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Incisional and parastomal hernias continue to be vexing problems for patients and surgeons. Risk factors are generally patient-related and/or technical in nature, and in some cases, can be altered, resulting in improved outcomes. Improved fascial closure techniques can only partly reduce the risk of incisional hernia formation. Even under optimal circumstances, using time tested closure techniques and materials, the rate remains high, due primarily to factors that are not modifiable or are unidentifiable. In such cases, there may be a beneficial role for prophylactic mesh augmentation (PMA), wherein mesh is implanted at the time of initial surgery or stoma formation. Several high-risk groups that might benefit from PMA have been identified, including patients undergoing open abdominal aneurysm repair or colorectal procedures, obese patients, and patients requiring creation of permanent gastrointestinal or urological stomas. Although the initial results of PMA are promising, the benefits of this strategy must be weighed against potential risks. Outcome measures to assess efficacy should include not only hernia recurrence but also quality of life, surgical-site occurrences, and cost. Further studies are warranted to predict which specific patient populations might benefit most from PMA and to identify ideal mesh materials as well as preferred implantation sites and methods of mesh fixation.

Components separation is a widely used technique for defect size reduction in abdominal wall reconstruction, and ultimately helps achieve gold standard primary fascial reapproximation in many cases. Even with perforator-sparing techniques, oftentimes there are undermined skin flaps to varying degrees that can lead to complications such as seromas. In this article, the author describes the previously published technique of "progressive tension sutures" reported in the cosmetic literature and extrapolates it to reconstructive abdominal surgery with statistically significant decreases in drain output. This technique also enables recruitment of skin to the midline to afford tension-free reapproximation and excision of redundancy, thereby discarding the most random portion of the skin flaps.

Background: Pedicled and free transverse rectus abdominis musculocutaneous (TRAM) flaps remain popular for autologous breast reconstruction, but the incidence of abdominal donor-site bulge and hernia is significantly greater when compared with deep inferior epigastric artery perforator (DIEP) flap reconstruction. Mesh repair after muscle harvest, however, may reduce the complication rate to that observed with perforator flaps alone., Methods: A retrospective review of all free flap breast reconstructions at the University of California, Los Angeles Medical Center from 2002 to 2007 was performed. Abdominal bulge and hernia were noted for patients undergoing free TRAM and muscle-sparing free TRAM flap reconstructions and were compared with those observed following DIEP flap reconstructions., Results: A total of 275 free TRAM plus muscle-sparing free TRAM flaps and 200 DIEP flaps were performed. Among patients with free and muscle-sparing free TRAM flaps, 11.3 percent were found to have postoperative abdominal bulge or hernia. Only 3.5 percent of DIEP flap patients had abdominal complications. Incorporating mesh into the rectus fascia repair significantly reduced the abdominal complications reported to 5.1 percent. Of the 86 free and muscle-sparing free TRAM flaps that were bilateral, 12.8 percent had hernias/bulges. Use of mesh with bilateral free and muscle-sparing free TRAM flaps reduced the complication rate to 3.7 percent., Conclusions: Incorporating mesh into rectus fascia repair in free and muscle-sparing free TRAM flap cases significantly reduces the rate of postoperative abdominal complications to levels equivalent to those for DIEP flap reconstructions. The authors advocate deciding intraoperatively between DIEP and muscle-sparing free TRAM flap dissections based on ease of dissection and whichever offers optimal safety and flap perfusion. Routine use of mesh in donor-site repair will decrease postoperative abdominal morbidity in unilateral and bilateral cases.

Abdominal wall competence is a major concern of all plastic surgeons using the TRAM flap for breast reconstruction. Low hernia rates and adequate abdominal stability are standard expectations in abdominal wall closure. Described here is this institution's experience with the use of a large piece of synthetic mesh as a supplementary reinforcement for the entire abdominal wall in an attempt to stabilize it and achieve a superior abdominal aesthetic result. Twenty-five consecutive patients had routine reinforcement with the extended mesh technique. Mean patient follow-up was 24 months with a minimum of 1 year. No hernia or mesh-related infection were encountered and only one patient had a lower abdominal bulge. We recommend the use of a large synthetic mesh for improved strength and aesthetic quality of the abdominal wall after TRAM flap breast reconstruction.

Reconstruction of the breast and other tissues by the free transverse rectus abdominis myocutaneous (TRAM) flap is an accepted, reliable technique with a high success rate. Closure of the anterior rectus sheath defect that results from this flap and the related rectus abdominis muscle-only (RAM) free flap has been the subject of debate, since hernia formation is considered a risk. Some authors prefer direct closure, while others recommend a variety of synthetic mesh reinforcements. We have reviewed 81 patients from a consecutive series of free TRAM and RAM flaps performed by one surgeon (Pennington) over an 8-year period. The majority of patients had repair of the anterior rectus sheath with a 1-mm-thick synthetic patch of polytetrafluoroethylene (Gore-Tex), used in 52 of 71 patients having the TRAM flap and 4 of 10 patients having the RAM flap. There were 5 wound infections (6.2 percent) overall, 3 of which occurred in the Gore-Tex group (5.4 percent). In all 3 of the latter patients, Gore-Tex was removed, although usually only after some months. Even after patch removal, no hernias developed subsequently. The two other infections occurred in patients with a Prolene mesh patch and no patch, respectively. One hernia was found in 71 patients with TRAM flaps, and that was in a patient in whom no patch was used. No hernias occurred in 52 TRAM flap patients with Gore-Tex patches. Hernia formation was noted in 6 of 10 RAM flap patients, although only 1 hernia occurred in the 4 patients with Gore-Tex patches. We conclude that the 1-mm polytetrafluoroethylene (Gore-Tex) patch is a satisfactory method for repair of the anterior rectus sheath after harvesting of either free RAM or TRAM flaps. Even if removal of the patch is required because of infection, the risk of subsequent hernia formation appears minimal.

The value of synthetic mesh use in the treatment of recurrent abdominal hernias is well recognized and has led to its advocacy by some authors as an adjunct in primary hernia repair. Mesh use in the donor-site closure associated with TRAM flap reconstruction is typically restricted to situations where undue tension or questionable tissue integrity may be predisposing factors to herniation. Although more liberal use of mesh has been advocated for these circumstances, fear of mesh complications may continue to restrict its use. We present a series of 65 consecutive patients who had routine mesh application to fascial closures following TRAM flap breast reconstruction. The use of mesh provides an added margin of strength to fascial reconstruction and was found to have additional benefit as a technical adjunct to the aesthetic aspects of the abdominoplasty. Mean patient follow-up was 56.4 months. The resulting rates of hernia (1.5 percent) and mesh-related infection (1.5 percent) demonstrate its considerable safety. We recommend consideration of polypropylene mesh use for improved strength and aesthetic quality of the donor-site closure following TRAM flap breast reconstruction.

Abdominal-wall defects, whether occurring as perioperative or postoperative phenomena, have been variously managed. Where the defect cannot be repaired by the use of the patient's own tissues, synthetic material is commonly utilized. Where both the preceding are unsuccessful, closure by means of muscles transferred from the thigh should be considered. Muscles have distinct advantages over fascial grafts or synthetic materials: they are dynamic structures that are effective in controlling herniae, may relieve symptoms in the case of symptomatic scoliosis resulting from the muscle loss, and may improve bowel action by improving expulsive abdominal efforts. Preliminary experience with for patients is presented, together with details of the operative technique. Since this report was submitted, a fifth patient suffering from a congenital "prune belly" syndrome has been treated.