Tummy Tuck With Mesh Reinforcement

Tummy Tuck With Mesh Reinforcement

The upper abdomen develops a noticeable bulge that cannot be reduced with diet or exercise. This bulging makes the breast contour less noticeable. Physically, the separation of the abdominal muscles can be uncomfortable and even painful to touch in the worst cases. And, it can also rob someone of their core strength, which leads to back pain and other problems.

Mesh abdominoplasty is a technique pioneered by Dr.Dumanian that entails reinforcing the abdominal wall with permanent mesh. He typically uses it in cases of severe rectus diastasis, where there is a separation of more than 6 cm. Can the mesh become infected.

Tummy Tuck With Mesh Reinforcement

Cosmetically, rectus diastasis is not ideal. The upper abdomen develops a noticeable bulge that cannot be reduced with diet or exercise. This bulging makes the breast contour less noticeable. Physically, the separation of the abdominal muscles can be uncomfortable and even painful to touch in the worst cases. And, it can also rob someone of their core strength, which leads to back pain and other problems. Rectus diastasis is also linked to epigastric and umbilical hernias.

What is the mesh abdominoplasty technique?

Mesh abdominoplasty is a technique pioneered by Dr. Dumanian that entails reinforcing the abdominal wall with permanent mesh. He typically uses it in cases of severe rectus diastasis, where there is a separation of more than 6 cm.

Can the mesh become infected?

Infection is always a risk but it is less common with an experienced surgeon like Dr. Dumanian. He has a very low mesh removal rate.

What are the advantages of the mesh abdominoplasty technique?

The mesh abdominoplasty technique is superior to other techniques because it:

1. enforces the entire linea alba instead of patching a hole
2. distributes the forces with the mesh to reduce the chance for suture pull-through and recurrence of the bulging
3. helps ensure primary healing through attention to detail for skin blood flow

Is the procedure successful?

Yes. A few years ago, Dr. Dumanian published a paper on a study he conducted reviewing the safety and success of mesh abdominoplasty for rectus diastasis in a group of his patients. He found that after more than a year of follow-up, none of the patients experienced a recurrence of a bulge or hernia. Complications were very rare and cosmetic results were excellent.

Is Mesh Used In Abdominoplasty

Abdominoplasty is a well-established procedure that consistently ranks in the top 5 most common cosmetic surgical procedures performed in the United States per year. In cases of severe myoaponeurotic laxity some surgeons choose to supplement their procedure with the placement of mesh to reinforce their plication. Some surgeons place mesh on a more routine basis. There is limited data in the literature to substantiate the use of synthetic mesh. This is a case report and review of the literature for the use of mesh reinforcement during abdominoplasty.

Materials and Methods:

A case report is presented, detailing the infectious complications suffered by 1 patient subsequent to abdominoplasty with mesh reinforcement. A thorough review of the literature was performed. Literature was evaluated with respect to the number of patients, age range, type of mesh, method of fixation, follow-up interval, complications, and cosmetic results.

Results:

Four studies were found assessing the use of mesh reinforcement during abdominoplasty. Number of patients was limited, ranging from 18 to 52. Types of mesh included Polypropylene, Prolene, and Vicryl. No infection, dehiscence, or extrusion of mesh were reported. Authors report stable repair with follow-up ranging from 6 months to 54 months in cases involving severe myoaponeurotic laxity only.

So why don’t I love to use mesh?

I did a PubMed search on mesh to see what the current scientific literature is out there. Most of the articles were discussing the difference between artificial mesh and biologic mesh (cadaver dermis) and when they used mesh (usually large diastasis or ventral hernias). This is an area where there is not a clear consensus on what people do. Biologic mesh disappears over time, as it is converted essentially into scar tissue. There is some thought that Biologic mesh loses its reinforcement strength over time.

• What is the pro of using mesh? Well, if your tissue stretched with pregnancy and didn’t bounce back, the tissue likely has some weakness. The mesh adds an extra layer of oomph to the tissue to help it hold its tightening and closure.
• What is the con of using mesh? Mesh is a foreign object. It can encapsulate, get infected, cause a seroma (a collection of fluid), cause fistulas (little tunnel connections to other areas). It adds cost to the procedure. In super thin patients, there is a risk the mesh could be visible.

Mesh Used In Tummy Tuck

• enforces the entire linea alba instead of patching a hole.
• distributes the forces with the mesh to reduce the chance for suture pull-through and recurrence of the bulging.

Following review of the literature, it is clear that the evidence to support routine placement of mesh during abdominoplasty is lacking. As demonstrated by the case report described, placement of mesh in any procedure puts the patient at risk for undue sequelae. Our recommendations are as follows:

1.

Do not use mesh reinforcement during routine abdominoplasty.

2.

In only the worst cases of myoaponeurotic laxity, consider placing mesh using an onlay technique or in a submuscular layer (if experienced with this procedure), recognizing the limitations of the current literature on this subject. In either case, the surgeon should be aware of the significant risks of complications involved with these procedures, including seroma, umbilical and flap necrosis, as well as infection.

3.

If mesh is placed at the time of surgery, make certain that the patient is aware of the fact.

4.

In cases of wound infection where mesh was placed, have a high suspicion for mesh infection and a low threshold for reoperation.

The improved classification by Bozola et al.¹ of abdominoplasty has enabled surgeons to consider the possibility of minimal access surgery incorporating liposuction and endoscopic techniques for a wider patient population. ²–⁵ However, in patients with severe musculoaponeurotic laxity on whom multiparous abdominoplasty has been performed, the central plication alone has been found to be insufficient in preserving a durable waist improvement and body contour. ¹,⁶–¹² It is apparent that patients presenting for abdominoplasty should be evaluated on an individual basis.¹³ In this article we advocate a stable reinforcement of the midaponeurotic plication with stapled Prolene^® (Ethicon, division of Johnson & Johnson Co., Somerville, NJ) mesh in multiparous women with severe musculoaponeurotic laxity who request an abdominoplasty.

Patients and Methods

Included in the study from October 1, 1995, to November 1, 1997, were 21 consecutive multiparous women who had given birth to four to six children and presented with “globular” external appearance and advanced musculoaponeurotic laxity. They ranged in age from 31 to 59 years (average = 38 years). All patients were above their ideal body weight by 10% to 20%, but none were morbidly obese. The midfascial plication wasfurther augmented with Prolene^® mesh, which was fixed in place by use of a fascial stapler instead of the usual nonabsorbable sutures.

Preoperative Management

All patients were cleared for surgery by a consultant in internal medicine. Adult-onset diabetes (in three patients) and early hypertension (in two patients) were controlled. No smokers or patients with previous heart disease or a history of thromboembolism were identified. Before surgery all patients were started on incentive spirometers and intravenous first-generation antibiotics and were instructed about early postoperative ambulation. No prophylactic anticoagulation therapy was used. Bowel preparation by a saline solution enema the morning of surgery was administered.

Operative Technique

How do we fix the muscles? We don’t actually sew the muscles.  What we sew is the covering over the muscles called fascia. We are fixing the diastasis, which is a fancy term for the separation of the rectus abdominis muscle, your “six pack” muscle, which always separates with pregnancy. How much diastasis you have varies from person to person—how tall are you? how many pregnancies did you have? how big did you get? how strong was your core before? etc.

The whole idea for this blog came from a current patient. She is in some mommy blog chat room, and people are peppering her with questions about her tummy tuck. And a big question that keeps recurring is “Does your doctor use mesh?” For me, that answer is almost always no. Then she asked why not?

Fixing the abdominal muscles is a key part in your result after a tummy tuck. Not only does it help give you back a defined waistline, but it also helps with the integrity of your core, and it is the muscle repair which likely is the cause of improving issues with low back pain or urinary incontinence.

When doing the muscle repair, all plastic surgeons do not do it the same way. In my own practice, how I do the muscle repair evolved, and I am happy with the technique I now use. How surgeons differ:

• How many layers of repair? (I do two.)
• What type of suture? Permanent or dissolving? (I use permanent)
• Interrupted or running? (I used to do one layer interrupted, and one layer running, but I stopped doing a running suture and converted to doing two layers of interrupted sutures because if one part of a running suture loosens, the whole thing loosens. Think of it as interrupted sutures =buttons vs. a zipper = a running suture.  If your zipper busts, the whole thing unzips.  If a button busts, the other buttons are still intact and holding. )
• Do you use mesh? (I have done so rarely- I only use if the integrity of the tissue is poor, so it can’t hold my sutures. In that case, I use mesh just like you would use backing when sewing tulle- it keeps the stitches from ripping through the tissue.)