Poly-4-hydroxybutyrate (Phasix™) mesh onlay in complex abdominal wall repair.

BACKGROUND: Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement. METHODS: All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study. RESULTS: 105 patients (52 male, 53 female; mean age 59.2 years, range 22-84) met inclusion criteria. Mean BMI was 29.1 (range 16-48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9-63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma. CONCLUSIONS: These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.

Abdominal Wall Plication and Correction of Deformities of the Myoaponeurotic Layer: Focusing on Materials and Techniques Used for Synthesis.

The different types of sutures utilized in plications and for correction of diastasis during abdominoplasty are reviewed and discussed. Because correction of abdominal deformities also involves fascia and muscle advancement, this review also covers the suture materials used in muscle advancement. The selection of specific techniques to treat different types of abdominal wall deformity is also considered. This is important, because the outcome when correcting these deformities depends not only on suture materials but also on employing the optimum technique. A PubMed/Medline search was performed with the following search terms: rectus diastasis, diastasis recti, diastasis recti abdominis, correction of rectus diastasis, abdominoplasty. Relevant articles identifying the type of suture (rapidly absorbable, slowly absorbable, nonabsorbable), monofilament or multifilament sutures, antibiotic-coated sutures, and barbed sutures were evaluated. In addition, articles about surgical technique comparing continuous and interrupted sutures, in both the anterior and posterior aponeurosis, to correct rectus diastasis are discussed. Efficacy of suture materials was evaluated based on the long-term results and recurrence rates reported in these articles. The current literature provides sufficient data to recommend a single-layer continuous suture, with slowly absorbable sutures of 0 polydioxanone or 2-0 nylon, for correction of abdominal diastasis. An interrupted triangular suture is a good alternative to correct the vertical elongation of the myoaponeurotic layer that occurs after pregnancy.

Comparative analysis on the effect of low-thermal plasma dissection device (PEAK PlasmaBlade) vs conventional electrosurgery in post-bariatric abdominoplasty: A retrospective randomised clinical study.

Post-bariatric patients undergoing abdominoplasty have a relatively high risk of complications due to residual obesity and major comorbidities. Also, conventional electrosurgery and the associated thermal tissue damage may compromise outcomes. This retrospective randomised clinical study evaluated the effect of low-thermal plasma dissection device (PEAK [pulsed electron avalanche knife] PlasmaBlade) in comparison with conventional electrosurgery. A total of 52 post-bariatric patients undergoing abdominoplasty were randomised to PEAK PlasmaBlade (n = 26) and to monopolar electrosurgery (n = 26). Wounds of 20 patients per group were examined histologically for acute thermal injury depth. In PEAK PlasmaBlade incisions, acute thermal damage was significantly reduced compared with standard of care (40% vs 75%; P = .035). Also, acute thermal injury depth from PEAK PlasmaBlade was less than that from electrosurgery (2780 µm vs 4090 µm). Significantly less total complication rate (30.8% vs 69.2%; P = .012) was found by PEAK PlasmaBlade compared with electrosurgery. Moreover, the PEAK PlasmaBlade showed less than half as many wound healing problems (19.2% vs 46.2%; P = .075), far fewer secondary bleeding (7.7% vs 30.8%; P = .075), and no seroma compared with four seroma with the standard of care (0% vs 15.4%; P = .11). PEAK PlasmaBlade appears to be superior to traditional monopolar electrosurgery for post-bariatric abdominoplasty, because it demonstrated significantly less tissue damage, less total complication rate, and fewer postoperative seroma resulting in faster wound healing.

Repair of the Severe Muscle Aponeurotic Abdominal Laxity with Alloplastic Mesh in Aesthetic Abdominoplasty.

BACKGROUND: Abdominoplasty is the most frequently performed surgical procedure for body contour; in our experience, we have observed some patients with prominent bulging that is difficult to treat and that presents results that are unsatisfactory or have recurrences to conventional treatments. This leads us to carry out an analysis of the elements responsible for the containment and abdominal format. We determined that it may be due to an inability of an important sagging aponeurotic muscle of primary origin to support the abdomen and could be caused by predisposing factors. For these specific cases, we developed a treatment proposing the use of a mesh. METHODS: We present these cases over a period of 24 years. Fourteen patients were treated with primary and secondary abdominoplasties. The abdominal wall reinforcement was performed by placing polypropylene mesh at the sub-muscular plane, fixed with U-stitches on the fascia transversalis, seeking to strengthen the muscle and the fascia transversalis. RESULTS: The results were satisfactory after long-term observation, gaining resolution of the abdominal bulges. Only two complications occurred; the presence of localized chronic pain and the appearance of umbilical fistula. DISCUSSION: We emphasize the importance of avoiding unnecessary interventions in patients with marked bulging, associated with inability of abdominal restraint. We only consider its indications in patients with conventional recurrence treatment, also identifying the predisposing factors, the knowledge of the abdominal anatomy, the muscular dynamics of the abdomen and understanding its indication in these specific cases of difficult treatment. LEVEL OF EVIDENCE IV: 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 .

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.

Prevention of Seroma Formation Following Abdominoplasty: A Systematic Review and Meta-Analysis.

Background: With seroma formation being the most common complication of abdominoplasty, multiple surgical strategies have been proposed to lower the seroma rate, yet their effectiveness is unclear. Objectives: The objective of this systematic review and meta-analysis was to comprehensively summarize and quantify the effects of preventive surgical measures for seroma in patients undergoing abdominoplasty. Methods: A predetermined protocol was used. An electronic search in MEDLINE, Scopus, the Cochrane Library, and CENTRAL electronic databases was conducted from inception to June 2016. This search was supplemented by a review of reference lists of potentially eligible studies and a manual search of key journals in the field of plastic surgery. Eligible studies were prospective controlled studies, which investigated prevention of seroma formation and reported on seroma rate. Secondary outcomes were rate of hematoma, wound dehiscence, infection, reoperation and hospital readmission, time to drain removal, total drain output, and length of hospital stay. Results: The meta-analysis included nine studies with 664 abdominoplasty patients. Seroma rate was 7.5% in the prevention group and 19.5% in the control group with the odds ratio (95% confidence interval) being 0.26 (0.10-0.67), P = .006, favoring the prevention group. Similar results were also revealed for infection rate, time to drain removal, and length of hospital stay. Subgroup analysis showed that preservation of Scarpa's fascia, tissue adhesives and, possibly, progressive tension sutures reduce, independently, seroma formation. Conclusions: This meta-analysis provides strong evidence that the use of certain preventive measures during abdominoplasty, compared to conventional procedure, reduces seroma formation.

The Retro-Rectus Prosthesis for Core Myofascial Restoration in Cosmetic Abdominoplasty.

BACKGROUND: The retro-rectus placement of a prosthesis for reinforcement of a hernia repair is a powerful surgical maneuver and results in reduced hernia recurrence rates in the absence of ventral hernia. Fascial reinforcement theoretically should improve columnar support to the spine and enhance athletic activity. The purpose of this study was to demonstrate the long-term efficacy of the restoration of the cylindrical lumbar abdominal myofascial complex as an adjunct to cosmetic abdominoplasty. OBJECTIVES: A retrospective evaluation of retro-rectus inlay prosthesis during cosmetic abdominoplasty was undertaken to subjectively assess aesthetic and functional benefits. METHODS: Six patients with severe anterior fascial laxity presenting for abdominoplasty underwent prosthetic augmentation of the posterior rectus sheath. The prosthesis was measured and contoured to provide structural support to the rectus sheath and linea Alba and to restore normal anatomic features to these structures. All procedures were performed via a traditional low abdominal curvilinear incision for optimum cosmesis. RESULTS: All 6 patients had long-term follow up, ranging from 13 to 40 months. All patients reported improved core strength and relief of back pain. All patients were pleased with the cosmetic results. CONCLUSIONS: Retro-rectus prosthetic augmentation for cosmetic abdominoplasty is effective in restoring anatomic relationships and can be used to improve core strength and to enhance aesthetic objectives. LEVEL OF EVIDENCE: 4.

Single-Layer Plication for Repair of Diastasis Recti: The Most Rapid and Efficient Technique.

Background: Plication of the anterior rectus sheath is the most commonly used technique for repair of diastasis recti, but is also a time-consuming procedure. Objectives: The aim of this study was to compare the efficacy and time required to repair diastasis recti using different plication techniques. Methods: Thirty women with similar abdominal deformities, who had had at least one pregnancy, were randomized into three groups to undergo abdominoplasty. Plication of the anterior rectus sheath was performed in two layers with 2-0 monofilament nylon suture (control group) or in a single layer with either a continuous 2-0 monofilament nylon suture (group I) or using a continuous barbed suture (group II). Operative time was recorded. All patients underwent ultrasound examination preoperatively and at 3 weeks and 6 months postoperatively to monitor for diastasis recurrence. The force required to bring the anterior rectus sheath to the midline was measured at the supraumbilical and infraumbilical levels. Results: Patient age ranged from 26 to 50 years and body mass index from 20.56 to 29.17 kg/m2. A significant difference in mean operative time was found between the control and study groups (control group, 35 min:22 s; group I, 14 min:22 s; group II, 15 min:23 s; P < 0.001). Three patients in group II had recurrence of diastasis. There were no significant within- and between-group differences in tensile force on the aponeurosis. Conclusions: Plication of the anterior rectus sheath in a single-layer with a continuous suture showed to be an efficient and rapid technique for repair of diastasis recti.

Abdominal Subcutaneous Mass After Laser-Assisted Lipolysis and Immediate Multiple Treatments with a Dual-Wavelength Laser, Vacuum and Massage Device.

UNLABELLED: Body contouring by means of minimally invasive procedures is a growing trend. Current approaches to body contouring often involve a combination of surgical techniques (eg, laser-assisted liposuction) and a series of noninvasive device-based treatments aimed at accelerating recovery and improving aesthetic outcomes. In this case study, we describe a 38-year-old woman who presented with an abdominal-wall mass that resembled a tumor when assessed with magnetic resonance imaging. Twenty-six months before presenting to our office, the patient had undergone laser lipolysis and a series of treatments with a device that delivered dual-wavelength laser energy and vacuum-assisted massage. To address the patient's concerns, we removed the mass and performed abdominal dermolipectomy. No postoperative complications occurred, and the patient was highly satisfied with the aesthetic outcome. The results of histologic studies indicated that the mass was pseudocystic and fluid-filled, surrounded by a fibrous capsule, and characterized as a foreign-body granuloma. Further analysis is warranted regarding the safety of laser lipolysis without aspiration combined with a device delivering dual-wavelength laser energy and vacuum-assisted massage. LEVEL OF EVIDENCE: 5 Risk.

[[Substantiation of choisce of the kind, localization and method of the implant fixing in alloplasty of the abdominal wall complex defects].]

The method of the implant fixation for prophylaxis of complications after alloplasty of complex abdominal wall defects was proposed. Taking into account physico-mechan- ical parameters of implant, degree of anisotropy, in accordance to mechanical and morphological characteristics of the abdominal wall musculo-aponeurotic structures, it is possible to individualize the choice maximally, to plan the alloplasty kind, and to determine the method of optimal surgical treatment objectively.

[AN EXPERIMENTAL STUDY OF THE HISTOLOGICAL FIBRO GENESIS ABILITIES IN THE AREA OF IMPLANTATION OF ALOTRANSPLANTATES APPLYING INTRAABDOMINAL AND PREPERITONEAL PLASTIC SURGERY].

The histological fibro genesis abilities in the area of implantation of allotransplantates applying intraabdominal and preperitoneal plastic surgery were examined during experimental research. The experiment involved 12 Russian chinchilla rabbits. The animals were spitted into two groups: I group--operated using IPOM methodology (intraperitonealonlaymesh, n = 6) with the installation "Proceed" mesh made by "Ethicon", group II--modeling preperitoneal plastics with the installation of "Ethicon's Ultrapro" mesh (n = 6). After removing the animals from the experiment, the implants with adhering musculo-aponeurotic tissue layer were excised and sent for histological examination. At the same time the severity of the inflammatory process were rated, the composition of the inflammatory infiltrate, germination of the connective tissue through the pores of the prosthesis and neovascularization. Analyzing the research data of histological connective abilities complexes formed in the area of the allotransplants implantation using intra-abdominal and pre-peritoneal plastic during the experiment, we can conclude that intra-abdominal installation of mesh prostheses reduces the severity of inflammatory changes surrounding tissues and reduces the probability of seroma formation in comparison with the placement of the pre-peritoneal implant.

Safety and tolerability of a focused ultrasound device for treatment of adipose tissue in subjects undergoing abdominoplasty: a placebo-control pilot study.

BACKGROUND: High-intensity focused ultrasound (HIFU) lipolysis is a noninvasive alternative to existing surgical body-sculpting methods. OBJECTIVE: To evaluate the safety, tolerability, and histologic outcome of HIFU lipolysis using a novel device in human subjects. METHODS AND MATERIALS: In a single-blind pilot study, six healthy subjects scheduled to undergo abdominoplasty within 4 weeks received HIFU lipolysis on one side of the umbilicus. An identical placebo treatment was given to the contralateral side. Patient evaluation of complications, blood tests, and urine analysis were performed 1, 3, 7, 14, and 28 days after treatment. Excised tissue from the treated areas was sent for histologic review. RESULTS: Treatment was well tolerated. Average visual analogue pain scale scores were 3.5 ± 2.3 (range 1-7) and 0.17 ± 0.41 (range 0-1). No major adverse events were documented, and laboratory analysis after HIFU lipolysis was normal. Fat necrosis with infiltration of lymphocytes and macrophages without adjacent tissue damage was documented on histology 2 to 4 weeks after HIFU lipolysis. Damage extent correlated with size of the area treated. No pathologic findings were found on the control side. CONCLUSIONS: High-intensity focused ultrasound treatment was well tolerated and safe. Focal damage to target tissue was documented, with adjacent tissues remaining intact.

Incorporating barbed sutures in abdominoplasty.

Barbed sutures can be used in body contouring procedures to close long incisions better than conventional sutures. The results of a literature review focusing on the use of barbed sutures in abdominal contouring procedures suggest that they are safe and effective in wound closure with complication rates similar to conventional sutures but with possibly faster incision-closure times. An update on one author's (K.A.G.) personal experience with barbed progressive tension sutures in abdominoplasty procedures is presented, along with practical technique recommendations for barbed suture use.

Barbed sutures in body surgery.

Wound-closing technology continues to evolve with the advent of barbed sutures, which appear to address some of the limitations of traditional sutures (numerous knots and time-consuming insertion, among other things). Advantages of knotless suture devices, specifically in body contouring, have been discussed in the literature over the past decade, with a recent increase over the past several years due to the US Food and Drug Administration (FDA) approval of unidirectional V-Loc (Covidien, Mansfield, Massachusetts) and bidirectional Quill (Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada) barbed sutures for soft tissue approximation. A thorough review of the existing literature and evaluation of the author's personal experience are presented in this article. As with any new surgical device, a learning curve is present that needs to be overcome to realize the full benefits of utilizing barbed sutures in body surgery while minimizing their complications.

The application of barbed sutures in body contouring surgery.

Even with the evolution of primary surgical techniques in body contouring, wound closure remains primarily traditional and has not advanced beyond the techniques followed in past decades. Streamlining wound closure would be the next advance for body contouring surgery. Absorbable barbed sutures offer a potential solution, and they are the subject of this review investigating the applications of absorbable barbed sutures in body contouring surgery. Barbed sutures hold tension as closure proceeds, theoretically decreasing the time required for wound closure, approximating dead space, and obliterating subcutaneous knots that may result in palpable, painful granulomas. Review of the literature reveals some evidence of time savings (in some cases significant and, in some, not); however, the literature also shows some wound complications from the use of barbed sutures, including infections and extrusions. Barbed sutures have not yet been conventionally embraced, and the technology will certainly continue to evolve in order to make the devices more desirable for plastic surgeons.

A new technique involving a spherical stainless steel device to optimize positioning of the umbilicus.

BACKGROUND: Creating an aesthetically pleasing umbilicus may be challenging due to various factors that involve the patient limitations and suboptimal techniques available to the surgeon. Although many techniques aim to locate the umbilicus after abdominoplasty, none are ideal. The authors use a new technique involving a stainless steel spherical device for definite location of the new neo-umbilicus site. METHODS: Abdominoplasty with full muscle plication and umbilicoplasty was performed to test the effectiveness of this new technique that involves a stainless steel marble called the Umbilicator. It has a diameter of 1.5 cm and three 2-mm holes drilled 120° apart in an equilateral triangle. The Umbilicator is secured to the inferior and superior dermis of the umbilical stalk to help identify the future location of the umbilicus on the abdominal skin. Once the marble is secured, the superior abdominal flap is redraped and trimmed, the suture is repaired, and the location of the umbilicus is determined by feeling for the smooth spherical surface bump with gentle downward pressure on the overlying abdominal skin located within the proximity of the umbilicus. RESULTS: The result of this technique produced a definitive means of identifying and delivering the umbilical stalk during abdominoplasty. This technique has been performed in 23 consecutive abdominoplasty procedures with no difficulties locating the umbilical stalk and no infections resulting from the procedure. CONCLUSIONS: Accurate identification of the umbilicus provides the ability to create an aesthetically pleasing neo-umbilicus, thus optimizing abdominoplasty results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction.

BACKGROUND: Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common. DATA SOURCES: With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results. CONCLUSIONS: This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques.

SUMMARY: Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.