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Optimizing the fascial closure: an analysis of 812 abdominally-based reconstructions
Emily C. Cleveland, BA, John P. Fischer, MD, Jonas A. Nelson, MD, Brady Sieber, BA, Stephen J. Kovach, III, MD, Liza C. Wu, MD, Joseph M. Serletti, MD.
University of Pennsylvania, Philadelphia, PA, USA.

Background
The incidence and severity of abdominal donor site morbidity following autologous free flap breast reconstruction continues to be debated. In a continued effort to further prevent donor site morbidity, the purpose of this study was to critically examine a consecutive cohort of patients at a single institution. We present our findings, as well as an algorithm for optimizing fascial closure in order to prevent donor site morbidity.
Methods
We reviewed our prospectively maintained database to identify all patients who underwent abdominally-based free tissue transfer for breast reconstruction from 2005-2011 at the Hospital of the University of Pennsylvania. We reviewed patient characteristics including prior abdominal surgery, BMI, and medical comorbidities; flap type, reconstructive timing, and method of fascial closure; and subsequent donor site morbidity. Data was analyzed both for overall significant donor site morbidity, as defined by hernia/bulge or reoperation for either removal of mesh or significant wound debridement, as well as for hernia/bulge alone.
Results
In total, 812 patients underwent 1261 free tissue transfers. Overall, 53 patients (6.5%) experienced significant abdominal donor site morbidity. Of these, 27 developed a hernia or bulge (3.3% of patients). No significant difference in overall abdominal morbidity was found with regard to unilateral versus bilateral reconstruction, any prior surgery violating the rectus sheath, or the type of flap used (msTRAM, DIEP, or SIEA for unilateral cases, or any combination thereof for bilateral cases). However, reconstructions with msTRAM flaps did have a higher incidence of hernia (3.0%) compared to DIEP or SIEA (0.4% and 0.0%, respectively; p =0.02). Additionally, overall abdominal wall morbidity was associated with prior lower abdominal surgery (p=0.04), preexisting hypertension (p=0.012), and the presence of two or more medical comorbidities (p<0.001). Despite an increased incidence of overall abdominal wall morbidity, patients with prior lower abdominal surgery were not significantly more likely to develop a hernia or bulge (OR=1.4, p=0.27). Donor site morbidity was less common when the rectus fascia was closed primarily than when mesh was used (p=0.02), however the rate of hernia formation was not significantly affected by the use of mesh (p=0.46). Delayed abdominal would healing was associated with a significantly increased incidence of subsequent hernia formation (p<0.001). Patients with delayed healing were over six times more likely to develop a hernia or bulge (OR=6.3, p<0.001). Patients who developed a subsequent hernia or bulge were more likely to be obese (51.9% versus 32.9%, p=0.04), however this did not hold true in a multivariate regression (OR 1.2, p=0.25).
Conclusion
When appropriate care is given to closure of the abdominal donor site, low rates of hernia and overall donor site morbidity are achievable. Furthermore, neither prior abdominal surgery nor intraoperative fascial closure technique was associated with higher rates of hernia or bulge formation, suggesting that the abdominal wall can be successfully reconstructed despite prior or intraoperative violation of the rectus sheath and muscle. We conclude that the low rate of hernia or bulge formation results from adherence to a donor site protocol focused on meticulous fascial closure and appropriate reinforcement.


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