Weight loss likely best for hernia and cosmetic outcome
From you description of multiple recurrent abdominal hernias and being 50 lbs overweight, weight loss is probably the surest way to increase your chances of success with another hernia repair operation.
As previously mentioned, complex hernia repairs do benefit from collaboration with a plastic surgeon that has expertise in these procedures. In your case, an abdominal wall reconstructive procedure may be needed. Complex procedures such as "Component Separation" and reconstruction of the abdominal wall are performed by a subset of plastic surgeons.
A significant focus of my practice is performing plastic surgery on patients that have lost "massive" amounts of weight--often 70 to 100 lbs or more. Some of these patients have had recurrent and multiple hernias, and in no case have I had to resort to using mesh or a complex abdominal wall reconstructive procedure.
For a significantly overweight patient, weight loss leads to loss of intra-abdominal fat, which "loosens" the abdominal wall. The net result is that hernia repair becomes much simpler after weight loss, and therefore the anticipated rate of hernia recurrence decreases significantly as well.
Here is an example of a patient that had multiple large and recurrent abdominal hernias. She is a 52 yo that previously was 100 lbs overweight. She underwent a gastric bypass procedure and presented a normal weight, but with significant excess skin and laxity of her tissus. All of her hernia were repaired easily without mesh, and we were simultaneously able to get significant body contour improvements by performing a lower body lift.
Repeated hernia repair and abdominoplasty
Without weight loss it is likely that your 4th surgery will undoubtedly result in a 5th surgery. I agree that you would, at this point most likely benefit from a "separation of parts" repair of your anterior abdominal wall. Understand that this is pulling out all the stops to repair your hernia and could result in a final cure to your problem but why would you jeopardize this by remaining at your current weight which is the most probable cause of your previous herniorrahphy failures?
Tummy tuck is a good approach to hernia repair
Abdominoplasty, or tummy tuck, gives exposure to the entire abdomen and is an excellent approach to hernia repair. Often hernia repair is a planned part of the abdominoplasty procedure and it is typical to repair an umbilical hernia from pregnancy, a small ventral, or incisional hernia from gastric bypass procedures, as the abdominplasty is performed.
Hernias are also encountered "incidentally" or in other words are discovered at the time of the abdminoplasty and are repaired along with repair of the muscle layer or diastasis as is frequently done in tummy tuck procedures. If diagnosed before abdominoplasty, insurance coverage may be available for the hernia portion of the procedure. Incidental hernias encountered will usually be denied coverage after the fact.
Keep in mind that hernia repairs and tummy tuck are separate procedures with distinct goals. Though there are times that the procedures will compliment one another, there are times that they may not. With your history of many failed hernia repairs, you are best to take a first things first approach and seek an expert in restoring the strength in the abdomen through a sound and successful hernia repair, and leave abdominplasty for another day.
Best of luck.
Time for a different hernia repair
Dear in Pain,
It sounds like the best thing for you is a great hernia repair. In your case, if your hernia is in the vertical midline, then your anterior rectus sheath should be separated from your rectus muscle on both sides and the mesh can be re-placed from the lateral rectus sheath on one side to the lateral rectus sheath on the other side.
If the mesh is placed correctly (on tension), then the medial rectus sheath of the left and right side will sit right next to each other after the mesh placement. Then, the rectus sheath can be closed primarily. This is part of a hernia repair called "component separation," which many general surgeons do know how to perform and a few plastic surgeons.
My description is a little technical, sorry, I usually draw this part for patients. You can have a tummy tuck at the same time, but it won't lower your chance of recurrence.
Finally, you will be better off losing the weight first, as I am sure you know!
You need to lose the 50 pounds first
You simply cannot keep repairing this hernia over and over again. You must do everything to give yourself your best chance of having the next repair be your last. In order to optimize your chances, you absolutely must lose all excess weight before surgery. Also, if you happen to be a smoker and especially if you have a cough, you must cease this because the cough will tear your repair and the nicotine could cause your skin to die if a component separation is done. Don't expect your insurance to cover the tummy tuck either as they will certainly call this cosmetic. Finally, you need to find a plastic surgeon who has extensive experience with component separation techniques for abdominal hernia reapirs.
You have a difficult problem
The first thing you need to do is lose those extra 50 pounds. You are doing yourself a disservice by being overweight.
Once you have lost the weight, then a combined approach by a plastic surgeon and a general surgeon might help you.
Role of the plastic surgeon...
I think it is imperative to determine why you are in need of a fourth hernia repair. If you had reputable surgeons operate on you, you need to determine what would be different this next time around that would make success more likely. Your weight, especially if much of it is intra-abdominal, may be the culprit and therefore until your solve this part of the puzzle, your hernia will continue to present problems.
If it is determined that something different can be proposed to solve the hernia issue, and this is part of the value of having a plastic surgeon involved, then you can look at the value of doing a simultaneous abdominoplasty. Now you have to distinguish between one type of abdominoplasty and another. There has to be a reason to do more surgery. If you do not solve the hernia problem, which is a musculo-fascial problem, adding a skin-fat abdominoplasty may simply add risk and not any long-term benefits. Your situation is more of a reconstructive dilemma and that takes precedence over the cosmetic aspects of the abdominoplasty. An abdominoplasty that tightens the skin will not prevent a recurrence of your hernia.
A combined procedure with a plastic surgeon and general surgeon likely the best option
When a patient has a complicated hernia and has had several operations, it is often recommended that a plastic surgeon and a general surgeon work togehter to give the best chance of healing.
The plastic surgeon will not be doing a cosmetic "tummy tuck" but a reconstructive procedure to alleviate stress on the hernia repair and also to try and help the wound heal as uneventfully as possible.
I would definitely recommend that you follow your general surgeon's recommendations and consult with a plastic surgeon, especially one who has experience in large/complex hernia type operations.
Tummy tuck and complex hernia
It is likely that a tummy tuck would be very helpful for your problem.
However, the complexity and risk of your surgery is relatively high. It will likely be necessary to go into the abdomen, which has a unique set of risks.
Complex hernia surgeries are best accomplished with a combination of a general surgeon and a plastic surgeon, each using their unique expertise.
Also, surgery such as this should generally be performed in a hospital setting.
It is also best to be at an ideal weight, if at all possible, before proceeding.
Tummy tuck and hernia repair
Certainly a tummy tuck and hernia repair can be done at the same time. If you have a complicated hernia( which it sounds like you do), you may need a components separation to release the abdominal musculature laterally to reduce the tension on the repair.