J Reconstr Microsurg 2017; 33(01): 008-018
DOI: 10.1055/s-0036-1586495
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Reducing Postoperative Abdominal Bulge Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction with Onlay Monofilament Poly-4-Hydroxybutyrate Biosynthetic Mesh

Blair A. Wormer
1   Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
,
Nicholas W. Clavin
1   Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
,
Jean-Francois Lefaivre
1   Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
,
Jason M. Korn
1   Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
,
Edward Teng
1   Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
,
Anthony S. Aukskalnis
1   Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
,
J. Michael Robinson
1   Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
› Author Affiliations
Further Information

Publication History

21 February 2016

22 June 2016

Publication Date:
05 September 2016 (online)

Abstract

Background The purpose of this study was to evaluate the use of a biosynthetic mesh onlay on reducing postoperative abdominal bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods All patients undergoing DIEP reconstructions from January, 2010 to January, 2014 at a tertiary center were reviewed. Patients were divided into two groups for comparison based on whether a biosynthetic mesh onlay (Phasix [monofilament poly-4-hydroxybutyrate], Bard Inc., Warwick, RI) was used for reinforcement of the anterior rectus fascia. Rates of postoperative abdominal bulge were compared between the groups utilizing standard statistical methods.

Results During the study period, 319 patients underwent 553 DIEP reconstructions, 160 (50.2%) used mesh and 159 (49.8%) did not (nonmesh). The mean follow-up was 16.4 ± 11.1 months. There was no difference in age (49 ± 9.3 years), current tobacco use, diabetes, or mean body mass index (BMI, 29.4 ± 4.4) between the mesh and nonmesh groups (p > 0.05); however, there was a higher proportion of obese patients (BMI > 30) in the mesh group (45.0 vs. 33.3%; p = 0.03). Abdominal bulge rate following DIEP with mesh was lower than the nonmesh group (0 vs. 5.0%; p = 0.004). In the entire sample, 234 (73.4%) underwent bilateral DIEP and 85 (26.6%) underwent unilateral DIEP. In unilateral DIEP patients, the bulge rate was similar between the mesh and nonmesh groups (0 vs. 4.4%; p > 0.05); however, in bilateral DIEP patients, the bulge rate was lower in the mesh group compared with a nonmesh group (0 vs. 5.5%; p = 0.008).

Conclusion Reinforcement of the anterior rectus with an onlay monofilament poly-4-hydroxybutyrate biosynthetic mesh may reduce the risk of postoperative bulge rate in patients undergoing DIEP reconstruction.

 
  • References

  • 1 Parker PA, Peterson SK, Bedrosian I , et al. Prospective study of surgical decision-making processes for contralateral prophylactic mastectomy in women with breast cancer. Ann Surg 2016; 263 (1) 178-183
  • 2 Elsayegh N, Profato J, Barrera AM , et al. Predictors that influence election of contralateral prophylactic mastectomy among women with ductal carcinoma in situ who are BRCA-negative. J Cancer 2015; 6 (7) 610-615
  • 3 Yao K, Stewart AK, Winchester DJ, Winchester DP. Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998-2007. Ann Surg Oncol 2010; 17 (10) 2554-2562
  • 4 Crosby MA, Garvey PB, Selber JC , et al. Reconstructive outcomes in patients undergoing contralateral prophylactic mastectomy. Plast Reconstr Surg 2011; 128 (5) 1025-1033
  • 5 Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69 (2) 216-225
  • 6 Chang EI, Chang EI, Soto-Miranda MA , et al. Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg 2013; 132 (6) 1383-1391
  • 7 Egeberg A, Rasmussen MK, Sørensen JA. Comparing the donor-site morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery: a meta-analysis. J Plast Reconstr Aesthet Surg 2012; 65 (11) 1474-1480
  • 8 Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 2010; 126 (2) 367-374
  • 9 Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124 (3) 752-764
  • 10 Nahabedian MY, Momen B. Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction. Ann Plast Surg 2005; 54 (2) 124-129
  • 11 Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004; 240 (4) 578-583 , discussion 583–585
  • 12 Luijendijk RW, Hop WC, van den Tol MP , et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000; 343 (6) 392-398
  • 13 Ver Halen JP, Stoikes N, Webb D, Powell B, Voeller G. Comprehensive analysis of donor-site morbidity in abdominally based free flap reconstruction. Plast Reconstr Surg 2015; 135 (1) 226e-227e
  • 14 Boehmler IV JH, Butler CE, Ensor J, Kronowitz SJ. Outcomes of various techniques of abdominal fascia closure after TRAM flap breast reconstruction. Plast Reconstr Surg 2009; 123 (3) 773-781
  • 15 Breuing K, Butler CE, Ferzoco S , et al; Ventral Hernia Working Group. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010; 148 (3) 544-558
  • 16 Kim M, Oommen B, Ross SW , et al. The current status of biosynthetic mesh for ventral hernia repair. Surg Technol Int 2014; 25: 114-121
  • 17 Davol, A Bard Company. PhasixTM mesh. Promotional material. Available at: http://www.davol.com/product-listing/sp/phasix-mesh/ . Accessed February 12, 2016
  • 18 Rozen WM, Ashton MW, Murray AC, Taylor GI. Avoiding denervation of rectus abdominis in DIEP flap harvest: the importance of medial row perforators. Plast Reconstr Surg 2008; 122 (3) 710-716
  • 19 Rozen WM, Ashton MW, Kiil BJ , et al. Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 2008; 122 (5) 1321-1325
  • 20 Bottero L, Lefaucheur JP, Fadhul S, Raulo Y, Collins ED, Lantieri L. Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg 2004; 113 (1) 156-161
  • 21 Yao K, Winchester DJ, Czechura T, Huo D. Contralateral prophylactic mastectomy and survival: report from the National Cancer Data Base, 1998-2002. Breast Cancer Res Treat 2013; 142 (3) 465-476
  • 22 Chatterjee A, Ramkumar DB, Dawli TB, Nigriny JF, Stotland MA, Ridgway EB. The use of mesh versus primary fascial closure of the abdominal donor site when using a transverse rectus abdominis myocutaneous flap for breast reconstruction: a cost-utility analysis. Plast Reconstr Surg 2015; 135 (3) 682-689
  • 23 Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Evaluation of high-risk, comorbid patients undergoing open ventral hernia repair with synthetic mesh. Surgery 2013; 153 (1) 120-125
  • 24 Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg 2005; 116 (5) 1263-1275 , discussion 1276–1277
  • 25 Levasseur JC, Lehn E, Rignier P. Experimental study and clinical use of a new material in severe postoperative evisceration of the abdomen (author's transl) [in French]. Chirurgie 1979; 105 (7) 577-581
  • 26 Williams SF, Rizk S, Martin DP. Poly-4-hydroxybutyrate (P4HB): a new generation of resorbable medical devices for tissue repair and regeneration. Biomed Tech (Berl) 2013; 58 (5) 439-452
  • 27 Martin DP, Badhwar A, Shah DV , et al. Characterization of poly-4-hydroxybutyrate mesh for hernia repair applications. J Surg Res 2013; 184 (2) 766-773
  • 28 Deeken CR, Matthews BD. Characterization of the Mechanical Strength, Resorption Properties, and Histologic Characteristics of a Fully Absorbable Material (Poly-4-hydroxybutyrate-PHASIX Mesh) in a Porcine Model of Hernia Repair. ISRN Surg 2013; 2013: 238067
  • 29 Davol, A Bard Company. PhasixTM mesh. Value analysis committee (product information kit). Available at: http://www.davol.com/default/assets/File/Phasix%20VAC%20DAVPHSX06150055.pdf . Accessed February 12, 2016
  • 30 Alkhoury F, Helton S, Ippolito RJ. Cost and clinical outcomes of laparoscopic ventral hernia repair using intraperitoneal nonheavyweight polypropylene mesh. Surg Laparosc Endosc Percutan Tech 2011; 21 (2) 82-85
  • 31 Vyas RM, Dickinson BP, Fastekjian JH, Watson JP, Dalio AL, Crisera CA. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008; 121 (5) 1519-1526
  • 32 Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?. Plast Reconstr Surg 2005; 115 (2) 436-444 , discussion 445–446
  • 33 Nelson JA, Fosnot J, Selber JC, Wu LC, Serletti JM. Age and abdominal wall strength: assessing the aging abdominal wall after autologous breast reconstruction. Microsurgery 2013; 33 (1) 14-23