Document Type : Original Article
Authors
Surgery Department, Suez Canal University, Ismalia, Egypt.
Abstract
On-lay versus sub-lay placement of proline mesh in patients with mutilated abdomen through abdominoplasty approach
Shereif H Farrag, MD; Ashraf H Abbas, MD; Amr M Moghazy, MD; Osama A Adly, MD
Surgery Department, Suez Canal University, /smalia, Egypt.
Co"esponding author: e.mail: dr_ashrajhussein@yahoo.com, Tel: 00201005051983.
Abstract
Introduction: Abdominoplasty in patients with mutilated abdomen is still a challenging procedure. These patients need anterior wall reconstruction with prosthetic mesh placed either superficial to the primary repair (on-lay), or deep to the musculo-aponeurotic layer (sub-lay). Both techniques have their advantages and disadvantages.
Objective: To compare the on-lay and sub-lay prosthetic mesh application to propose the best technique as standard in cases of mutilated abdomen abdominoplasty.
Patients and methods: 140 patients were subjected to this clinical controlled randomized study conducted in Plastic Surgery Unit in Suez Canal University Hospital, Ismailia, Egypt from March 2003 to March 2011. Each group was formed of70 patients.
Results: Seroma,hematoma,wound complications,mesh removal, days before drain removal,
days of post-operative pain, hospital stay, and time before return to work were significantly higher in the on-lay group than in sub-lay group. In addition, the higher rates of DVT, chest complications and hernia recurrence observed in the on-lay group were not statistically significant.Similarly longer operative time in sub-lay group was without statistical significance.
Conclusion: Sub-lay mesh herniorrhaphy with concomitant abdominoplasty offers significant better functional and cosmetic results. Significant reduction of post operative complications in sublay technique than in the onlay technique was proved.
Introduction:
Abdominoplasty has become a popular procedure since its first description in 1899 by Kelly.It is indicated for abdonrinal wall laxity, excess skin, striae, and diastases of the rectus muscles.l-5
Before 1960, most of abdominal defects were repaired by tissue approximation, which was accompanied by a recurrence rate ranging from 30% to 40%. This was noticed in particular with large defects causing the fascia to be under additional tension after closure. The use of a prosthetic mesh for ventral hernia repair started in the early 1960s, when Usher described the usefulness of a knitted polypropylene mesh for repair of complex inguinal and anterior abdominal wall hernias. Although prosthetic mesh improved the
recurrence rate (5% to 20%), yet it was associated with a higher risk of seroma, hematoma, and tissue necrosis from extensive dissection.6-9
Polypropylene mesh can be used as a "bridge" or "inlay" attached to the margins of the aponeurotic defect, or as "onlay" reinforcement over a primary repair. The placement of prosthetic material in a pocket beneath the rectus muscles and outside the peritoneum was devised in Europe by J. Rives and Rene Stoppa in the 1970.10,11
The abdominoplasty approach to recurrent hernias is extremely helpful. It provides the best exposure obtainable. It allows access to all components of the abdominal wall permitting a number of techniques for hernia repair. Other hernias, which otherwise may
not have been detected, can be found. Finally, it may help to reduce the incidence of recurrence by enabling removal of a large pannus and the resultant weight on the anterior abdominal wall.I2
The onlay technique requires less dissection because the prosthesis is placed anterior to the abdominal wall fascia; however, in theory the intra abdominal pressure is transferred to the edges of the mesh at the lateral aspect of the defect, and recurrences tend to occur in these regions laterally. The sublay technique is an attractive alternative because it offers many theoretical advantages. First, by preserving the hernia sac, a layer of viable autogenous tissue persists to serve as a barrier between the prosthesis patching the defect and the intraperitoneal contents. Second, intraparietal placement of the prosthesis allows well vascularized anterior soft tissue coverage of all aspects of the prosthesis. Third, fixation of the prosthesis within the abdominal wall. Fourth, the intraabdominal pressure tends to hold the mesh in place opposed to the posterior rectus muscle over a wide surface area. Finally, this is a tension-free repair.2,13-15
Patients and methods:
This study was carried out as a clinical controlled randomized study.It was conducted in Plastic Surgery Unit in Suez Canal University Hospital, Ismailia, Egypt from March 2003 to March2011.
During this period, 140 patients with huge mutilated, deformed abdomen were operated on for abdominoplasty with mesh repair.
The inclusion criteria were those ofMatarsso III (Moderate skin laxity, variable fat and moderate abdominal flaccidity) and IV (Severe skin laxity, variable fat and significant
abdominal flaccidity).16 Patients with mild to moderate redundant abdomen, upper abdominal scars, recent pregnancy, and severe chronic illness were excluded.
All patients were operated on by the same surgical team and technique. All included patients completed at least 6 months follow up period.
Patients were randomly assigned to one of the two groups:
- Group 1: Abdominoplasty with on-lay mesh repair (70 patients).
- Group 2: Abdominoplasty with sub-lay mesh
repair (70 patients.
Preoperative preparations:
Patients were subjected to detailed history taking and clinical examination. Routine preoperative investigations were done. Prophylactic antibiotics (cephalosporin 3rd generation) and anticoagulants were introduced.
Surgical techniques:
Lower abdominal skin crease incision, extended laterally to both anterior superior iliac spines, was done. The incision was deepened to reach the anterior rectus sheath medially and external oblique muscles laterally. Dissection was then completed cephalically to reach the xiphestemum in the mid-line and the costal margins laterally. During this dissection any old meshes were removed. Hernial sacs were opened and adhesolysis was done when indicated. Any anterior wall defect was located.
In group 1, primary repair of the defects in
two layers was done then the polypropylene mesh was placed aver the repair (on-lay). The edges of the mesh were sutured to the abdominal wall under tension with polypropylene 0 Figure(l).
Figure(l)
In group 2t bilateral anterior fasciotomy through the anterior rectus sheath was donet thus exposing the medial edge of the rectus muscle, and developing the space laterally was done bluntly to the midclavicular line (lateral edge of the rectus muscle). The mesh was placed between the rectus muscles superiorly
and posterior rectus sheath and fascia transversalis or peritoneum inferiorly. If the peritoneum was deficient, the omentum was mobilized to cover the defect. Multiple polypropylene 0 sutures were taken to secure the position of the mesh without tension Figare(l).
Figure(2)
Two closed suction drains were left in the subcutaneous space. Drains were removed
Results:
The mean age of the study population was
36.34±9.04 years, ranging from 20-57 years, with group (1) patients had having slightly higher age, but no statistically significant
when the accumulation of fluid in the container was less than 50 ml/day.
difference was found between both groups (p
< 0.05) Table(l). Moreover, 70.7% of the patients were females with slightly higher
percentage among group (1), (p > 0.05) Table(l).
Table (1): Distribution of both groups according to age & Body Moss Index "BMI".
|
Gt'oup (1) On-lay repair |
Gt'oup (2) Sub-lay repair |
Student t-test |
p-value |
Age (years) BMI (kglm2) |
Mean±SD
38.2±8.98
31.95 ± 5.36 |
Mean±SD
35.36±9.25
31.3 ±4.4 |
1.85
0.79 |
0.067
0.429 |
-&iVHI!AifP*WtM#fliM'
Regarding the preoperative risk factors, diabetes mellitus was slightly higher among group (2) patients (27.1% compared to 24.3% in group (2); p > 0.05), while body mass index, hypertension, smoking and chest diseases were slightly higher among group (1) patients (p >
0.05) Table(l&2). The majority of patients in
both groups was of grade 3 Mattarsso (58.6% of group 1 compared to 51.4% in group 2); however, no statistically significant difference was found between them (p > 0.05). On the other hand, 64.3% of patients in both groups had previous hernia repair Table(2).
Table (2): Comparison of common pre-operative risk factors between both groups.
|
Group (1) On-lay repair No. % |
Group (2) Sub-lay repair No. % |
Unadjusted odds ratio and 95% CI |
Chi-square |
p-value |
Sex Male female Diabetes Mellitus Hypertension Smoking Chest diseases
Mattarsso Grade3
Classification Grade4
Previous hernia repair |
19 27.1
51 72.9
17 24.3
17 24.3
16 22.9
11 15.7
41 58.6
29 41.4
45 64.3 |
22 31.4
48 68.6
19 27.1
12 17.1
15 21.4
8 11.4
36 51.4
34 48.6
45 64.3 |
1.23 (0.59, 2.55)
1.16 (0.54, 2.48)
0.65 (0.28, 1.48)
0.92 (0.41, 2.05)
0.63 (0.26, 1.84)
1.34 (0.69, 2.6)
1.00 (0.5, 2.00) |
0.31
0.15
1.09
0.04
0.55
0.72
0.00 |
0.577
0.699
0.297
0.839
0.459
0.396
1.000 |
*Statistically significant at p< 0.05 and 95% confidence level
On-lay repair operation took a slightly shorter time than sub-lay repair operation (p value > 0.05). However, drains were removed earlier, and postoperative pain disappeared faster in patients who underwent sub-lay repair (p-value < 0.05) Table(4).
Complications were more common in the on-lay repair group (1) when compared to patients with sub-lay repair group (2). Seroma developed early in 15.7% of patients in group
1 compared to 1.4% in group 2. No patient in group 2 developed late seroma while it was detected in 27.1% of patients in group 1 (p value < 0.05). Similarly, hematoma, wound complications and mesh removal were significantly higher among group 1 patients when compared to group 2. Although deep venous thrombosis (DVT), chest complications and hernia recurrence were higher in group 1 than in group 2, the difference was not statistically significant (p-value > 0.05) Table(3) & Figure(2). On the other hand, sub lay repair operation was found to be
significantly associated with less hospital stay and earlier return to work compared to on-lay repair (p-value < 0.05) Table(4).
Logistic regression analysis of independent predictors of common postoperative complications in both groups was done. Covariates in the model were surgical technique, sex, age, body mass index, Mattarsso grade, diabetes mellitus, hypertension, previous hernia repair, chest diseases and smoking. Surgical technique (On-lay versus sub-lay repair) was found to be a predictor for seroma, hematoma, wound complications and recurrence; on-lay repair was associated with those complications more than sub-lay repair Table(5).Mattarsso grade was also a predictor for hematoma, wound complications, recurrence and deep venous thrombosis with more representation among on-lay repair patients Table(5&3). However,previous hernia repair was a predictor for seroma and hematoma only Table(5&3).
Table (3): Comparison of post-operative complieations between both groups.
|
Group(l) On-lay repair No. % |
Group(l) Sub-lay repair No. % |
Unadjusted odds raUo and 95% CI |
Chi-square |
p-value |
No
Seroma Early
Late
Hematoma
Wound complications
Mesh removal
DVT
Chest complications
Recurrence |
40 57.1
11 15.7
19 27.1
22 31.4
15 21.4
4 5.7
4 5.7
14 20.0 6 8.6 |
69 98.6
1 1.4
0 0.0
3 4.3
3 4.3
0 0.0
2 2.9
8 11.4
1 1.4 |
0.1 (0.03,0.35)
0.16 (0.05, 0.6)
0.49 (0.41, 0.58)
0.49 (0.09, 2.74)
0.52 (0.2, 1.32)
0.16 (0.02, 1.32) |
35.05
17.58
9.18
4.12
0.7
1.94
3.76 |
<0.001*
<0.001*
0.002*
0.042*
0.404
0.164
0.053 |
*Statistically significant at p< 0.05 and 95% confidence level
,
:. • Otoup(l)
• Group(2)
i>
1"·
1
%
1·
p
\•
Figure(:.
H"o\at·oml Wound Me.h Removal
CompllnUco ns
ovr Cheost Re<torreo\<e
Complkallons
Table (4): Comparison ofpostoperlllive prognostic factors for on-illy & sub-illy repair operations.
|
Group (1) On-lay repair Mean± SO |
Group(l) Sub-lay repair Mean± SO |
Student t-test |
p-value |
Operative Time (hours) Follow-up Period (months) Days before Drain Removal Days before Pain Disappearance
Hospital Stay (days) Return to Work (months) |
3.17±0.52
11.53±4.82
6.47±2.14
8.78±2.38
9.46±2.55 4.67±1.40 |
3.29±0.59
9.98±3.78
5.11±1.21
5.91±1.6
7.61±1.25
2.90±1.30 |
1.22
2.12
4.62
8.38 5.42
7.76 |
0.224 0.037.
<0.001*
<0.001*
<0.001*
<0.001* |
*Statistically significant at p< 0.05 and 95% confidence level
-&iVHI!AifP*WtM#fliM'
Predictors |
D |
P-value |
Adjusted OR (95% CI ) |
Seroma
Surgical technique
Age
DM
Previous hernia repair
Hematoma
Surgical technique Mattarsso Grade Previous hernia repair Wound complications
Surgical technique
Sex
Mattarsso grade
Recurrence
Surgical technique
Mattarsso grade
DVT
Mattarsso grade
Chest diseases
Chest complications
DM
Chest diseases
Smoking |
-4.343
-0.055
-1.070
0.997
-2.380
-0.979
0.904
-1.865
1.621
-1.768
-1.804
-1.582
-2.013
2.475
1.001
1.394
1.604 |
< 0.001
0.056
0.091
0.071
< 0.001
0.062
0.102
0.006
0.046
0.010
0.101
0.151
0.088
0.008
0.063
0.022
0.003 |
0.013 (0.002, 0.106)
0.946 (0.894, 1.001)
0.343 (0.099, 1.186)
2.711 (0.919, 7.995)
0.093 (0.026, 0.335)
0.376 (0.134, 1.052)
2.468 (0.836, 7.291)
0.155 (0.041, 0.589)
5.059 (1.031, 24.831)
0.171 (0.044, .657)
0.165 (0.019, 1.421)
0.206 (0.024, 1.781)
0.134 (0.013, 1.348)
11.882 (1.930, 73.148)
2.721(0.946, 7.829)
4.030 (1.222, 13.293)
4.973 (1.705, 14.500) |
Variable(s) entered on the Jst step of logistic regression: Surgical technique, sex, age, BML Mattarsso classification, DM, HTN, previous hernia repair, chest diseases and smoking.
Discussion:
All mesh repair techniques have high complication rates with classical abdominoplasty. Modifications in surgical procedures and techniques for incisional hernia repair and the availability of newer prosthetic materials have allowed improvement of surgical results with reduced complication rates.17
In our study, wound complications were
21.4% in onlay repair while it was only 4.3% in the sublay group. Also; 30 patients of 70 of onlay group developed seroma (early and late) while only one patient of 70 of the sublay group developed early seroma.
Infections of the implanted mesh prosthetics
can be especially difficult to treat and can lead to mesh resection and hernia recurrence. The use of mesh is not necessarily related to a higher incidence of wound infection (5.5% with mesh versus 6% without mesh).18 A similar study had an infection rate of9.6%.19
The few observed minor wound complications of small cutaneous dehiscence without infection are consistent with previous reports of abdominoplasty combined with hernia repair.2o Postoperative wound infections occurred in 0-
18% of the patients of many previous studies.11,21-23
Postoperative seromas are a common finding after ventral hernia repairs. Some surgeons
have categorized these as postoperative findingsrather than as true complicationsdue to the fact that they represent a nearly universal finding. Seroma is the most common complication of these proceduresoccurring in 1-23% ofcases.24 Bauer and his colleagues' rate ofseroma formation (12.3%) was similar to those in previous series of incisional hernia repairs using prostheses.I6
Our data revealed significant correlations between smoking history and any of postoperative chest complications.Krueger et alfound that the complication rates for abdominoplasty are significantly higher in smokers.25
Regarding co-morbidities in our patients; we found that diabetes mellitus, chest diseases and previous hernia repair were significant predictors for post-operative complications . Hensel et al. and van Uchelen et al. found the same observation that patients suffering from co-morbid conditions like diabetes mellitus and hypertension had significantly higher complication rates after abdominoplasty.26,27
Obesity is a major contributing factor in the initial development of a hernia. When the morbidly obese patients are consideredboth the recurrence rates and the complication rates tend to increase regardless of the technique.28-31
Mean body mass index of our patients was
31.95 in onlay group and 31.3 in the sublay group. There was no significant difference between the two groups regarding BMI. We could not find that BMI was a predictor of post operative complications in our work. We can explain these findings by that our patients were not having a high BMI.
The development of tension-free incisional hernia repairs employing prosthesis has decreased recurrence rates markedly, to about
6-10%.21 Bauer et al. series had no recurrences (except in one patient whose prosthesis was removed) and an infection rate of3.5%. These results are superior to those generally achieved with onlay repairsfor which the recurrence rate is about 4-6% and the infection rate approximately 7-10%_16 Recurrence rates in previous studies of Stoppa repairs range from zero to approximately 4%_11,21,22,32,33
Recurrence in our patients was 8.6% in onlay group and 1.4% in sublay group.
Since its introduction in 1989the Rives Stoppa technique has been popularized by many surgeons and recently was proclaimed to be the gold standard for open mesh hernia repairs by the American Hernia Society. The advantages of a large mesh with significant overlap placed under the muscular abdominal wall can possibly be explained by Pascal's Principles ofHydrostatics. The intraabdominal cavity functions as a cylinder, so pressures are distributed uniformly to all aspects of the system. The same forces that are attempting to push the mesh through hernia defects are also holding it in place against the adjacent intact abdominal waU_lO,lS
Inour series DVT was 5.7% in onlay group and 2.9% in sublay group. In Mark F. Berry, and his colleagues series; the most common postoperative complications were thromboembolic events (13%).33
Avoidance of onlay methods has been recommended because of minimal tissue incorporation of the prosthesis,34 excessive tension on the repair,35 and a possible increase in the risk of seroma and infection_ll,24,36,37
Conclusion:
For patients with complex recurrent hernias
and deformed abdomen, sub-lay mesh herniorrhaphy with concomitant abdominoplasty offers significant functional and esthetic results. Sub-lay placement of prosthetic mesh in the repair of abdominal wall is effective and superior to other methods. Approaching the recurrent abdominal wall hernia and certain primary hernias through an abdominoplasty incision; provides access to all components of the abdominal wall and identifies previously undetected hernias. Significant complications are low and patient satisfaction is high.
References:
1- Sozer SO, Agullo FJ, Santillan AA, Wolf C: Decision making in abdominoplasty. Aesth Plast Surg 2007; 31: 117:127.
2- Temudom T, Siadati M, Sarr MG: Repair
of complex giant or recurrent ventral hernias by using tension-free intraparietal prosthetic mesh (Stoppa technique): Lessons learned
from our initial experience (fifty patients).
Surgery 1996; 120: 738-744.
3- Schoetz DJ, CollerJA, Veidenheimer MC: Closure of abdominal wounds with polydioxanone: A prospective study.Arch Surg 1988; 123: 724.
4- Mudge M, Hughes LE: Incisional hernia: A 10-year prospective study of incidence and attitudes. BrJ Surg 1985; 72: 70-71.
5- Kendall SWH, Brennan TG, Guillou PJ: Suture length to wound length ratio and the integrity of midline and lateral paramedian incisions. Br J Surg 1991; 78:
705-707.
6- Awad ZT, Puri V, LeBlanc K, Stoppa R, Fitzgibbons RJ, Iqbal A, Filipi CJ: Mechanisms of ventral hernia recurrence after mesh repair and a new proposed classification. JAm Col! Surg 2005; 201(1).
7- Arbosa MA, Ferrandoa JM, Quilesa MT, Vidal J, L6pez-Canob M, Gil J, Maneroc JM, Peiiac J, Huguet P, Schwartz-Riera S, Reventosa J, Armengol M: Improved surgical mesh integration into the rat abdominal wall with arginine administration.Biomaterials 2006; 27:758-
768.
8- Zhao R, Song KX, Wang CF, Sun BD, Qiao
Q: Application of abdominoplasty and polylene to repair the abdominal defect. Zhonghua Zheng Xing Wai Ke Za Zhi 2007;
23(3): 223-225.
9- Timerbulatov VM, Popov OS, Popova OV, Sorokina VO: Abdominoplasty during operations for ventral hernias. Chirurgiia
2006; (4): 24-27.
10-Stoppa RE: Treatment of complicated groin and incisional hernias. World JSurg 1989;
13: 545-554.
11-McLanahan, King L, Weems C, Gibson K: Retro rectus prosthetic mesh repair of midline abdominal hernia.Am J Surg 1997;
173: 446-449.
12-Gardner PM, Vasconez LO: Repair of abdominal wall hernia through the abdominoplasty approach. Operative Techniques in Plastic and Reconstructive Surgery 1996; 3(1): 62-66.
13-Kingsnorth A, LeBlanc K: Hernias: Inguinal
and incisional. Lancet 2003; 362: 1561-
1571.
14-Breuing K, Butler E, Ferzoco S, Franz M, Hultman CS, Kilbridge JF, Rosen M, Silverman RP, Vargo D: Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair, doi:10.10 16/j .surg.20 10.0 1.008.
15-Novitsky YW, Porter JR, Rucho ZC, Getz
SB, Pratt BL, Kercher KW, Heniford T: Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias. JAm Coil Surg 2006; 203: 283-
289.
16-Matarsso A: Classification and patient selection in abdominoplasty. Operative Techniques in Plastic and Reconstructive Surgery 1996; 3(1): 7-14.
17-Bauer JL, Salky BA, Gelernt IM, Kree11: Repair of large abdominal wall defects with expanded polytetrafluoroethylene. Ann of Surg 2002; 206: 765-769.
18-Soler M, Stoppa RE, Verhaeghe P:Polyester (Dacron) mesh. In:Prostheses in abdominal wall hernias. Bendavid R (Editor); Austin: RG Landes Company (Publisher); 1994; p.268-277.
19-DeBord J, Wyffels P, Marshal J: Repair of large ventral incisional hernias with expanded polytetrafluoroethylene prosthetic patches. Post grad Gen Surg 1992; 4: 156-
160.
20-Bang RL, Behbehani AL: Repair oflarge, multiple, and recurrent ventral hernias: An analysis of 124 cases. Eur J Surg 1997;
163: 107-114.
21-Temudom M, Siadati M, Sarr M: Repair of giant or recurrent ventral hernias by using tension free intraperitoneal prosthetic mesh (Stoppa technique). Surgery 1996;
120: 738-743.
22-Duce A, Muguerza J, Martin J: The Rives Stoppa operation for the repair of incisional hernias. Hernia 1997; 1: 175-177.
23-Finan KR, Vick CC, Kiefe CI, Neumayer L, Hawn MT:Predictors of wound infection in ventral hernia repair. The American Journal of Surgery 2005; 190: 676-681.
24-Morris S, Hugles L: The outcome of non absorbable mesh places within the abdominal cavity, literature view and clinical experience. AM College Surg 1998;
186: 352-367.
25-Krueger J, Rohrich R: Clearing the smoker: The scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg 2001; 108: 1063-1077.
26-Hensel J, Lehman J, Tantri M: An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties. Ann Plast Surg 2001; 46: 357-363.
27-Van U, Werker P, Kon M: Complications
of abdominoplasty in 86 patients. Plast
Reconstr Surg 2001; 107: 1869-1873.
28-Velanovich V:Ponderal index as a predictor of post-operative complications. Ann Surg
1990; 56: 659-661.
29-Moore M, Bax T, MacFarlane M, McNevin MS: Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese. Am J Surg 2008; 195: 575-579.
30-Rogliani M, Labardi L, Maggiulli F: Obese and non-obese patients complications of abdominoplasty. Ann Plast Surg 2006; 59:
1152-1155.
31-Murshid M, Khalid K, Shakir A: Abdominoplasty in obese and in morbidly obese patients. Plastand Recon Surg 2009;
1-6.
32-Flament J, Rives J, PallotJ: Major incisional hernia.In: Hernia and surgery of abdominal wall. Chevrel JP (Editor); Berlin Heidelberg, New York: Springer (Publisher); 1995; p.116-144.
33-Berry MF, PaisleyS, Low DW, Rosato
EF: A Repair of large complex recurrent incisional hernias with retromuscular mesh and panniculectomy. The American Journal of Surgery 2007; 194: 199-204.
34-Amid P, Lichtenstein I, Shulman A,
Hakakha M: Biomaterials for "tension free" hernioplasties and principles of their applications. Minerva Chir 1995; 50: 821-
826.
35-Nagy K, Fildes J, Barrett J: Experience with three prosthetic materials intemporary abdominal wall closure. Am Surg 1996;
62: 331-335.
36-Le H, Bender JS: Retrofascial mesh repair of ventral incisional hernia. The American Journal of Surgery 2005; 189: 373-375.
37-Robertson JD, de la Torrell, Gardner PM, et al:Abdominoplasty repair for abdominal wall hernias. Ann Plast Surg 2003; 51: 10-
16.