Late Breaker Break Session #2: Plastic Surgery Topics (Non-CME) Thursday, September 26 Thu, Sep 26 4:00-5:00 p.m. PDT

Introduction: The gold standard of microsurgical breast reconstruction is the deep inferior epigastric perforator (DIEP) free flap (1-3). As techniques have evolved, DIEP flaps have significantly reduced the morbidity previously caused by transverse rectus abdominis muscle (TRAM) and muscle-sparing TRAM (msTRAM) flaps. However, abdominal wall complications continue to persist after DIEP flap surgery, with bulge rates reported as high as 33% (4,5).

Methods: The first 25 patients undergoing DIEP flap surgery with the use of Duramesh (MSI, Chicago, IL) by the senior author were identified. A retrospective chart review of patient and surgical details was performed. Charts were reviewed for outcomes including incisional hernia (IH) formation, bulge, surgical site infections (SSI), and/or surgical site events (SSE). Standard descriptive summary statistics were used for patient characteristics, surgical details, and primary and secondary outcomes.

Results: 25 patients were reviewed. Average age was 51.0±10.7 years. Average body mass index (BMI) was 28.3±3.8 kg/m2. 84% (N=21) had a breast cancer history. Of those, 57% (N=12) had chemotherapy and 38% (N=8) had breast radiation. 72% (N=18) of patients had a history of prior abdominal and/or abdominal wall surgery. Average follow-up duration was 216±39 days. One patient developed a bulge, no patients developed an incisional hernia.

Conclusions: Duramesh mesh suture provides a promising opportunity for DIEP surgeons to minimize abdominal wall morbidity as well as mesh-related complications. Mesh suture can be used in a similar fashion as other sutures to perform primary closure of the anterior rectus sheath while also providing force-distribution benefits typically unique to planar mesh. This pilot study suggests that Duramesh is a safe, simple alternative to existing techniques in DIEP flap surgery and can be considered by microsurgeons to reduce fascial dehiscence, bulge, and/or hernia formation in postoperative patients.

1. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg. 2006;59(6):571-9. doi:10.1016/j.bjps.2006.01.004
2. Lee BT, Agarwal JP, Ascherman JA, et al. Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps. Plast Reconstr Surg. Nov 2017;140(5):651e-664e. doi:10.1097/PRS.0000000000003768
3. Masoomi H, Hanson SE, Clemens MW, Mericli AF. Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database. Ann Plast Surg. Sep 1 2021;87(3):242-247. doi:10.1097/SAP.0000000000002664
4. Parmeshwar N, Lem M, Dugan CL, Piper M. Evaluating mesh use for abdominal donor site closure after deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis. Microsurgery. Nov 2023;43(8):855-864. doi:10.1002/micr.31107
5. Lindenblatt N, Gruenherz L, Farhadi J. A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction. Gland Surg. Aug 2019;8(4):389-398. doi:10.21037/gs.2019.06.05

Background: Ventral hernia repair (VHR) poses a significant challenge due to high recurrence rates, with reported incidences of nearly 30% following repairs with mesh.(1) Hernia recurrence following mesh repair can occur due to a multitude of reasons including excessive tension, suture failure, or "cheese-wiring" of fixation sutures through tissue. To address this, efforts have focused on enhancing mesh reinforcement. The T-Line Hernia Mesh is a novel synthetic, polypropylene mesh specifically designed to prevent anchor point failure by evenly distributing tension through mesh suture reinforcement thus reducing the rate of hernia repair failures.(2) While the T-Line Hernia Mesh has proven to be safe and effective in the early postoperative period, limited literature exists on long-term outcomes.(3) Therefore, the aim of this study is to illustrate the long-term outcomes of VHR following T-Line Hernia Mesh use.

Methods. We conducted a single institution retrospective cohort study of patients who underwent VHR with the T-Line Hernia Mesh. Data collected included patient demographics, medical comorbidities, operative details, complications, and hernia recurrence. Additionally, postoperative patient reported outcomes (PROs) were collected using the Hernia-Related Quality-of-Life (HerQLes) survey. Descriptive statistics were used to analyze this patient population.

Results: A total of 19 patients (9 males and 10 females) underwent VHR with T-Line Hernia Mesh fixation during the study period. The median age was 60 years (range 53-64) with a median BMI of 30.26 kg/m2 (range 28.2-34.08). The prevailing medical comorbidities included hypertension in eight patients (82.11%), followed by tobacco use and diabetes in two patients (10.53%). Additionally, three patients (15.79%) had previously undergone hernia repairs, all of which were open repairs with mesh fixation.

Intraoperatively, the median defect area was 90.00 cm2 (range 144-194) and median T-Line Hernia Mesh area was 260 cm2 (range 163.25-300). Mesh placement was onlay in 17 patients (89.47%) and sublay in two patients (10.53%). Furthermore, three patients (15.79%) underwent a concomitant procedure with panniculectomy during hernia repair. The median operative time was 158 minutes (range 119.5-197), with a median estimated blood loss (EBL) of 50 mL (range 30-100).

Postoperatively, one patient experienced a complication, a seroma necessitating hospitalization within 30 days of the hernia operation. Additionally, no hernia recurrences were observed during a median follow-up time of 371 days (range 185-535). Regarding PRO data, nine patients (47.37%) responded to the survey with a median time to survey response from operation of 618 days (range 522.5-813). Among the respondents, majority of patients denied having any pain or symptoms related to their abdominal wall and reported that their abdominal wall had a significant impact on their life (55.56%, n=5). Notably, only one patient reported a perceived recurrence of their hernia; however, this has not been confirmed through clinical examination.

Conclusions:

In this study, VHR with T-Line Hernia Mesh proved to be effective and safe in preventing long-term hernia recurrence.

References:

1. J. W. Burger et al., Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240, 578-583; discussion 583-575 (2004).
2. D. L. Lima et al., A Novel Polypropylene Mesh (T-Line(R)) for Abdominal Wall Repair: Early Experience at Three Centers in the United States. Surg Technol Int 42, (2023).
3. A. W. Hollins, H. Levinson, Report of novel application of T-line hernia mesh in ventral hernia repair. Int J Surg Case Rep 92, 106834 (2022).

Background Today's wound dressings include adhesive paper strips, cyanoacrylate and polyester mesh systems, transparent films, foams, and hydrogel/hydrocolloid dressings. Many of these dressings are made from synthetic compounds which can cause complications known as Medical Adhesive Related Skin Injuries (MARSI) (1). The prevalence of MARSI in the United States has been on the rise with up to 1.5 million patients annually having serious complications to surgical adhesives (2). Silk fibroin is an emerging biomaterial with enhanced properties of cellular regeneration, growth and proliferation (3). The use of a biocompatible silk fibroin wound dressing has the potential to decrease the incidence of wound healing complications and improve patient outcomes compared to synthetic dressing alternatives (4).

Methods A prospective, randomized, single-blinded clinical trial was conducted from August 2022 to June 2023 on 50 patients who were dressed with a silk fibroin wound dressing on one side of their body and on the contralateral side with 3M Steri-Strips® (semisynthetic nonwoven rayon) after undergoing abdominoplasty, reduction mammaplasty, mastopexy or brachioplasty procedures (n=100). Data was collected over 5 postoperative visits using photographs and an investigator administered questionnaire to track erythema, blistering, discomfort, surgical site infection, pharmaceutical intervention, wound dehiscence and early detachment.

Results 20.8% (10/48) of patients were assessed by surgeons as having skin erythema surrounding the incision on the Steri-Strip® control side and 0% (0/48) on the silk bioprotein dressing side (p=0.002). The frequency of breast triple point separation in 43 cases was 30.2% (13/43) on the Steri-Strip® side and 9.3% (4/43) on the silk side (p=0.012). 75% (36/48) of patients had partial or total detachment of Steri-Strips® while 0% (0/48) had total detachment of the silk dressing and 18.8% (9/48) had partial detachment of the silk dressing within the first two weeks (p<0.001). Given the high rate of premature detachment of Steri-Strips®, the exposed incisional site was more prone to delayed wound healing.

Conclusion The beneficial properties of a woven silk fibroin wound dressing include high biocompatibility, non-allergenicity, ease of application and removal, oxygen permeability across the healing surgical site, wound exudate egress, flexibility, mechanical strength, the promotion of skin edge de-tensioning and the minimization of shear forces at the level of the dermis. This study presents an innovative alternative for surgical site wound dressings through the modern reinvention of one of the oldest biomaterials known to humanity, silk (5).

(1) Dhivya S, Padma VV, Santhini E. Wound dressings - a review. Biomedicine (Taipei). Dec 2015;5(4):22. doi:10.7603/s40681-015-0022-9

(2) Kim J, Shin Y. Medical Adhesive-Related Skin Injury Associated with Surgical Wound Dressing among Spinal Surgery Patients: A Cross-Sectional Study. Int J Environ Res Public Health. Aug 30 2021;18(17)doi:10.3390/ijerph18179150

(3) Fumarola S, Allaway R, Callaghan R, et al. Overlooked and underestimated: medical adhesive-related skin injuries. Journal of Wound Care. 2020;29(Sup3c):S1-S24. doi:10.12968/jowc.2020.29.Sup3c.S1

(4) Jao D, Mou X, Hu X. Tissue Regeneration: A Silk Road. J Funct Biomater. Aug 5 2016;7(3)doi:10.3390/jfb7030022

(5) Patil PP, Reagan MR, Bohara RA. Silk fibroin and silk-based biomaterial derivatives for ideal wound dressings. Int J Biol Macromol. Dec 1 2020;164:4613-4627. doi:10.1016/j.ijbiomac.2020.08.041