What is the best procedure to alleviate abdominal bulge 13 years after tram flap surgery? Is it a hernia, or something else?

Question

After researching this question myself, and reading about a variety of procedures, some doctors say fascial plication is the answer, others say that internal oblique or external oblique with mesh or even laparoscopic repair with prolene mesh is the best to prevent recurrence. Each doctor is claiming that what they do is best. And, if this 'abdominal bulge' is indeed an exaggerated hernia, is a plastic surgeon even necessary? Is simply fixing the hernia not going to be enough to look normal?

Andrew Elkwood, MD, FACS · Answer

This is a great question and it is something that I treat very often.  This is very common after a TRAM flap if your surgeon doesn't reinforce you abdominal wall with mesh after he/she lifts up the flap.  Most likely he/she only reinforced you abdominal wall with one piece of mesh to fill the deficient, which is standard of care, but then you can have this bulging problem you are experiencing.  For my TRAM flap I also preform a procedure called the "BARs procedure".  You can do a google search for the "BARs procedure" and find plenty of info.  This website will not allow me to post a link to my institutes for you.  This procedure creates an internal girdle, so no chance of any bulge or hernia.Thank you for your question and I hope I help you find your answers.

Pablo Prichard, MD · Answer

Dear Noesky,Thank you for your post.  I assume you have a ventral hernia or abdominal muscular laxity and not talking about the upper abdomen/rib cage area where the abdominal rectus crosses into the chest into the tram flap.  If it is the hernia that you are talking about, then simply re-inforcing the hernia with mesh or dermal matrix is not going to get rid of the 'bulge'.  The bulge is most likely caused by the weakness and spreading of the abdominal fascia.  If the abdominal fascia is not tightened, then you will still have a bulge.  Also, if the fascia is tightened, but not re-inforced, it is likely to recurr.  I believe a combination procedure where the fascia is tightened and re-inforced is most likely to give you a good long-term result.  Post-operative management is very important as well, wearing an abdominal binder, as well as no lifting, reduced activity.Best wishes, Pablo Prichard, MD

William Lambeth, MD (retired) · Answer

when doing a tram flap the rectus muscle is removed to a large extent from the lower 1/3 of the rectus sheath.this  usually leads to a "bulge".  which is hard to fix. If it progresses, it may become a true hernia which may require surgery. I approach externally and reinforce with ultra pro mesh. It can also be repaired endoscopically with mesh.

What is the best procedure to alleviate abdominal bulge 13 years after tram flap surgery? Is it a hernia, or something else?

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What is the best procedure to alleviate abdominal bulge 13 years after tram flap surgery? Is it a hernia, or something else?

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