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Which Plane Meshes Well With The Rectus Abdominis Fascia For Autologous Breast Reconstruction With Abdominal Free Flaps?
Alan T. Nguyen, BS1, Dominic Henn, MD2, Jennifer Cheesborough, MD2, Gordon K. Lee, MD, FACS2, Rahim Nazerali, MD, MHS2.
1Oakland University William Beaumont School of Medicine, Auburn Hills, MI, USA, 2Division of Plastic & Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA, USA.

PURPOSE: It has been demonstrated that the use of mesh to reinforce the abdominal wall in breast reconstructions with abdominal free flaps can decrease the risk of bulging and herniation. However, whether the plane of mesh placement in relation to the rectus abdominis fascia has an impact on postoperative abdominal complications has not yet been investigated.
METHODS: We performed a retrospective chart review and identified 329 patients who had undergone autologous breast reconstruction with free DIEP (n=36), resp. muscle-sparing (MS-) TRAM flaps (n=293) and polypropylene mesh reinforcement of the abdominal wall between 2014 and 2018. We compared postoperative abdominal complications between DIEP and MS-TRAM patients as well as different mesh positions such as underlay (underneath the rectus sheath), overlay (above the rectus sheath), and inlay (bridging the rectus sheath defect) + overlay mesh.
RESULTS: Mesh position included inlay in 1 DIEP and 7 MS-TRAM patients, inlay with overlay (IO) in 5 DIEP and 139 MS-TRAM patients, overlay in 22 DIEP and 69 MS-TRAM patients, underlay in 8 DIEP and 69 MS-TRAM patients, underlay with overlay (UO) in 3 MS-TRAM patients . Abdominal hernias or bulging occurred in 1 DIEP (2.8%) and 17 MS-TRAM patients (5.8%) without significant differences between the groups (p=0.7) . Other complications included wound dehiscence and infections, skin and fat necrosis, hematoma, and seroma and occurred at higher rates in DIEP (22.2%) compared to MS-TRAM patients (8.5%, p=0.02). In patients with MS-TRAM flaps, hernias/bulging occurred significantly more often in patients who had received overlay mesh (13%) compared to patients with IO mesh (4.3%, p=0.04) or underlay mesh (2.67%, p=0.03).
CONCLUSION: Our data indicate that hernias/bulging occur at comparable rates in patients with DIEP and MS-TRAM flap reconstructions. Mesh placement in an underlay or combined overlay and inlay position might be more protective of hernia related complications after MS-TRAM reconstructions compared to mesh placement in an overlay position.


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