Hernia and Abdominal Reconstruction
We enjoy collaborating with our general surgery colleagues in the treatment of complicated abdominal wall defects and hernias. When a patient has had multiple prior surgeries, multiple scars, or other complicating factors we often perform surgery as a team, to minimize risk and maximize benefit. While every patient is different, we typically access the hernias through a low transverse incision or “tummy tuck” approach, applying the principles of aesthetic surgery to minimize the risks of problems with wound healing, and maximizing the long term aesthetic result. We can help mobilize the soft tissue and muscular layers to provide a belt and suspenders approach to hernia repair. Conversely, we often involve our general surgery colleagues for patients initially seeking cosmetic abdominal corrections, who are also found to have umbilical or abdominal wall hernias.
Many of these patients have already had a long and complicated medical course, and it is our goal to solve their problem with the lowest chance of recurrence or creation of new problems. Patients are carefully screened for risk factors, and optimized prior to surgery. Patients felt to be high risk for blood clots may be given blood thinners around the time of surgery. In order to speed recovery we believe in multimodal pain control and use of long acting local anesthetics. We keep patients in the hospital for observation, and to ensure they are comfortable. We have found with this approach, patients usually recover quickly with limited pain and early mobilization.
Risks of hernia repair include bleeding, infection, recurrence, seroma or fluid collection, problems with wound healing, and blood clots. With these in mind we try hard to minimize these risks. This is also an area of academic interest for Dr Sullivan who has published his work on repairing massive abdominal wall hernias.
Abdominal Wall Reconstruction, Tummy Tuck, and Hernia
Young woman who had multiple operations as a child and was left with unsightly scars and multiple hernias. Dr. Sullivan and Dr. Taylor placed tissue expanders in her upper abdomen (middle image), which they slowly inflated to stretch the skin. Several weeks later, she underwent abdominal wall reconstruction with repair of several hernias, removal of scar tissue, reconstruction of her belly button, and abdominoplasty (tummy tuck) (right image).
Preoperative Abdominal Hernia
Man with history of multiple abdominal operations and attempts at hernia repair by other surgeons who is left with recurrent ventral, incision and umbilical hernias, abdominal bulge, abdominal scars. Dr. Taylor, Dr. Sullivan and Dr. Gutweiler performed abdominal wall reconstruction.
Postoperative Abdominal Hernia
Same man shown above more than one year after after abdominal wall reconstruction with Dr. Taylor, Dr. Sullivan, and Dr. Gutweiler. The hernia was repaired using a low transverse incision, the same approach used with an abdominoplasty or “tummy tuck”. The scar is hidden in the underwear line. This approach is used to improve exposure and improve safety and recovery. The hernia was repaired with mesh using the Rives-Stoppa technique, which has the lowest rate of hernia recurrence. Abdominal wall component separation is also used to repair the muscle layers. Finally, excess skin is removed.
Diastasis recti refers to the separation of the vertical rectus muscles of the abdomen which most often happens with pregnancy, but can also occur with age and changes in weight. This widening of the space between the abdominal muscles can cause a bulge, and weakening of the core. Unlike a hernia however there is no true hole in the fascial layer, just a thinning and lateral migration. Diastasis repair plays an integral role in most tummy tuck or cosmetic abdominoplasty procedures, but may also be performed to reinforce a hernia repair. While we often feel that this muscular repositioning is a functional or reconstructive procedure, most (dare we say all) insurance carriers consider diastasis recti repair to be a cosmetic procedure.
Hernia, Abdominal Wall, Panniculectomy and Abdominoplasty (Tummy Tuck) Instructions
In the week before your operation
Consider eating pineapple, it may help reduce bruising
Consider supplementing with Arnica montana, it may help reduce bruising
Complete household chores and prepare meals for the first few days of postoperative recovery
Follow preoperative instructions with eating, drinking, and medications
Postoperatively, get out of bed and walk (with assistance) every few hours after your operation to decrease the chance of postoperative problems such as blood clots or deep venous thrombosis, which can lead to pulmonary embolus
You may need to walk slightly “stooped over” (bent at the hips) for a few days to release tension on the suture line. When in bed keep your head elevated about 30 degrees (two pillows under your head and back) with the knees slightly flexed (one pillow under your knees)
Practice 15-20 deep breaths every hour to keep your lungs open
Take your medications as directed to manage your discomfort and symptoms
Tylenol 1000 mg every 8 hours to prevent pain
Ibuprofen 800 mg every 8 hours to prevent pain and reduce swelling. The Ibuprofen and Tylenol should alternate such that one or the other medication is taken every four hours
Gabapentin 300 mg every 8 hours for 7 days to prevent pain
Vitamin C 500 mg daily for 50 days to prevent pain and help with healing
Oxycodone 5 mg – 1-2 tablets every 6 hours as needed
Colace 100 mg twice daily to prevent constipation
Zofran 8 mg every 8 hours if needed for nausea
Eat a light diet for 2-3 days and avoid spicy food. To ease abdominal discomfort or indigestion after surgery, drink water or warm liquids. Prune juice may help prevent constipation.
Keep your drainage bulbs collapsed and record time and amounts of drainage over a 24-hour period. All patients heal differently according to many factors. Usually the drains will be removed when the drainage is 30cc or less in a 24-hour period. Please use the Drainage Output Form to record your output.
You may shower or sponge bath the day after the operation with assistance. Avoid submerging the drains in water.
Wear the abdominal binder continuously for 3 weeks after surgery, then for 12 hours of each day for an additional 3 weeks, and thereafter as needed for comfort. You can take it off to shower. The binder helps control swelling and fluid build-up. If the binder rubs your skin, it can be worn over a soft t-shirt. We can provide suggestions for other types of binders to order.
Most wounds will be closed with absorbable sutures and skin glue. The skin glue forms a barrier to water. Please do not remove the glue, it will fall off on its own after a few weeks. It can be trimmed as it falls off.
Please call Dr. Taylor and Dr. Sullivan immediately at any sign of infection which would be signaled by fever, increased pain, new redness or swelling in the abdominal area.
For the first few days following surgery, raising your blood pressure and heart rate can cause bleeding. Stress on your abdominal muscles or vigorous activity could stretch or break the stitches. We recommend walking at first and a gradual increase in activity tailored to your recovery. It is good to walk for 15-20 minutes 2 to 3 times per day.
Please do not drive for 7-10 days or while taking pain medications such as oxycodone.
Do not lift anything heavier than 10 lbs., run, lift weights, or perform strenuous exercise for 6 weeks. You may begin having sexual intercourse 4 weeks postoperatively.
Moderate swelling of your abdomen is to be expected. This is most notable in the pubic region, above the incision, and in areas of liposuction should you elect to have this performed at the same time. You may find that your clothes do not fit as easily as before. Please be patient. And because of the removal of tissue from your abdomen, a feeling of tightness is to be expected. The swelling and feeling of tightness will gradually subside over the following months.
Scars take one full year to mature. You may notice that they become red, raised and firm for several weeks to months before becoming soft, flat and pale. Avoid Vitamin E as it can irritate the scar. Mederma has no proven benefit and is not worth the expense. Skin moisturizer with sunscreen or sunblock can be helpful. Consumer Reports has found that Trader Joe's and Walmart offer exceptional moisturizer with sunscreen for low cost. Silicone may have benefit with flattening the scar. Some silicone cream also includes sunscreen. Gentle massage of scars may also be helpful.
Infrequently after surgery you may have fluid build up after the drains are removed, known as a seroma. If this happens, you may notice a feeling of fullness or sloshing fluid and may even have some drainage. Please contact our office so we can aspirate it easily.
It is important to be seen by Dr. Taylor or Dr. Sullivan after your operation. They will see you in follow-up appointments at 1 week, 2-4 weeks, 3-6 months, and 1 year or as often as needed post-op. Call to schedule your appointments at Taylor & Sullivan Plastic Surgery at (617) 492-0620 or visit our webpage at www.massplasticsurgeons.com and submit a request for us to contact you.