Episode 42: Hernia after Breast Reconstruction | Hernia Talk Live Q&A

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Speaker 1 (00:00:02):

Good evening everyone. Welcome to Hernia Talk Live. This is another Tuesday where you are sharing time with me on Hernia Talk Live with our questions and answers. As you know, my name is Dr. Shirin Towfigh. I am your host for today, and we’ll be answering your questions with our guest panelist. You can follow me on YouTube, on Facebook at Dr. Towfigh, where many of you are joining me currently as a Facebook Live, as well as on Twitter and Instagram at hernia doc. Today’s guest Palace is someone you’re going to fall in love with. He’s very, very lovely plastic surgeon, very gifted Dr. Maurice Nahabedian. He is in practice at McLean, Virginia, and you can follow him on Instagram at Maurice Nahabedian. We’ll get to learn so much about him soon. Good evening.

Speaker 2 (00:00:59):

Hi, how are you? Thanks for having me on your show.

Speaker 1 (00:01:02):

Thank you so much. So we were catching up just earlier. Dr. Nahabedian is in private practice. He is a big time plastic person in the plastic surgery world, but also in my world, in the hernia world, we have a handful of plastic surgeons that really enjoy the abdominal wall and much of their practice seems to be geared to abdominal wall reconstruction. And we learn from you all because your approach and your training is very different than a general surgeon’s approach and general surgeon training. So you’re one of them. You’re one of the top that I get to meet at meetings and have gotten to know it’s, it’s been a pleasure. So thank you for giving your time to us.

Speaker 2 (00:01:48):

Oh, happy to do it. It’s been a good journey for this past 25 years doing a variety of things and abdominal wall has always been one of my favorite areas.

Speaker 1 (00:01:59):

So was that part of your plastic surgery training or did you learn mostly what you do now with time?

Speaker 2 (00:02:05):

When I was a resident at Johns Hopkins, we did a fair amount of abdominal wall reconstruction, mainly because the general surgeons would have these complex defects. So I was exposed to it as a resident and then as an attending, we just continued on with that and we were actually writing papers about complex abdominal wall reconstruction using flaps and various component separation techniques. And then when I got to Georgetown, we took it to another level when Steve Evans and I started the abdominal wall reconstruction conference back in 2011. And that was a huge success. And since then we’ve been doing these things on a regular basis.

Speaker 1 (00:02:51):

The A W R conference, I went to the first one in dc. Yeah, loved it. It was fantastic. It was revolutionary because up until then there was the America’s Hernia Society, and it was just a different take. We didn’t take advantage of our plastic surgery colleagues in learning that aspect. And the component separation was invented by a plastic surgeon, and you have all an understanding of the blood flow and the nerves and the anatomy much more than the average general by far more than the average general surgeon, but also more than the average hernia surgeon, I would assume, because of how you do to manipulate all that anatomy.

Speaker 2 (00:03:37):

Right. Well, it’s all part of our training, especially when it comes to soft tissue management and the anatomy as it relates to reconstruction, because we’re so used to moving tissues around. So the whole concept of a component separation that was described by Oscar Ramirez, who’s a plastic surgeon, was really based on knowing where the arteries are, where the nerves are, where the muscle layers are, and what the safe planes are. And then we realized that we could actually move these tissues around in order to close some of these complex defects, where historically we would just try to close these things under tension and they looked good in the beginning, but then they would fall apart down the road. But by doing these specialized techniques, we really took it to another level. And now fortunately, component separation is open to the world. Everybody does component separations, which is really good for the patients. I mean, at the end of the day, we want our patients to have the best outcomes possible, and these are all things that we can do to help.

Speaker 1 (00:04:38):

So maybe you can spend some time answering just an initial question, which is related to how your work differs from the traditional or the average plastic or surgeon or surgeons that deal with cosmetics. So plastic surgery has to do with the cosmetic aspect, but also you have a very strong component of your training and the work that you do, which is reconstructive. Whereas let’s say if I go for Botox or something that’s not really reconstructive surgery, but you do something in your practice, which is even beyond. Can you just explain the difference between reconstructive surgery and cosmetic surgery?

Speaker 2 (00:05:16):

Sure. So reconstruction is really about bringing people back to normal. It’s not about making them beyond normal. So we don’t really focus on, what do you mean? Yeah, because we’re trained in oncology, and I’ve always had an interest in reconstruction, but what we’ve done now is we’ve kind of blended reconstruction with aesthetics and function. So these three components all really go together now. So for me personally, I’ve always had much more gratification, putting people back together and taking some of these complex defects and really get a lot of satisfaction from it, mainly because my patients can get back to a point in their lives where they have self-confidence and esteem and can function and really integrate back into society, not about making them super normal. Yeah, it’s just about bringing ’em back to a normal functional level.

Speaker 1 (00:06:18):

And when you do these operations, one of the questions I already posed is how do you minimize risk of scarring and also risk of adhesions? Can you explain what you know about adhesions and also scars?

Speaker 2 (00:06:32):

Yeah. So I mean, when I do as a plastic surgeon, when I’m involved in a complex hernia, I’m usually working with a hernia surgeon as well. So I think the combination of the two has worked out really well for us. Not everybody needs to do that, but that’s what we do. So when it comes to minimizing adhesions, then it depends on how much we have to do, what type of Mesh we’re going to use, where we place that Mesh. When it comes to the external scars, then I kind of take a more active role and really kind of take over. So closing things with minimal tension, using barbed sutures or sutures that are completely buried. Every once in a while in a real complex patient, I will have to use staples, but most of the time we’re really focusing on the aesthetics and how things look on the outside. So I’ll, I’ll be very careful about assessing blood supply, minimizing tension, doing buried sutures when possible and using the appropriate dressings. We now know that by using negative pressure type dressings over some of these complex incisions actually promotes optimal wound healing and improves the appearance of scars because we can reduce the amount of edema and swelling and drainage, all of which leads to optimal outcomes.

Speaker 1 (00:08:01):

So you used the VAC for the wound after wound closure?

Speaker 2 (00:08:05):

In fact, I just put a VAC on last week on a patient who had a complex wound, and it worked great. So not every patient will get a vac, but if I’m worried about fluid collections, soft tissue edema, maybe the blood supply isn’t perfect, then I’ll put a negative pressure device on the incisions just to kind of help things along.

Speaker 1 (00:08:28):

So I work in Beverly Hills. I’m in what we call the golden triangle, where most of your colleagues are,

Speaker 1 (00:08:36):

And then there’s me. But they have a luxury of operating on thin patients. People have lost a lot of weight. They’re often optimized before they get, let’s say a tummy tuck, but you don’t have that luxury. So many of your patients have cancer, right? Often breast cancer, and you use your talent for reconstructive surgery to take tissue from one area of the body and reconstruct another. So they may be obese or they may be have medical problems that are not necessarily necessarily optimized, but they need their cancer surgery so that by definition, you’re going to have more wound complications. Right?

Speaker 2 (00:09:19):

Absolutely. When you have something like breast cancer or if you’ve had a complex hernia, oftentimes these patients aren’t the most slender patients. I mean, they may have an elevated body mass index, they may have larger breasts, they may have excess skin and fat around the abdomen, so they may be good candidates for what we’re going to do. We take all comers. I mean, if I had to kind of pick the average BMI for my breast reconstruction patients who have had deep flaps or tram flaps, it’d probably be in the low thirties, but I’ve operated on patients that have BMIs in the forties, so I don’t discriminate. If they’re a good candidate and I think that I can get the job done, I’ll go ahead and operate. So

Speaker 1 (00:10:07):

They can be overweight, obese, or morbidly obese. Yeah.

Speaker 2 (00:10:10):

Yeah. Now, if somebody is really morbidly obese, if they come in with A B M I over 45, then it gets a little bit more complicated because the risk of a wound healing complication goes beyond a point that I’m comfortable with and that yes, the patient may not benefit from. So sometimes I recommend just minimizing the reconstruction or doing no reconstruction, let everything heal, and then come back and do a delayed reconstruction where I can control things a little bit more optimally.

Speaker 1 (00:10:45):

Okay. So maybe you should just briefly explain what we’re talking about. These are deep flaps, D I E P, tram flaps, and other ways of using abdominal tissue to reconstruct a mastectomy. Correct?

Speaker 2 (00:11:00):

Correct. Yeah. So initially, these operations really started in 1980s, and in the 1980s, they were doing what’s called the traditional tram flap. And the tram flap was where we would take the skin and fat from the lower abdomen, and we would take all or most of the rectus abdominus muscle, and we would take that muscle because that’s where all the blood vessels resided. So those patients would get the tissue rotated up into the chest, but it would leave the muscle void of one or both rectus muscles, which in some patients was very problematic because it could lead to a bulge or a hernia. And then what

Speaker 1 (00:11:44):

We, first of all, they call a, sorry, a pedicle tra correct skin fat muscle from the belly gets moved up to the The other side of breast?

Speaker 2 (00:11:53):

That’s correct. Okay. So it’s known as a pedicle TRAM flap. And then probably in the late eighties, we started doing these microvascular free tram flaps that were sometimes muscle sparing. And then the deep flap, the D I E P flap really was introduced in the mid 1990s. I started doing the deep flap in 1999, and the deep flap is different than the TRAM flap in that no portion of the muscle is removed. We just make an incision in the muscle, separate the blood vessels from the muscle, and then detach it and then transplant it up into the chest. So the benefit of that is really for the abdomen. So it per preserves the contour of the abdomen and the function of the abdomen. Plus you get the benefit of having a tummy tuck essentially because we’re removing that excess skin and fat. So it’s a double benefit. You get a new breast made of your own tissue and a tummy tuck.

Speaker 1 (00:12:56):

So the original TRAM flap, because you’re removing muscle and you are left behind with an area where there’s no muscle, and all you have is the fascia and below your belly button, there’s not that much fascia. The entire area is not all fascia. Were they closing it just with stitches or they were putting Mesh in? How were they dealing with that defect?

Speaker 2 (00:13:24):

So it varied around the country. So there were some people who would use a Mesh routinely, and back when we were doing more TRAM flaps where the muscle was removed, people were using polypropylene meshes. I remember that. And then there were some cases where we didn’t have to remove as much of the fascia and we could close the fascia primarily. And that had the benefit of one, minimal disruption. And two, the fact that we didn’t have to use a Mesh if it wasn’t necessary. There were times where if there was still a little bit of a contour abnormality, we might tighten it up a little bit more and then put an Onlay Mesh, yes, on the anterior rectus sheath or that fascia just to give it more support. And there are times where we still do that today, even with deep flaps, just to minimize the risk of any stretching of that anterior sheath or fascia that may cause a bulge. So even though we do a lot of deep flaps and we don’t see a lot of hernias, we still can see a bulge, which is different than a hernia because there’s no hole in that fascia. It’s just stretched out and it bulges a little bit.

Speaker 1 (00:14:42):

Okay. That was going to be my next question. With a deep D I E P, you’re taking the skin and fat, but not the muscle. Correct. And you’re not making a hole in the muscle, but I’ve seen patients with hernias after a deep flap. So what’s the explanation for that?

Speaker 2 (00:14:58):

Well, a couple things can happen. What we have to do is we have to make, do a myotomy have make an incision in the muscle to separate the blood vessels from the muscle, and then we take the skin fat and artery and vein leaving the muscle behind. Now since you’ve got a split in the muscle, if you don’t repair that muscle, primarily there is a possibility of that muscle separating, creating a pathway for a future hernia. And if you repair the fascia and it’s under tension, then that fascia repair can fall apart. And then you’ve got a situation where you’ve got the deep layers of the posterior fascia where the transversesalis fascia is kind of poking through, coming through the muscle, through the hole in the anterior sheath, and then all of a sudden you’ve got a hernia with a hernia sac. Okay. So that’s kind of the mechanism. Usually it’s because they’ve either damaged the muscle, made a hole in the muscle that they didn’t repair, and then the fascia falls apart, and then you get a true hernia.

Speaker 1 (00:16:07):

Okay. And can you explain why a surgeon would choose to use Mesh in some deep flaps and why other surgeons do not? If you’re not making a hurt, a defect in the muscle, why use Mesh with a deep flap ever?

Speaker 2 (00:16:23):

So it’s really to reinforce that anterior rectus sheath. So I can tell you that

Speaker 1 (00:16:29):

The anterior,

Speaker 2 (00:16:31):

Yeah. So what I historically, with a deep flap, I would never put an Onlay Mesh on because really you’re just repairing that anterior sheath. So we would put an Onlay Mesh on. I would not have to do that very often, and my bulge rate was about four to 6%. So you like to think that everything’s going to turn out perfect, but at the end of the day, it doesn’t always turn out perfect. You may get a bulge in a contour abnormality, and the patient may not be happy with that. So one of the things that we’re doing now is we’re placing a resorbable Mesh, it’s called phasix. It’s a poly for hydroxybutyrate Mesh. It’s a dissolvable Mesh. We lay it on there as an Onlay after we’ve repaired everything, and that has reduced our bulge rate to about two or 3%. So that’s why that’s one reason why we use a Mesh now more regularly is really as a preventative maneuver to decrease the risk of having any contour issues.

Speaker 1 (00:17:35):

So we have a patient who may be actually reacting to that Mesh. Some people get systemic. We see it actually in hernias. I know there’s BII the breast implant illness, we don’t call it MII Mesh implant illness, but it is a real problem that I treat a lot and we’re researching, try and figure out if we can predict it any way or at least test it any way. We haven’t been successful, but I personally have a pretty large, relatively large number of patients that have this Asia syndrome or Shoenfeld syndrome, which they have a systemic reaction to the Mesh. And the only treatment is Mesh removal. If this patient that has deep flap Mesh reaction, can that Mesh be safely removed and with no consequences, or do they need a biologic or something else to reinforce?

Speaker 2 (00:18:29):

No, they wouldn’t necessarily need anything to reinforce. If I had somebody who was having any sort of an issue and we thought it was related to the Mesh, then I would go back and take the Mesh out. If they need, let’s say if they had a bulge and we had to do something to remove the Mesh, then what I might do is replace it with a biologic Mesh, something that would probably be less reactive. But there have been situations where I’ve gone in and removed the Mesh. Most of the times when that’s happened, it’s because of an underlying infection. There might have been a little wound that started, and then the Mesh gets, oh yeah, secondarily seated, and we have to take the Mesh out. But if somebody had an allergic reaction, some sort of a systemic reaction to the Mesh, and that’s what it was felt to be from, there was no other explanation, then I would go in and take the Mesh out, and I wouldn’t probably put anything back in. I would just rely on the sutures that are holding everything together.

Speaker 1 (00:19:30):

One question is how many, or have you had any patients develop foreign body reaction from the pH?

Speaker 2 (00:19:39):

There have been a couple of patients that have had wounds where a portion of the pH Mesh got infected, and I had to go back in and take the Mesh out. But I can tell you that the majority of patients have tolerated the phasix Mesh well, and I know it’s a little bit controversial. Not everybody will place a Mesh into patients after this, especially since we’re putting it in prophylactically. They don’t really have a true need for it. We’re just doing it as a preventative measure. But we’ve, we’ve been very fortunate in that our outcomes have been very favorable using this. There are other centers. I know that there’s a group in North Carolina that have reported some additional complications because of this Mesh, but I guess a lot of it is really going to depend on the patient population, some of the underlying comorbidities, the techniques used. There’s so many variables that go into determining outcomes.

Speaker 1 (00:20:39):

We just don’t know. In my series, I’ve had two patients that have had reactions to biologic Mesh, pretty significant. And one of them actually, when I replaced it with just suture, even responded to the sutures. So of course, very rare, not expected. And phasix is a synthetic absorbable, so it’s synthetic like Mesh, but it’s absorbable like biologics. So theoretically it shouldn’t be that bad, but I believe it is more inflammatory in nature than an organic biologic because it is synthetic. So it has been more of an inflammatory response. So anything is possible. These numbers are very low, but we have to be diligent in patients that may be suspected to have this. I have a complicated patient for you. Are you ready for this one?

Speaker 2 (00:21:34):

I’m ready.

Speaker 1 (00:21:36):

Okay. Hi, doctor N. In 2015, I had a true deep flap, no muscle removed, and S G A P flap reconstruction after breast cancer. What’s S G A P?

Speaker 2 (00:21:49):

It’s a superior gluteal artery perforator flap. It’s from the upper buttock.

Speaker 1 (00:21:55):

Wow. After breast cancer, I was a thin with a B M I of 21, so that’s basically normal weight person. On the lower end of normal, after the deep flap, I had degradation of the abdominal wall with donor site morbidity. This caused a recurring abdominal bulge with incisional and bilateral inguinal hernias. This paralyzed my anterior rectus muscles, and they have thinned polypropylene Mesh was put in, and now I’m suffering from autoimmune diseases and chronic infections from the Mesh. I’ve reached out to countless ex plant specialist surgeons and all have said if they remove the Mesh, they have to replace it with another Mesh given autoimmune disorders or Asia syndrome, chronic foreign body Mesh rejections from Mesh. I’ve been told to have no Mesh put in what can be done for me. Good question.

Speaker 2 (00:22:50):

Yeah. Well, it sounds like a very complex situation in terms of the denervation of the abdominal wall. Even when you do a deep flap, you have to really respect the nerves that are going into that muscle, and it’s easy to damage those nerves. So you have to be very cognizant of where they are and then make every effort to preserve them. And every once in a while, we have to still divide one of those motor nerves, the rectus muscles, segmentally innovated. In other words, the nerves come into the muscle at various different locations. But if you cut enough of those nerves, that muscle will stop functioning. You will become more flacid. You’ll probably develop a bulge because you’ve lost some abdominal support. And oftentimes when that happens, a Mesh repair is usually indicated. Now, if you’ve had a reaction to the polypropylene Mesh, which it sounds like you had, then the thing to do would be to go in, remove that Mesh, and most of the time I would, if I felt I really needed a Mesh, I would use a biologic Mesh. I think the likelihood of having any sort of an autoimmune reaction to a biologic Mesh is less because it’s essentially collagen and elastin and all these other structural elements that are normal in everybody’s tissues. The Mesh is, the biologic meshes are all processed, so there’s no cellular elements. It’s just a matrix of all these different components. So that’s typically what I would recommend. But sounds like a complicated situation, but that’s so,

Speaker 1 (00:24:40):

Yeah. So patients with degradation like this patient, usually the way I treat it, and I do these with plastic surgeons, is they get an intense placation of a denied portion just to tighten it down because it’s lax and really has no trigger to it. There’s no function to it, and it keeps stretching out. And then I do a very wide overlay Onlay of Mesh that covers not only the placated tightened area of the denied muscle, the muscle that lacks the nerves, but also covers normal healthy tissue, including areas of the body that don’t move, like the Rives and the hip pelvis, the al ligament, basically areas that you can suture the Mesh to. So it doesn’t stretch over time. Is that that’s hundreds. Let’s say this lady does not have a Mesh problem. Is that what you would do if you have donation from a deep flop?

Speaker 2 (00:25:45):

Yeah, so whenever I do an Onlay Mesh for somebody who’s got a bulge or denervation, I do exactly as you said, I create a pocket, an abdominal wall pocket that goes to the ed, the inferior edge of the Rives all the way down to the pubic bone, and then extends out towards the anterior auxiliary line. So the entire anterior abdominal wall is going to be covered with this Mesh? Yes, because you can’t just put the Mesh specifically over the area of the bulge or the contour abnormality. You have to extend it out all the way towards the borders of the anterior abdominal wall, and then you have to place quilting sutures. You have to anchor the Mesh to the abdominal wall with sutures in the Mesh so that you, yes, when you sit up and flex your waist, you don’t get boast stringing of the Mesh. So you want that Mesh to incorporate to that anterior sheath throughout its entire surface. So those are important points. You need a wide Mesh when you have a bulge like that.

Speaker 1 (00:26:54):

So now, in this lady’s situation, sounds like she needs that, but she can’t get Mesh. So what’s your experience in using biologic Mesh for these problems? Because biologic Mesh absorbs,

Speaker 2 (00:27:09):

Right. So I mean, Mesh is, there’s pros and cons of all these different meshes. Resorbable, Mesh, synthetic Mesh, biologic Mesh. Biologic Mesh will tend to, if they revascularize and incorporate, then you’ll get the true benefit of a biologic Mesh. But if the biologic Mesh completely reabsorbs, then you’ll have lost the long-term benefit. But you may get enough short-term benefit by having this Mesh stay in that plane for six months, eight months, or a year so that you develop enough scar tissue that it will provide the support you need long term. Now Mesh, the biologic meshes will stretch over time. Anything, if you apply a force to any of these meshes, those meshes are going to stretch. And if that intra-abdominal pressure is too high, then that Mesh will stretch. And I, I’ve seen that in the abdominal wall when I’ve used just a small strip of me. I put in a 16 by eight piece of Mesh, the patient got a recurrent bulge, I went back in and that Mesh had doubled in its size, and I took a picture of this published, it must report

Speaker 1 (00:28:23):

25% or something or 50%, right?

Speaker 2 (00:28:26):

It’s stretched quite a bit. So it was a very interesting thing, and that’s when I kind of realized that these biologics will stretch if given enough force. And early on in the teaching it was that, oh, it’s just all technique and they won’t stretch if you’re doing it right. But I did it. I took a picture before and I took a picture after and it stretched. So no, Mesh is perfect. I wish we had the perfect Mesh. People have thought about the perfect Mesh and maybe one day it will exist. But for the time being, we have the tools that we have and try to make the best use of them, and there’s a variety of things that we can use and we try to individualize as much as possible to try to pick the right one for the right patient.

Speaker 1 (00:29:13):

Yeah, I pre-stretch the Mesh before I put it in. Is that what you do?

Speaker 2 (00:29:17):

Yes. Now some of the Mesh, like the human meshes, you can really stretch them manually. Some of the other meshes, the bovine or the cow meshes and the pig meshes are much less elastic. But anytime you can, if you can to your advantage, but even if you pre-stretch and then sew in kind of pre-stretch and then apply a force to that Mesh over time that Mesh is going to continue to stretch. It’s just like the concept of tissue expansion. You can put a tissue expander under the skin and stretch it and stretch it and stretch it. It’s amazing how much stretch you can get from skin, which is what these meshes are. They’re dermis, it’s skin it, they’re elastic in nature.

Speaker 1 (00:30:08):

And which of the biologic meshes do you use?

Speaker 2 (00:30:11):

I don’t know if you want me to name brands, but I use the porcine Mesh. I typically would use Strattice, the biologic Mesh for hernias that I have the most experience with. I’ve used a variety of meshes, both synthetic resorbable and biologic. And when it comes to biologic, that’s the one that I prefer.

Speaker 1 (00:30:34):

We use at Cedars, we have Flex HD. Back in the day I was using AlloDerm, but which I still think is great. It just stretches a lot. It stretches too much FlexHD is what we have at Cedars. Yeah, I’m not sure we really have stratus, but I I’ve had good response with FlexHD. I have another question. We have someone who’s on here. What do you do in a patient that has abdominal wall hernias and Ehlers Danlos syndrome?

Speaker 2 (00:31:13):

Oh, a connective tissue disorder.

Speaker 1 (00:31:14):

Yes. So she has a collagen deficit, and you can’t put synthetic Mesh in her

Speaker 2 (00:31:22):

Ehlers Danlos syndrome. You have to, there’s various types, and I think I’m not a hundred percent sure, but I think it might be the Ehlers Danlos type four that is going to be the most complex. And there are some patients with Ehlers Danlos that you have to be very careful when talking to them about surgery, because the last thing you want to do is make them worse off. So if you’ve got certain, and I’d have to go back and review all the different classifications for Ehlers Danlos. There are some patients with Ehlers Danlos that you can safely operate on, some that you have to be very careful who you operate on. In terms of what I would do, what I use a Mesh and somebody with Ehlers Danlos, it depends on the severity of the hernia. If I could placate and not have to worry about anything, or if I could get everything closed without tension, then I might choose to just do that and have them wear some sort of an external device, maybe use braided sutures to really get good tensile strength inside the abdomen. But a lot of it failed,

Speaker 1 (00:32:39):

Failed all tissue repair. She’s failed all attempts, and she’s reacted to synthetic Mesh. So the only option that I think she has is a plication with biologic, but I don’t know how good that is. If you leave a biologic as your only way in especially a patient with Ehlers Danlos down lows in addition to a tummy talk.

Speaker 2 (00:33:01):

Well, you don’t because you don’t even know what the incorporation is going to be like when you use a biologic. Biologic relies on incorporation if you don’t get blood supply or decellularization of a biologic, it’s just going to basically be a synthetic it. It’ll just be there as strong as your sutures are, and then it’ll detach and won’t give you any support sutures maybe the way to go trying to avoid Mesh. But again, it would be, it’s a tough one without kind of seeing the patient or without seeing photographs.

Speaker 1 (00:33:38):

She’s in your neck of the woods, so I may have her come see you.

Speaker 2 (00:33:42):

Happy to see her.

Speaker 1 (00:33:46):

Okay. Let’s see. Sorry, they started to do construction next door. Okay. So this patient we talked about with a deep flap that has managed, that needs to be removed. Yes. So she says she’s still waiting for phase two due to odd symptoms she was having. Would it be appropriate to ask the plastic surgeon to remove the Mesh in her phase two operation, or does she need a specific surgeon other than the breast plastic surgeon to deal with the Mesh removal? What are your thoughts on that?

Speaker 2 (00:34:26):

I think that if it was somebody who had had a deep flap with Mesh placement, I would recommend going back to that plastic surgeon or a plastic surgeon who’s familiar with those operations. You could go to a hernia specialist as well, because the hernia specialists are all very skilled and savvy when it comes to matters related to the abdominal wall, and certainly are more than qualified to take care of these things and can easily remove a Mesh. So I think going to somebody with expertise in the abdominal wall is the important part.

Speaker 1 (00:35:02):

Okay, very good. Are you familiar with the Meyers procedure? Bill Meyers up in Pennsylvania, he does sports hernias, and part of the reconstruction of the athletic pubalgia is they redirect the angle of the rectus. So they detach the rectus muscle off its insertion from the pubic bone, and then they reattach it down into the al ligament. In your experience, but does that destroy the muscle in any way?

Speaker 2 (00:35:36):

Well, I think it’s going to certainly compromise the function. I think part of the rectus muscle really works on the fact that its origin is at the pubic and the insertions along the costal margin and Rives. So you need those two anchor points in order to get the muscle to work and for you to able to flex at the waist if you detach the origin of the muscle and then insert it on the inguinal ligament, essentially compromised the function functionality of that muscle. So I would think that it’s going to be more difficult for somebody to do things like sit-ups and things like that. So I would think there’s a real trade-off in a situation like that where you detach the muscle in order to repair a sports hernia. I don’t know Dr. Myers, and I’m not as familiar with that procedure, but just thinking about it intuitively, I don’t know that I would want to have that done for myself if I had one.

Speaker 1 (00:36:36):

Hopefully you don’t need it. Okay. Let’s backtrack a little bit. Ooh, I don’t want that wrong sharing of the screen. Okay. So how exactly is what you do different than a tummy tuck?

Speaker 2 (00:36:56):

So a true tummy tuck, we’re just removing the skin and the fat. So we basically start that operation by making an incision along the bottom of the area, and then we undermine, we cut around the belly button, we undermine all the way up to the Rives and to the xiphoid, which is between at the angle of the Rives. And then what we do is we cut away that excess tissue and sew everything up back down below with a tummy tuck. We don’t have to cut into the anterior sheath. We do not cut into the rectus muscle with the deep flap. We do cut into those structures. So I tell patients who are having a deep flap, it’s going to look like you had a tummy tuck, but it’s a very different operation because we’re cutting into the supportive layer with the deep flap, whereas with the tummy tuck, you do not cut into the supportive layer. So tummy tuck patients don’t usually get hernias or bulges, whereas deep flap patients are potentially at risk for those.

Speaker 1 (00:38:06):

Yeah, very true. Next question has to do with suturing. Were the risk of sutures pulling out or muscle tearing when suturing the muscle? And can that be reduced by suturing technique or suture selection?

Speaker 2 (00:38:19):

Yeah, so it’s a good question. So I think when you’ve cut into the muscle, it’s always a good idea to put a couple of sutures, and I basically would just use an absorbable suture just to realign that muscle, and patients aren’t really doing anything aggressive for the first month after surgery, so that’s usually plenty of time for that muscle to heal back up and kind of fuse along that cut point. So it would just be an absorbable suture, and that usually takes care of it.

Speaker 1 (00:38:54):

Next question is, how does a patient with a deep or tram flop, do they even do tram flops anymore? How do they know if they have a hernia?

Speaker 2 (00:39:04):

Well, the first thing that you would notice is you would get a bulge, and then that bulge tends to get a little bit bigger. If you think you have to differentiate whether you have a hernia or a bulge, you’d really have to see your hernia surgeon or a plastic surgeon with a hernia. You’re going to have a defect in the supportive layer. So you could actually kind of stick your fingers through that defect and feel the edges with a bulge, you’re not going to have that defect. You’re going to have just stretching, but there won’t be what we call fascial defect. So there’s no area where the intestines are actually poking through the fascia with a bulge. They’re just kind of pushing up on the fascia. So it’s really hernia versus bulge is going to be based on physical examination.

Speaker 1 (00:39:59):

Very good. Going back to the Mesh reaction, do people that react to synthetic Mesh are also at risk for reacting to biologic Mesh? I think in my experience, the reverse may be true. If you react to something as non-reactive as biologic Mesh, then you’ll react to a lot of things. Whereas reacting to synthetic Mesh doesn’t necessarily mean, in fact, it may imply you would need a biologic Mesh because you’re much less likely to respond to that. What are your thoughts on that?

Speaker 2 (00:40:31):

I completely agree. I think you’re more likely to have a reaction to a synthetic than a biologic. You can have reactions to both. I mean, certainly in the breast reconstruction world where we use things like AlloDerm in the breast, we can see a phenomena known as red breast syndrome where patients may actually get red and inflamed because of there’s an inflammatory response, maybe an allergic response. It hasn’t really been completely elucidated, but it is still possible to have reactions to biologic, but they’re less frequent. I mean, this is something that happens maybe one out of 500 or one out of a thousand patients where you’ll get this red breast syndrome. The same phenomenon can occur in the abdomen.

Speaker 1 (00:41:22):

I’ve seen people use GalaFLEX, which is basically phasix for the breast reconstruction. What are your thoughts about that?

Speaker 2 (00:41:32):

And phasix are exactly the same. They’re just marketed and distributed by different Condon companies. You’re right. GalaFLEX is for the breast, and phasix is for the abdomen. I’ve used both products, GalaFLEX in the breast and phasix and the abdomen, and honestly, they’ve worked okay. I GalaFLEX when I need support. If I’m doing a mastopexy and there might be a little bit more weight that would maybe result in recurrent ptosis or drooping, I may put something like GalaFLEX to support that lower pole. Or if I need to maintain implant position in somebody who’s had breast implants or breast reconstruction with implants, I could use GalaFLEX to give me support where I need it. So it’s worked well.

Speaker 1 (00:42:26):

Do you need to use, oh, we already discussed that. What are your thoughts and concerns when you see a patient with a hernia after breast reconstruction flap? Because that is a complex operation now, the anatomy is very different. The reaction of what you have left to deal with is different. You have less muscle, maybe a fascia problem. So when you see a patient that may have a hernia after a tram or deep flap or other recon construction, what are your thoughts and concerns before you treat them?

Speaker 2 (00:42:58):

So a lot of what I would do, I mean, I’d first do an examination, find out how long this hernia has been there, is it getting bigger? What sort of functions does the patient have, make sure that they’re healthy and in good physical health. If they’ve had one-sided, it was a unilateral tram or a bilateral tram, that’s going to be important because if they took one muscle, that’s one thing. If they took both muscles, then it becomes really challenging because that eliminates the possibility of doing an anterior component separation because you don’t really have that rectus muscle. Now, you could still perhaps do a tar procedure. I’ve had situations like this where we had no muscles, the skin was tight. I had to put in tissue expanders into the subcutaneous space, adjacent to the defect, stretch the skin, but also stretch the internal muscles and then come back and move that skin around.

Speaker 2 (00:44:05):

But you have to use a Mesh in these cases. It’d be very difficult to repair a large tram bulge in somebody who’s got no rectus abdominus muscles without using some sort of tissue rearrangement or Mesh to reinforce. I’ve done it before. Yeah, it’s complex, but I’ve done it before with tissue expanders and Mesh, and it’s actually worked pretty well. I saw the patient for up to two years following surgery, and she was flat, and prior to that she had a large hernia. It was a true hernia, but again, I worked with our hernia surgeon. So we do this team approach on some of these complex cases,

Speaker 1 (00:44:53):

So necessary. Absolutely.

Speaker 2 (00:44:54):

Yeah. So I don’t want to always take it on myself. Sometimes I like operating with other surgeons. When it’s the operation, it makes the operation a lot more fun and you can bounce things off one another. And I think it’s really good for patient outcomes, and I think studies are starting to demonstrate that kind of this team approach works really well.

Speaker 1 (00:45:16):

Yeah, I love it. And one of the things that I push on hernia talk is how important teamwork is. Hernia talk kind of represents what I do, which is working with different specialists for one purpose of improving someone’s hernia related problem. So yeah, I think it’s very fun to do that. Operate with a plastic surgeon, a urologist, gynecologist, and I learned so much because so much of our medical and training is vertical, and most of my friends don’t know what I’m talking about, right. Because they don’t have the privilege of operating with others or seeing patients of the variety that I do in my specialty, they do bladders and hernia hernias and stuff, but it’s not as multidisciplinary. And I feel that the patients really, really benefit when they see me. Let’s say like today, I had a patient, she clearly needed a tummy tuck. She came to me with a belly button hernia, and I knew enough to be able to educate her a little bit about what to look for and what kind of what’s important, and guide her a little bit before she just goes cold into a plastic surgeon’s office not knowing what to ask and so on. So it’s fun.

Speaker 2 (00:46:37):

Yeah, it, no, it’s never underestimate the benefits of teamwork, like you’ve mentioned. It definitely improves outcomes.

Speaker 1 (00:46:47):

Yeah, totally agree. More questions or are in, do patients who have undergone multiple abdominal operations have a thinner abdominal wall than normal? So let’s say someone’s had multiple laparotomies, are they likely to have any type of thinning of their abdominal wall or not necessarily

Speaker 2 (00:47:05):

It? It’s possible. It just depends on what approach was made with these operations. Certainly if you make a midline incision and go through the linear alba, then it’s probably unlikely that you’re going to denervate anything, and you’re not going to really be going through the thicker fat layers. You’re not going through the muscle. So that area probably won’t have much of a consequence. Now, if you start making what we call right paramedian incisions where you’re actually going through the muscle and dividing the nerves and damaging the blood vessels, then you can get thinning, and then you are going to be predisposed to getting a bulge, a contra abnormality, or a hernia. And if you do transverse incisions, then you’re dividing muscles, you’re cutting nerves. Denervation is going to be more of a problem, and thinning could be a potential consequence. So there’s a lot of theories on what the optimal incisional approach is for patients having abdominal surgery, some of which may increase the risk of a bulge or hernia, some of which may decrease the risk of a bulge or hernia. But it is possible to have thinning.

Speaker 1 (00:48:25):

When we’re taught to operate on the abdominal wall, we usually focus on sutures in the fascia. We’re taught that don’t put sutures in the muscle. It doesn’t hold, but you do put sutures in the muscle. So are we being taught the wrong thing or just you have to be very careful how to suture muscle? What do you say?

Speaker 2 (00:48:47):

Yeah, well, so we’re putting sutures in the muscle when we’re splitting the muscle after we do a deep flap. But it depends on what you’re doing the operation for. So if you really want strength and support of a repair, then you’re better off putting your sutures in the fascia so you can get good fascial bites, because that’s where your strength layer is. Just like your strength layers going to be in the dermis, it’s not going to be in the fat, but so you really want to grab onto those areas that have high collagen density and tensile strength to withstand the forces that are pulling them apart. But that said, we will go into the muscle sometimes with the sutures and take a bite of fascia and muscle just because we can get more purchase that way. In other words, get a better bite of the tissue. Yes, for lack of a better word. So we will go into the muscle sometimes, but that it’s really the strength layers that you want to get.

Speaker 1 (00:49:51):

Yeah, true. When you do component separation, can you get nerve damage?

Speaker 2 (00:49:58):

Oh, yeah. So if you do, component separation is an interesting operation because we talked about the rectus muscles, the paired midline muscles that go up and down. There’s another set of muscles called the oblique muscles that are basically exactly the way they’re oblique. They’re coming in towards the rectus muscles. So when you do a component separation, you have to get between the right layer, so there’s like the transverses and then the anterior. So you want to get between the first two layers, because that is where it’s a avascular plane. If you get between the second and third layers, that’s where the nerves are. So you don’t want to get into that layer because you’ll damage the nerves. And there have been some good studies on that. I mean, Alfie Carbon did that study where he was kind of doing an anterior component separation was both, was between the second, third layers and commented kind of indirectly about possibly having injured nerves, but not knowing if it happened, for sure. Yeah. So you just want to stay in the right plane so you can minimize or avoid nerve damage.

Speaker 1 (00:51:20):

Yeah, we’ve definitely seen patients who’ve had nerve damage from component separation. I see a lot of people with nerve damage after lateral spine. Yeah. Approaches and kidney operations, aortic operations, any kind of lateral flank, those are tricky. It used to be, we would say, sorry, can’t do much about it. It’s not a hernia, you know, you have to live with this very just deforming bulge. But we’ve had a really great success with the kind of combo mean a plastic surgeon doing a pretty extensive plication with Onlay, the Onlay, the placation has to be intense, and the Onlay has to be very wide and just very critical stable structures. And our patients many years out are still symmetric and doing well. So it works really well.

Speaker 2 (00:52:15):

Those are some of the most challenging, those flank hernias from where nephrectomy, where they go through those oblique muscles and damage the nerves. And you’re right, you got to have to put a wide Mesh and you have to anchor it to bone sometimes in order to

Speaker 1 (00:52:32):

Really Yeah, absolutely. That Mesh. Yeah, I think that’s part of the key of us not having any recurrences is we do anchor it to bone. Yeah. Prevents it from stretching out with the muscles. Another question on the same line of denervation, it’s interesting, I didn’t expect this many denervation questions. After Mesh placement for a large incisional hernia, can the rectus abdominus de denervation or ischemia lead to loss and functionality? First of all, you shouldn’t get as part of an incisional hernia repair, but go ahead. What’s

Speaker 2 (00:53:07):

Your Yeah, but that’s okay. If you denervate that rectus muscle, and the way you denervate a rectus muscle is you have to basically cut on the lateral aspect of the muscle because those nerves to the rectus muscle come in laterally and then go under the muscle and then pierce the muscle at the junction of the lateral and central third. But if you get on the edge of the muscle and cut those intercostal, you will denervate the muscle and you will lose function, and you could end up with a prune belly because you just have no tone to your abdominal wall because the rectus muscles completely diner. True. That’s why true. Yeah. With a deep flap, you really have to be careful. You have to preserve the nerves. If you’re not preserving the nerves with the deep flap, then you are not doing the patient’s service by not taking the muscle, because then you’re defunctionalizing the muscle.

Speaker 1 (00:54:04):

So true.

Speaker 2 (00:54:05):

And with a hernia, the straightforward midline hernia, the risk of ding rectus muscle is probably pretty low, unless you’re undermining in an area where you shouldn’t be undermining between that second and third layer of the obliques.

Speaker 1 (00:54:21):

We have another great question. Can liposuction, especially of the flanks, cause denervation

Speaker 2 (00:54:28):

Pretty unusual, and the reason is because motor nerves are not, motor nerves are the nerves that innervate the muscle. Those are not traveling in the anterior fat compartment. The motor nerves are coming off the spinal area, and then going between the muscles and staying within the muscle layer. What you’ll see with sensory nerves is the sensory nerves will then come up through the fascia and then go to the skin. So with liposuction, you can damage some of the sensory nerves, but you shouldn’t damage the motor nerves unless your cannula is in the wrong place. So you could, because it’s blind, you can’t see exactly. The cannula is, if you put that cannula into the muscle and start going back and forth, you can do some real damage. So

Speaker 1 (00:55:18):

I’ve seen that. Yeah.

Speaker 2 (00:55:19):

Oh yeah. No, surgeons have to be very aware where the tip of the cannula is. And in the worst case scenario, you can have somebody with a diastasis recti and then have a little bit of a midline bulge because you got thin tissue and somebody does liposuction, goes right through the diastasis, and you can actually perforate bowel,

Speaker 1 (00:55:41):

So Oh, absolutely. See that

Speaker 2 (00:55:43):

Too. Yeah. So there’s a lot of things you have to be careful of. So it’s really important for surgeons to do a real thorough physical exam, make sure you don’t have a diastasis, and if you do, make sure you don’t go anywhere near that with your liposuction cannula.

Speaker 1 (00:56:00):

So in la liposuction in women, but also a lot of men, and they like to have that kind of upper midline kind of indentation. So they lipo suck through the belly by this vertical line to give you that in athletic look. Yeah,

Speaker 2 (00:56:21):


Speaker 1 (00:56:21):

And they’re like, get a hernia. I’m like, that’s not a normal place to get a hernia. And he didn’t tell me that. Oh, by the way, got liposuction. And I’m like, it’s exactly the width of a liposuction cannula. And I asked him, because I’d seen it before. I’m like, have you had liposuction? He’s like, yeah, I’ve had some work. I’m like, the hernia was caused by this. Right. And yeah, it’s, I’ve also seen it where they’ve gone through the abdominal wall, and technically I guess you can have damage not just by bleeding, but also by denervating or get a hernia. I’ve seen hernias, not just the midline where there’s no muscle, but on the sides where they did liposuction. What are your thoughts on lipo? I feel like it’s one of those operations, it’s really hard to do a really good liposuction, and everyone kind of offers it, but I feel that it should only be done in their hands of these people that are really good at it. Otherwise, you get this lumpy, bumpy cottage cheese looking. And I must say, most of the plastic surgeons in my town don’t do good liposuction. And we have a handful of dermatologists that do amazing liposuction. That’s all they do. Yeah. What are your thoughts?

Speaker 2 (00:57:47):

I think liposuction from a technical standpoint is not that difficult, but from an artistic standpoint is Yes, exactly. So to really do it well, you have to understand the fat, the fat layers, the different types of fat, the different types of cannulas that you can use. You can use small boar cannulas with certain holes. You can use large boar cannulas, and yet it’s like golfing. You know? Don’t play golf with one club. I

Speaker 1 (00:58:18):


Speaker 2 (00:58:19):

That you doing liposuction. You really have to know the anatomy, and you have to use your tools properly. You know, have power assisted machines. You have just handheld, you have to know how to toes infiltrate that space. Yeah, there’s so many little things that we take for granted, but if you take shortcuts, you’re going to compromise outcomes.

Speaker 1 (00:58:40):

Yeah, I agree. I have some plastic surgeons I work with who’d refuse to do lipo because they’ve seen the outcomes long term. It’s just that I can do a better job surgically than with lipo, and many people don’t need the lipo. I don’t know. It’s one of those things that a lot of people are like, oh, I’ll just do a little lipo, but then it just doesn’t look good.

Speaker 2 (00:59:03):

Yeah. Well, anything just, you know, got to have the right background, the right experience, and really understand what you’re doing. And anybody, I mean, I’ve seen dermatologists do beautiful liposuction. I’ve seen plastic surgeons do beautiful liposuction, but I’ve also bad liposuction, so Yeah.

Speaker 1 (00:59:24):

Yeah. I feel it’s like hernias. Everyone thinks that was just a hernia or just lipo, but when it goes wrong, it’s really hard to reverse.

Speaker 2 (00:59:32):

A hundred percent correct. Yeah.

Speaker 1 (00:59:35):

All right, my friend, thank you so much for this. I really learned so much. I’m going send you this one patient for sure. I think you can help her all right. Or at least give her some of your experience. I wish I were there so we could operate together. Maybe I need to come

Speaker 2 (00:59:50):

There. I know. Well, one of these we’ll have to,

Speaker 1 (00:59:53):

We’ll operate together

Speaker 2 (00:59:55):

Well with. We can get Shirin and you know, and me, we’ll have a good time operating,

Speaker 1 (00:59:59):

Or I’ll have Shirin do my part. We’ll see. I really want to help this patient. Okay. Well, that’s the end for us tonight. Thank you everyone for joining us. This wraps up another hour, another week of Hernia Talk Tuesdays. Thank you to all of you who joined us by Zoom and also Facebook Live. We answered almost all your questions tonight. If you do want to watch us again or share it, I’ll make sure that our YouTube channel is uploaded with this webinar, and I’ll share all of the links on my different social media channels, including Facebook, Dr. Towfigh, Instagram, and Twitter at hernia doc. Thanks everyone, and please thank you, Dr. Nahabedian, for your time and hope you have a good evening. Thank you so much.

Speaker 2 (01:00:51):

Thanks for having me. Thank you very much. You take care. Bye-bye everyone. Bye.