PURPOSE: Primary workhorse flaps for autologous breast reconstruction include those harvested from the abdomen, however devastating side effects of this technique include the creation of iatrogenic fascial defects. Use of mesh over primary closure in abdominal wall reconstruction of ventral or inguinal hernias has been proven effective, however inconsistency remains regarding donor site closure techniques for abdominal wall-based breast reconstruction. We review the efficacy of reported operative techniques most commonly used to prevent or repair donor site fascial defects in abdominally-based autologous breast reconstruction.
METHOD: A meta-analysis was performed in accordance with PRISMA guidelines. Ovid MEDLINE was queried for records pertaining to the study question using appropriate Medical Subject Heading (MeSH) terms. Study characteristics and patient demographics were collected. Abdominal weakness was determined to be any report of bulge, hernia, or fascial weakness. Univariate Fisher’s exact and chi-square tests were used to analyze data.
RESULTS: Of 516 citations identified, 65 underwent full-text review with 40 unique citations included in this study across 31 (77.5%) retrospective reviews, 6 (15%) prospective studies and 3 (7.5%) case series. Thirty studies described preventative abdominal wall weakness techniques while 10 reported fascial defect repair following autologous reconstruction. Mean patient age was 49.7 + 7.5 years with a mean follow-up 23.4 + 17 months. Donor site closure techniques included primary closure (57.4%), primary closure with mesh (17.8%), or mesh alone (22.9%). Synthetic mesh was most commonly used for closure (n=1609/2056, 78.3%), most frequently with an inlay placement (n=1075/2335, 46.0%). Occurrence rate of abdominal wall weakness was 4.6% (n=147) following primary closure, 5.6% (n=55) following primary closure with mesh, and 6.1% (n=78) following mesh alone for donor site closure (p=0.095). Following this, incidence of abdominal wall weakness was highest with biologic mesh (n=30, 18.5%) compared to synthetic (n=86, 5.3%) or biosynthetic (n=13, 4.6%) meshes (p<0.00001). There was no difference in occurrence of abdominal wall weakness based on primary location of mesh placement (p=0.147). There was no difference in reoperation rates by primary closure or mesh techniques (p=0.204). When isolating for mesh type or location used for repair, there were significantly higher reoperation rates for synthetic mesh (3.6%, p=0.041) and mesh placed in onlay positions (4.3%, p=0.010). Of repair techniques used, there were no significant differences in prevention of abdominal weakness for closure techniques, mesh types, or mesh placement.
CONCLUSION: Our results indicate donor site closure with mesh trended towards higher rates of abdominal fascial defects than primary closure, with the highest incidence associated with biologic mesh. Following abdominally-based breast reconstruction, no difference was found in donor site closure techniques, but synthetic mesh and an onlay placement resulted in higher reoperation rates than other mesh types or placements. For primary prevention or repair of abdominal wall defects following autologous breast reconstruction, care should be taken when choosing mesh materials and techniques.