Efficacy of Biosynthetic Mesh in the Abdominal Donor Site Following Autologous Breast Reconstruction
Adam Levy, MD, Matthew A. Wright, BS, Christine H. Rohde, MD.
New York-Presbyterian Hospital, New York, NY, USA.
BACKGROUND: Synthetic mesh repair of the abdominal donor site significantly reduces the risk of bulge or hernia following transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap harvest. However, patients undergoing autologous breast reconstruction often wish to avoid permanent foreign bodies. Using an absorbable, biosynthetic mesh (poly-4-hydroxybutyrate; P4HB), we aimed to compare abdominal donor site complications following autologous breast reconstruction.
METHODS: A retrospective review of abdominal-based flaps for breast reconstruction identified 19 cases using P4HB onlay mesh at the donor site compared to a cohort of 19 consecutive patients receiving no mesh reinforcement during the same time period from 2014-2017. The intraoperative decision to place P4HB mesh reinforcement was based on risk of future hernia or bulge as judged by the senior author, particularly in those patients undergoing TRAM or bilateral DIEP, with pre-existing diastasis recti or poor fascial quality. Demographics, procedure type, and complication rates were compared.
RESULTS: Baseline characteristics were similar between the two groups of no mesh and P4HB with respect to mean age (51.1 vs 49.9 yrs, p=0.62), BMI (28.1 vs 27.9 kg/m2, p=0.93), and smokers (2 vs 1, p=1). The no mesh group consisted of 100% DIEP flaps (12 unilateral, 5 bilateral) and the P4HB group included 9 TRAM (47%) and 10 DIEP flaps (53%; 4 unilateral, 6 bilateral). Mean follow up was 23.9 vs 19.2 mo (p=0.23, range 1-47 vs 1-37). Three patients (16%) in the no mesh group developed bulges, of which one underwent operative repair, compared with zero patients in the P4HB group (p=0.23). One patient in the P4HB group required re-operation for superficial abdominal wall infection debridement and closure. Minor wound breakdown at the donor site was seen in one patient in the no mesh group and two in the P4HB group, all of which were treated with local wound care alone. No hernia occurred during the study period.
CONCLUSIONS: P4HB mesh onlay is safe and effective for the autologous breast reconstruction abdominal donor site without leaving a permanent foreign body. We found no bulges in the P4HB group, and reinforcement with this absorbable material may reduce this common complication. Our data is further strengthened by the inherent selection bias and disproportionate number of TRAM and bilateral DIEP patients in the P4HB group who are at highest risk for abdominal wall complications, yet showed reduced rates in this preliminary series.
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