant risk factor predicting hernia recurrence (P = .003). Contamination (P = .04) and enterocutaneous fistula (P = .02) at the time of surgery were associated with increased major complications, whereas body mass index (P = .01) and diabetes mellitus (P = .04) were associated with increased minor complications. CONCLUSIONS: Large complex hernias can be reliably repaired using the components separation technique despite the presence of open wounds, the need for bowel surgery, and numerous comorbidities. The long-term strength of the hernia repair is not augmented by acellular cadaveric dermis but seems to be improved with soft polypropylene mesh.

Soft polypropylene mesh, but not cadaveric dermis, significantly improves outcomes in midline hernia repairs using the components separation technique.

BACKGROUND: The search continues for the "ideal" repair of the midline ventral hernia, and the components separation technique has a low, but still concerning, hernia recurrence rate. The authors hypothesize that adding prosthetic or bioprosthetic meshes to the midline closure during components separation would reduce recurrence rates with minimal added morbidity. METHODS: Over a 3-year period, patients had a components separation procedure where either acellular cadaveric dermis (n = 26) or soft polypropylene mesh (n = 28) was used as an intraperitoneal underlay for reinforcement of the midline repair, but not as a "bridging material." In 36 operations, the mesh or cadaveric dermis was placed at the time of the components separation, and in the remaining cases (n = 18), the underlay was used to treat a recurrence after components separation. RESULTS: Cadaveric dermis was associated with a 46 percent "true" recurrence rate that required reoperation (mean follow-up, 17.3 months), whereas soft polypropylene mesh had a significantly lower recurrence rate of 11 percent (p = 0.0057) during a follow-up period of 16 months. Because of a higher incidence of concomitant bowel surgery and contamination in the cadaveric dermis group, additional subset analysis of uncontaminated cases was performed, demonstrating a 61 percent recurrence rate for cadaveric dermis compared with 12 percent for soft polypropylene (p = 0.0017). No significant differences in major and minor complications were seen between groups. CONCLUSION: Soft polypropylene mesh, but not acellular dermis, demonstrates acceptably low complication and hernia recurrence rates when used as a reinforcement of the midline ventral hernia closure in conjunction with components separation.

Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery.

INTRODUCTION: Management of a nonhealing femoral wound after vascular surgery can pose a challenging problem, particularly when there is prosthetic material involved. We prefer to use pedicled gracilis muscle flaps (PGMFs) to cover problematic groin wounds when more conventional management is not possible. METHODS: We describe the technique for using PGMFs to provide groin coverage, report a summary of our short-term and long-term results, and describe why we prefer this reconstructive technique. RESULTS: Twenty PGMFs were placed in 18 patients to treat nonhealing and infected groin wounds. Exposed prosthetic vascular reconstructions were covered with the PGMF in 14 wounds, and in situ autogenous vascular reconstructions were covered in four. Seven wound infections were polymicrobial, 10 had a single gram-positive organism, and one had a single gram-negative organism. Pseudomonas cultured out in four wounds, and Candida in one wound. Two patients had a virulent combination of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. Complete healing was initially achieved in all wounds, and no patient died within 30 days of surgery. Two PGMFs failed, at 2 weeks and 2 months, respectively, one from tension on the flap pedicle and one from acute inflow occlusion. Underlying prosthetic reconstruction was salvaged in 12 of 14 wounds; the remaining wounds with autogenous reconstructions or exposed femoral vessels all closed successfully. At a mean follow-up of 40 +/- 10 months there were no recurrent groin infections. Seven patients died, at 2.5, 3, 8, 12, 14, 22, and 28 months, respectively. CONCLUSION: PGMF transposition is an effective option to cover infected or exposed femoral vessels or salvage prosthetic graft material in the groin. In appropriately selected patients, when complete graft removal and extra-anatomic bypass is not an acceptable option, gracilis muscle flap coverage is a viable alternative. The technique is relatively simple, and morbidity from PGMF harvest is minimal.