Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA.
Microsurgery. 2023 Nov;43(8):855-864. doi: 10.1002/micr.31107. Epub 2023 Sep 12.
Despite improvement in abdominal morbidity with deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to prior abdominally-based free flap breast reconstruction, abdominal bulge, and hernia rates have been cited anywhere from 2% to 33%. As a result, some surgeons utilize mesh or other reinforcement upon donor-site closure, but its benefit in preventing abdominal wall morbidity has not been well-defined for DIEP flaps. The purpose of this systematic review is to evaluate DIEP donor-site closure techniques and the impact of mesh type and plane on abdominal-wall morbidity including hernia and bulge, relative to primary fascial closure.
MEDLINE, PubMED, Cochrane Library, and SCOPUS were systematically reviewed for studies evaluating DIEP flap breast reconstruction abdominal-donor site closure, where any mesh reinforcement or primary fascial closure was specified, and postoperative outcomes of hernia and/or abdominal bulge were reported. Analysis was performed in Review Manager (RevMan) evaluating mesh use, type, and plane relative to primary fascial closure, using the Mantel-Haenszel method to calculate odds ratios (ORs) of significance level p < .05, and a random effects model to account for inter-study heterogeneity.
Of the 2791 DIEP patients across 11 studies, 1901 patients underwent primary closure and 890 were repaired with mesh. When hernia and/or bulge were combined into a single complication, the use of any mesh did not significantly reduce its odds compared to primary closure (OR = 0.69, p = .20). Similarly, the use of any mesh did not significantly reduce the odds of bulge alone compared to primary closure (OR = 0.62, p = .43). However, the odds of hernia alone were significantly reduced by 72% with any mesh use (OR = 0.28, p = .03).
Mesh use was significantly associated with decreased odds of hernia alone with DIEP flap surgery, but there was no difference in bulge or combined hernia/bulge rates. As bulge is the more common abdominal morbidity after DIEP flap harvest in a patient with no prior abdominal surgery or risk factor for hernia, mesh use is not indicated in abdominal closure of all DIEP patients. Future prospective studies are warranted to characterize the specific indications for mesh use in the setting of DIEP flap surgery.
尽管与先前基于腹部的游离皮瓣乳房重建相比，深部腹壁下血管穿支（DIEP）皮瓣乳房重建降低了腹部发病率，但腹部膨出和疝的发生率为 2%至 33%。因此，一些外科医生在供区关闭时使用网片或其他加固物，但在 DIEP 皮瓣中，其预防腹壁发病率的益处尚未得到明确界定。本系统评价的目的是评估 DIEP 供区关闭技术以及网片类型和平面对包括疝和膨出在内的腹壁发病率的影响，与原发性筋膜关闭相比。
系统检索 MEDLINE、PubMED、Cochrane 图书馆和 SCOPUS，以评估评估 DIEP 皮瓣乳房重建腹部供区关闭的研究，其中指定了任何网片加固或原发性筋膜关闭，并报告了疝和/或腹部膨出的术后结果。使用 Review Manager（RevMan）进行分析，使用 Mantel-Haenszel 方法计算有意义水平 p < .05 的优势比（OR），并使用随机效应模型来解释研究间异质性，评估网片使用、类型和平面与原发性筋膜关闭的关系。
在 11 项研究的 2791 例 DIEP 患者中，1901 例患者接受了原发性闭合，890 例患者接受了网片修复。当疝和/或膨出合并为单一并发症时，与原发性闭合相比，任何网片的使用并不能显著降低其发生几率（OR=0.69，p=0.20）。同样，与原发性闭合相比，任何网片的使用并不能显著降低单独膨出的几率（OR=0.62，p=0.43）。然而，任何网片的使用都显著降低了单独疝的几率，降低了 72%（OR=0.28，p=0.03）。
在 DIEP 皮瓣手术中，网片的使用与单独疝的发生几率降低显著相关，但膨出或合并疝/膨出的发生率没有差异。由于在没有先前腹部手术或疝风险因素的 DIEP 皮瓣采集患者中，膨出是更常见的腹部发病率，因此在所有 DIEP 患者的腹部关闭中不建议使用网片。未来需要前瞻性研究来确定在 DIEP 皮瓣手术中使用网片的具体适应证。
