BSAPS Journal

INTRODUCTION

Abdominoplasty is among the most frequently performed aesthetic procedures by plastic surgeons.¹ It is commonly undertaken to address fascial laxity or diastasis recti, which often leads to the development of abdominal wall hernias. These hernias occur when intra-abdominal contents protrude into a hernial sac, presenting a complex challenge for surgical repair, particularly in cases of massive ventral hernias. The abdominoplasty approach not only facilitates access to all components of the abdominal wall but also helps identify previously undetected hernias, resulting in a more aesthetically pleasing postoperative appearance.The goal of an ideal reconstruction is multifaceted: it must correct and prevent visceral eventration, provide dynamic muscle support, and enable a tension-free repair in a single-stage procedure.² Various techniques have been developed to enhance the surgical approach to abdominoplasty, including the use of a transverse lower abdominal incision and the resection of excess skin.³ These techniques have been effectively incorporated into the management of ventral incisional hernias.

A significant consideration in hernia repair is the use of synthetic materials. While large sheets of synthetic material can be employed, they often result in a rigid, noncompliant, and adynamic abdominal wall, making them unsuitable in cases of contamination. Recognizing the limitations of synthetic materials, Ramirez et al. introduced the "components separation technique" in 1990. This innovative method bridges the fascial gap without the need for prosthetic material, allowing for up to 10 cm of unilateral advancement and facilitating a tension-free abdominal closure.⁴

This manuscript describes the application of abdominoplasty in conjunction with hernia repair, emphasizing the benefits of this combined approach in improving both functional and aesthetic outcomes for patients with large incisional hernias. Through a detailed exploration of patient selection, surgical techniques, and postoperative results, we aim to provide a comprehensive understanding of the advantages and challenges associated with this combined procedure.

METHODS

Patients with large incisional hernias and recurrent ventral hernias, as well as those with primary hernias and obesity, were included in this study. Exclusion criteria encompassed patients with paramedian or subcostal scars, while thin patients were not excluded. Patients with large incisional hernias and long midline incisions were also included, though these cases were approached through the previous scar rather than a low transverse incision. Known factors affecting recurrence rates, such as obesity, large hernia size, preoperative presence of mesh, and postoperative wound infection, were considered. We performed a retrospective review of 72 patients with incisional hernia, with or without diastasis recti, between January 1, 2018, and December 30, 2021, at the Department of Plastic Surgery, Combined Military Hospital, Dhaka. For each patient, demographic data, presence of comorbidities, characteristics of the incisional hernia, initial surgical procedure, postoperative complications, recurrence, and total follow-up were collected. Preoperative pictures were taken (Figures 1 & 2) after obtaining consent from the patients, with markings done thereafter. Photographs were captured in five different views: antero-posterior, right and left oblique, and right and left lateral views. The marking comprised a standard abdominoplasty incision in the lower abdomen just above the pubic hairline (Figure 3). For large hernias, general anesthesia was preferred to relax the muscles and facilitate the repositioning of abdominal organs back into the peritoneal cavity. For smaller hernias, combined spinal epidural anesthesia was administered to aid in postoperative pain relief. An incision was made, and the hernial sac was identified in the midline and delineated up to the neck. The sac was opened, adhesions between the omentum or intestine and the abdominal wall were released, and the contents were reduced. A mop was placed inside the peritoneal cavity to protect the viscerae. An incision was then made at the junction of the anterior and posterior rectus sheath to locate the rectus muscle, followed by Reeves Stoppa retro-rectus dissection to bring the posterior rectus sheath to the midline. If achieving midline placement was challenging, transversus abdominis release (TAR) was performed. The posterior rectus sheath from both sides was sutured at the midline. A soft prolene mesh with large pore size was placed over the posterior rectus sheath behind the rectus muscle and fixed with 2/0 prolene (Figure 4). The anterior rectus sheath was then closed in front of the mesh using number 1 prolene. If any supraumbilical divarication of recti was found, it was plicated with number 1 prolene (Figure 5). The skin and fat flap was split in the midline, and the umbilicus was relocated to a new position (Figure 6). If the umbilicus was distorted by the hernia, a new umbilicus was reconstructed. In cases of excessive skin redundancy, anchor-type excision for a better aesthetic outcome was performed, also referred to as a fleur-de-lis tummy tuck. If skin redundancy was not significant, a mini-abdominoplasty was performed along with mesh hernioplasty. The final skin flap closure was achieved in two layers, with a drain placed in the subcutaneous plane (Figure 7). The drain was typically removed on the third or fourth postoperative day.

RESULTS

Seventy-two patients were included in this study, comprising 67 females and 5 males, with an age range of 32 to 70 years and an average age of 53 years. Twenty-one patients had diabetes, 25 had hypertension, and 15 had both diabetes and hypertension. Eleven patients had no comorbidities. During the operation, 39 patients had incisional hernia alone, 28 had diastasis with incisional hernia, and 5 had diastasis recti. Initial surgical procedures included lower uterine segment cesarean section (LUCS) in 42 patients, gynecological surgeries in 23 patients, and laparotomy for malignancy surgeries in 7 patients. Full abdominoplasty without any component separation was performed in 41 patients, with component separation in 6 patients. Mini-abdominoplasties were performed in 20 patients, and rectus muscle plication with a vertical approach was performed in 5 patients. Complications were minimal and infrequent. There were 2 cases of partial flap necrosis, 2 cases of umbilical necrosis, and 1 case of wound dehiscence. There were no recurrences in any of the patients.

Table 1: Gender distribution (N=72)

Table 2: Comorbidities distribution (N=72)

Table 3: Hernia and Diastasis Distribution (N=72)

Table 4: Initial Surgical Procedures

Table 5: Types of Abdominoplasty

Table 6: Postoperative Complications

DISCUSSION

A thorough understanding of the abdominal wall anatomy, including blood supply, innervation, fascial components, and musculature, is essential for successful surgical outcomes. Large and long-standing hernias often result in significant laxity of the abdominal wall, accompanied by excess fat and skin. The heavy and pendulous lower abdomen in these patients frequently causes irritation, intertrigo, and fungal infections of the skin. In such cases, the combined approach of removing the lower abdominal skin and fat along with hernia repair proves to be more effective than hernia repair alone.⁵

During abdominoplasty, the repair of fascial or muscular defects is carried out over a larger area, which helps in uniformly dissipating pressure throughout the abdomen. This approach isolates the incision line from the hernial defect and repair site, reducing the risk of complications associated with the hernia repair. General surgeons performing abdominoplasty in conjunction with hernia repair must be acutely aware of the locations of perforator vessels that supply the skin flaps to avoid inadvertent damage and subsequent flap necrosis in the postoperative period.⁶

The technique of component separation with Transversus Abdominis Release (TAR) and the placement of sublay mesh in the retro-rectus plane requires considerable skill and meticulous dissection.4 This technique is particularly beneficial when a significant portion of the abdominal contents is inside the hernial sac, known as domain loss. In such cases, the application of Botox injections 3 to 4 weeks prior to surgery can be considered to achieve additional muscle relaxation, facilitating the repair of large hernial gaps.⁷

Our study's findings support the efficacy of combining abdominoplasty with hernia repair. Among the 72 patients included in the study, complications were minimal and infrequent, with only 2 cases of partial flap necrosis, 2 cases of umbilical necrosis, and 1 case of wound dehiscence. Importantly, there were no recurrences of hernia during the follow-up period. These results underscore the advantages of this combined surgical approach, offering both functional and aesthetic benefits to patients with large incisional hernias.

CONCLUSION

Combining abdominoplasty with hernia repair for patients with large incisional hernias offers significant benefits, both functionally and aesthetically. This approach effectively addresses abdominal wall laxity and excess skin, alleviating issues such as irritation, intertrigo, and fungal infections, which are common in patients with pendulous lower abdomens. Our study demonstrated that this combined procedure is safe and results in minimal complications, with no recurrence of hernias observed during the follow-up period. The techniques employed, including the component separation method and Transversus Abdominis Release, proved to be effective in achieving tension-free abdominal closure and optimal patient outcomes. Given these findings, abdominoplasty combined with hernia repair should be considered a valuable option in the surgical management of large incisional hernias, providing enhanced structural support and improved postoperative appearance for patients.

REFERENCES

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4. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plastic and reconstructive surgery. 1990 Sep 1;86(3):519-26.
5. Persichetti P, Simone P, Scuderi N. Anchor-line abdominoplasty: A comprehensive approach to abdominal wall reconstruction and body contouring. Plastic and reconstructive surgery. 2005 Jul 1;116(1):289-94.
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