Abdominal Wall Closure in Autologous Breast Reconstruction: Optimizing Aesthetics

Abstract

Background: In contrast to cosmetic abdominoplasty, abdominal flap harvest can result a high degree of morbidity to the abdominal wall. Poor abdominal wall aesthetics that can result following free flap harvest including a high abdominal incision and post-operative hernia or bulge. We report our experience in optimizing cosmesis of the abdominal donor site with the use of a low incision, fascial plication and routine mesh reinforcement. Methods: A retrospective chart review of patients who underwent breast reconstruction with free abdominal tissue transfer from 2013-2017. Pedicled flaps and superior inferior epigastric artery flaps were excluded. Patient demographics, oncologic history, ablative and reconstructive surgery details focusing on abdominal closure techniques, and postoperative complications were evaluated. Results: 135 patients were identified who underwent 223 abdominal free flaps. 59 (26.5%) DIEP flaps were harvested, while 160 (71.7%) msTRAM and 4 (1.8%) fTRAM flaps were harvested (p<0.0001). 160 (71.7%) donor sites closures utilized polypropylene mesh, 9 (4.0%) were closed with biologic mesh and 3 (1.3%) closures used no mesh (p<0.0001). No hernias were observed (0%), while 6 abdominal bulges were identified (2.7%). There were no differences in the rates of abdominal bulge after donor site closure in the DIEP compared with msTRAM and fTRAM groups (3.4% vs 2.4%, p=0.7). No patients required mesh explantation during the study follow up period. Conclusion: To parallel cosmetic abdominoplasty, our authors advocate for a low incision, fascial plication and routine mesh reinforcement of the abdominal wall following free flap harvest.

Minimizing Postoperative Pain in Autologous Breast Reconstruction With the Omental Fat–Augmented Free Flap

“…In addition, laparoscopic omental harvest leaves the abdominal wall musculature is intact without risk for denervation. Previous works have been published discussing surgical strategies to mitigate abdominal wall donor site risks with traditional abdominal free flap reconstruction including muscle-sparing techniques, fascial closure technique, and mesh implantation 9,10,19 . These risks are altogether avoided with O-FAFF reconstruction.…”

“…18 With traditional free abdominal tissue transfer, a large transverse abdominal scar, abdominal wall weakness, bulge, and hernia are well described. 9,10,19 These complications represent issues to patients that can results in poor patient outcomes and quality of life. 9,10 As increased attention is paid to the importance of the abdominal donor site, the O-FAFF is proving to be advantageous with small, laparoscopic port-site incisions.…”

“…9,10,19 These complications represent issues to patients that can results in poor patient outcomes and quality of life. 9,10 As increased attention is paid to the importance of the abdominal donor site, the O-FAFF is proving to be advantageous with small, laparoscopic port-site incisions. In addition, laparoscopic omental harvest leaves the abdominal wall musculature is intact without risk for denervation.…”

“…Recent studies in autologous breast reconstruction indicate that the abdominal donor site has implications on overall patient outcomes and well-being. 9,10 The focus on reducing narcotic use in the postoperative period has also gained increasing attention. 11,12 In this study, we aim to assess the outcomes of O-FAFF breast reconstruction with particular attention to postoperative pain, narcotic, and antiemetic use.…”

“…As our experience with O-FAFF breast reconstruction and the technique's popularity increase, we seek to critically analyze the results of our early series of cases. Recent studies in autologous breast reconstruction indicate that the abdominal donor site has implications on overall patient outcomes and well-being 9,10 . The focus on reducing narcotic use in the postoperative period has also gained increasing attention 11,12 .…”