The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction

Abstract

Background

This study aimed to evaluate the impact of semi-absorbable mesh on donor-site morbidity and patient-reported outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods

We conducted a retrospective cohort study of all patients who had DIEP flap breast reconstruction in our department from July 2007 to March 2019. Patients were invited to a comparative follow-up visit and grouped according to donor-site closure: primary fascial closure (the no-mesh group) and fascial reinforcement with semi-absorbable mesh in a subfascial position (the mesh group). The primary outcome of interest was donor-site morbidity, including bulging, hernia formation and rectus abdominis muscle strength. We also surveyed, surgical site complications and patient-reported outcomes using Patient and Observer Scar Assessment Scale v2.0 and BREAST-Q© version 2.0.

Results

A total of 191 patients had received DIEP flap breast reconstruction. Eighty-five patients (44.5%) with 108 DIEP flaps (53 patients in the mesh group and 32 patients in the no-mesh group) were included in the study. The mean BMI of the patients was significantly higher in the mesh group (mesh group, 26.9 vs. no-mesh group, 25.0, with p = 0.03). The incidence of hernia was significantly reduced in the mesh group (mesh group, 2.8% vs. no-mesh group, 13.5%, with p = 0.03). The incidence of bulging and the extent of rectus abdominis muscle strength were similar for both groups. Operative surgical site complications were reduced in the mesh group (mesh group, 7.5% vs. no-mesh group, 18.8%). There was no difference in patients’ physical well-being and satisfaction with the donor site between groups. Patient-reported scar outcome was significantly better in the no-mesh group (p < 0.001).

Conclusion

Our novel method of donor-site closure with semi-absorbable mesh in a subfascial position for reinforcement of the anterior rectus fascia on the DIEP donor site is safe. It has no negative impact on surgical site complications and patient-reported outcomes, while reducing the incidence of hernias on the donor-site in DIEP flap breast reconstruction.

Level of Evidence IV

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References

  1. 1.

    Nahabedian MY, Tsangaris T, Momen B (2005) Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 115(2):436–444 (discussion 445–6)

    Article  Google Scholar 

  2. 2.

    Chang EI et al (2013) Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg 132(6):1383–1391

    CAS  Article  Google Scholar 

  3. 3.

    Jeong W, Lee S, Kim J (2018) Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. Breast 38:45–51

    Article  Google Scholar 

  4. 4.

    Seal SKF et al (2018) Preoperative and postoperative assessment of rectus abdominis muscle size and function following DIEP flap surgery. Plast Reconstr Surg 141(5):1261–1270

    CAS  Article  Google Scholar 

  5. 5.

    Han HH et al (2018) Volume change in the rectus abdominis muscle after deep inferior epigastric perforator flap harvest. J Plast Reconstr Aesthet Surg 71(9):1310–1316

    Article  Google Scholar 

  6. 6.

    Nahabedian MY, Momen B (2005) Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction. Ann Plast Surg 54(2):124–129

    CAS  Article  Google Scholar 

  7. 7.

    Futter CM et al (2000) A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg 53(7):578–583

    CAS  Article  Google Scholar 

  8. 8.

    Tomouk T et al (2017) Donor site morbidity in DIEP free flap breast reconstructions: a comparison of unilateral, bilateral, and bipedicled surgical procedure types. J Plast Reconstr Aesthet Surg 70(11):1505–1513

    Article  Google Scholar 

  9. 9.

    Ingvaldsen CA et al (2017) donor-site morbidity after DIEAP flap breast reconstruction-a 2-year postoperative computed tomography comparison. Plast Reconstr Surg Glob Open 5(7):e1405

    Article  Google Scholar 

  10. 10.

    Jordan SW et al (2019) comparison of polypropylene and bioabsorbable mesh for abdominal wall reinforcement following microsurgical breast reconstruction. J Reconstr Microsurg 35(5):335–340

    Article  Google Scholar 

  11. 11.

    Licari L et al (2019) clinical and functional outcome after abdominal wall incisional hernia repair: evaluation of quality-of-life improvement and comparison of assessment scales. World J Surg 43(8):1914–1920

    Article  Google Scholar 

  12. 12.

    Wan DC et al (2010) Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 126(2):367–374

    CAS  Article  Google Scholar 

  13. 13.

    Nelson JA et al (2019) Function and strength after free abdominally based breast reconstruction: a 10-year follow-up. Plast Reconstr Surg 143(1):22e–31e

    CAS  Article  Google Scholar 

  14. 14.

    Lee SJ et al (2004) Changes in the local morphology of the rectus abdominis muscle following the DIEP flap: an ultrasonographic study. Br J Plast Surg 57(5):398–405

    CAS  Article  Google Scholar 

  15. 15.

    Pusic AL et al (2009) Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg 124(2):345–353

    CAS  Article  Google Scholar 

  16. 16.

    Lee BT et al (2010) A new classification system for muscle and nerve preservation in DIEP flap breast reconstruction. Microsurgery 30(2):85–90

    PubMed  Google Scholar 

  17. 17.

    Healy C, Allen RJ Sr (2014) The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg 30(2):121–125

    PubMed  Google Scholar 

  18. 18.

    Duchateau J, Declety A, Lejour M (1988) Innervation of the rectus abdominis muscle: implications for rectus flaps. Plast Reconstr Surg 82(2):223–228

    CAS  Article  Google Scholar 

  19. 19.

    Vyas RM et al (2008) Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 121(5):1519–1526

    CAS  Article  Google Scholar 

  20. 20.

    Shubinets V et al (2016) Surgically treated hernia following abdominally based autologous breast reconstruction: prevalence, outcomes, and expenditures. Plast Reconstr Surg 137(3):749–757

    CAS  Article  Google Scholar 

  21. 21.

    Bendavid R (2017) Mesh abdominal wall hernia surgery is safe and effective-the harm New Zealand media has done: response to Dr Steven Kelly’s article. N Z Med J 130(1467):97–98

    PubMed  Google Scholar 

  22. 22.

    Wormer BA et al (2017) Reducing postoperative abdominal bulge following deep inferior epigastric perforator flap breast reconstruction with onlay monofilament poly-4-hydroxybutyrate biosynthetic mesh. J Reconstr Microsurg 33(1):8–18

    Article  Google Scholar 

  23. 23.

    Jordan SW et al (2018) Implant porosity and the foreign body response. Plast Reconstr Surg 141(1):103e–112e

    CAS  Article  Google Scholar 

  24. 24.

    Rosch R et al (2003) Vypro II mesh in hernia repair: impact of polyglactin on long-term incorporation in rats. Eur Surg Res 35(5):445–450

    CAS  Article  Google Scholar 

  25. 25.

    Klinge U et al (1998) Modified mesh for hernia repair that is adapted to the physiology of the abdominal wall. Eur J Surg 164(12):951–960

    CAS  Article  Google Scholar 

  26. 26.

    Klinge U et al (2002) Impact of polymer pore size on the interface scar formation in a rat model. J Surg Res 103(2):208–214

    CAS  Article  Google Scholar 

  27. 27.

    Junge K et al (2002) Functional and morphologic properties of a modified mesh for inguinal hernia repair. World J Surg 26(12):1472–1480

    Article  Google Scholar 

  28. 28.

    Boehmler, J.H. et al (2009) Outcomes of various techniques of abdominal fascia closure after TRAM flap breast reconstruction. Plast Reconstr Surg 123(3):773–781

    Article  Google Scholar 

  29. 29.

    Stecco C et al (2018) Rectus abdominis muscle innervation: an anatomical study with surgical implications in diep flap harvesting. Surg Radiol Anat 40(8):865–872

    Article  Google Scholar 

  30. 30.

    Grunherz L et al (2020) Donor site aesthetics and morbidity after DIEP flap breast reconstruction-A retrospective multicenter study. Breast J 26:1980–1986

    Article  Google Scholar 

  31. 31.

    Christie B et al (2019) Divulge the bulge: an international survey of abdominal donor site morbidity in free autologous breast reconstruction. J Plast Surg Hand Surg 53(5):265–270

    Article  Google Scholar 

  32. 32.

    Tonseth KA et al (2005) Ultrasonographic evaluation of the rectus abdominis muscle after breast reconstruction with the DIEP flap. Ann Plast Surg 54(5):483–486

    Article  Google Scholar 

  33. 33.

    Erdmann-Sager J et al (2018) Complications and patient-reported outcomes after abdominally based breast reconstruction: results of the mastectomy reconstruction outcomes consortium study. Plast Reconstr Surg 141(2):271–281

    CAS  Article  Google Scholar 

  34. 34.

    Gao M et al (2010) Vypro II mesh for inguinal hernia repair: a meta analysis of randomized controlled trials. Ann Surg 251(5):838–842

    Article  Google Scholar 

  35. 35.

    Lee CN, Hultman CS, Sepucha K (2010) What are patients’ goals and concerns about breast reconstruction after mastectomy? Ann Plast Surg 64(5):567–569

    CAS  Article  Google Scholar 

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Acknowledgements

We acknowledge the effort from Clara Neuss in revising the manuscript.

Funding

There was no external funding source for this study.

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Authors

Contributions

All authors made substantial contributions. DKF designed the study. DKF, LS and LCS acquired all data. SF, CH, UK and YD interpreted and analyzed the data. DKF, LS and LCS drafted the article. SF, CH, UK and YD critically revised the manuscript. All authors gave their final approval of the version to be submitted.

Corresponding author

Correspondence to D. Kotsougiani-Fischer.

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The authors have no conflict of interest to declare.

Ethical Approval

This study was approved by the local ethical committee [837.516.16 (10834)] and a retrospective cohort study was designed following the ethical standards laid down in the World Medical Association Declaration of Helsinki (June 1964) and its later amendments.

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Informed consent was obtained from all study participants.

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Siegwart, L.C., Sieber, L., Fischer, S. et al. The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction. Aesth Plast Surg (2021). https://doi.org/10.1007/s00266-020-02096-0

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Keywords

  • DIEP
  • Breast reconstruction
  • Mesh
  • Donor-site morbidity
  • Hernia