173. DIEP and TRAM Flap Complications

This week, the topic of discussion was:
-DIEP
-TRAM
-Flaps
-Breast Cancer
-Breast Reconstruction
-Free Flaps
-Pedicle Flaps
-Denervation Injury
-Abdominal Bulging
-Asymmetry
-Hernia
-Incisional Hernia
-Complications
-Plastic Surgery
-Reconstructive Surgery
-Latissimus Dorsi Flaps

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

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Transcript

Dr. Towfigh (00:10):

All right. Hello, it’s Dr. Towfigh. Welcome everyone to Hernia Talk Live. I’m your host, Dr. Shirin Towfigh hernia and laparoscopic and robotic surgery specialist. Many of you’re joining me. Let’s see on Facebook Live. I can see you here. And then thanks to those of you who are logged in on the Zoom app, and of course this and all prior episodes, as you know, you can find on my YouTube channel at Hernia doc. So thanks everyone for joining me. It’s been a great day. I’m a little dehydrated and I’m a little hungry. If you see me munching on these bars, you’ll know why. I’ve had a long day. Oh, I had surgery today, saw a patient. I made it for Hernia Talk Live. And then I have an event tonight, so I missed lunch. I’m eating these bars. I don’t know, do you guys eat these bars? It’s called Synerje, S-Y-N-R-J-E, or Synergy, I think they pronounce it.

(01:18):

It’s made by a doctor actually. It’s really, really good. So if you see me munching on these, it’s because I missed my lunch and therefore I need energy. So this one’s called Ignition. If you want to buy it, you can just go to Instagram, S-Y-N-R-J-E or S-Y-N-R-J synerje.com, and you can buy these. It’s a hundred percent natural, no weird sugars, lots of fiber. This one has 12 grams of protein, which is pretty good. And this actual one has caffeine in it. So I’m not a big caffeine buff, but I definitely need it because I’m going to be out till about 10-11 PM tonight. We have an event, so if you hear me munching, it’s because I’m having my synerje bars. So thank you for whoever makes these because they’re a doctor. I really appreciate it anyway, and I’m also dehydrated because I operate all day and I haven’t eaten or drank anything.

(02:20):

So on that note, I just want to say thanks to those of you who were really involved last week, because last week we talked about a bunch of different topics related to complications. And what we came up in addition was this discussion about DIEP flaps and TRAM flaps. And so today’s episode is going to be focused on DIEP and TRAM flaps. If you have other questions, I’m happy to answer them. So it’s going to get a little technical. Most people don’t know what a DIEP or TRAM flap is, so I’ll do my best to explain it. But basically, if you’ve ever required any type of reconstructive surgery, let’s say you’re missing tissue, usually it’s a breast complication or breast surgery. So if you’ve had a mastectomy where you lose, you surgically have your breast removed, then you can opt to have reconstruction to make you a reconstructed breasts.

(03:32):

But there are also, we talk about flaps with any type of reconstruction where you’ve lost soft tissue, so it can be a trauma to your thigh or to your leg and so on. But most of what we talk about today will be relevant to women, especially women who have had breast cancer or breast surgery and now have missing breast tissue and are being treated by plastic surgeons. So let me think. Listen, it’s a hernia talk. Why are you talking about breast cancer? This has nothing to do. No, I see these patients, that’s why I’m talking to you all about it. We’ve actually had multiple prior episodes. If you go back, Dr. Maurice Nahabedian, Dr. Jeff Janice, two different plastic surgeons, and during their episodes where I interviewed them, I brought up the discussion about TRAM flaps and DIEP flaps. The two most commonly understood performed breast reconstruction flaps.

(04:41):

So why does a hernia surgeon even know about this, and why are we talking about it? Well, I know about it because you’ll hear soon that there’s a lot of abdominal wall complications that can occur with these operations. Why are we talking about it is because last week we had at least one of you maybe more that made little comments and we started talking a little bit about complications of DIEP and TRAM flaps. And I know that I’ve had guests on where we talked about it, but maybe I need to dial it down a little bit and do a really good, simple explanation of what we’re talking about. There are actual support groups on Facebook and elsewhere where all they talk about is their DIEP flap or their TRAM flap. So that’s kind of where the interest is. And then this week I have a patient that comes to my office and she’s had a complication, sorry, last week, had a complication from a DIEP flap reconstruction.

(05:50):

So I do see these patients, I do treat them. It’s very complicated, and I could have been a plastic surgeon at heart. So I do enjoy this population. Anyway, let’s start from the very beginning. What is a flap from a surgical standpoint? A flap is a piece of tissue, and usually this flap is moved, so it’s a tissue flap, it’s a myocutaneous flap, whatever the flap is, this flap is moved to cover a different area. So let’s say for example, actually this is a very interesting story. If you’re interested in surgical history, back in the day before, they actually had true plastic surgeons that are board certified. There’s a story, and I’m probably getting this story wrong, but basically the patient lost a lot of tissue in their nose. So what someone figured out is you can basically put a flap over it to close the exposed nose.

(06:58):

And the way they did it was they took a forearm flap and they brought it to the nose and covered it. Now, that kind of is weird to do, but they figured out if you take some tissue from your forearm and you slap it on this open defect in the nose, but still keep the blood flow coming or as it was originally coming from the arm, then over time the blood flow from the nose will take over the area and you now have a flap. And then eventually, so they would basically take the forearm and paste it to the nose, and you’d be like that for I think weeks. And once the nose took over the blood flow of that flap, then they disconnected it from the arm. And that is actually the arm, the symbol of the American Society of Plastic Surgeons Society. So kind of cool.

(08:10):

That’s very historic going really far back. Now, what do we do now? So what we do now is either what we call free flaps where you actually take a piece of tissue and it can include skin, it can have fat, and it can have fascia and it can have muscle or some combination of those. So you got skin fat, fascia and muscle. Then you take that flap, you cut it out from where it comes from, let’s say your abdominal wall, and you take it and reimplant it to where you want it to be, typically, let’s say to the breast, to reconstruct a breast. But they’ll also do it, let’s say to, let’s say someone was in a bad motorcycle accident. They sheared off all their thigh muscles or they have exposed broken bones, and you can use flaps. Let’s say they take it from your sides called the latissimus doci, and they take those muscles as a flap and they put it onto your leg.

(09:08):

There are people that they’ve had oral cancers of sorts and they lose their tongue or they lose their back of their throat due to cancer. And so they take a flap from your arm or your leg, and then they reimplant it as they make you a tongue or they cover your jawbone or your area of the back of your throat. Really interesting stuff. So there’s a whole specialty, usually plastic surgeons that only do reconstructive surgery and of this level of this complicated level. So over time, surgeons have decided that maybe it’s not a good idea for a female to have a mastectomy and leave them deformed looking. So plastic surgery or reconstructive surgery to replace the natural breast was some other type of tissue that will look and feel more like a breast became really popular, and in fact is mandated as part of healthcare kind of services that should be offered to a female undergoing breast surgery or less often a male.

(10:35):

So how do they do that? Back when I was a resident, they came up with something called a TRAM flap that was the original populated flap. It was very complicated. It was like 12 hours of surgery, good day from Australia. And what they did was they would take the rectus muscle, they would take your muscle from your abdominal wall and a little bit of skin and overlying fat. They would cut out the muscle from the abdominal wall and implant it into the breast. So it kind of gave you a hefty breast. And the fatter you were, the more skin and fat you had, the better the operation. This was because you had therefore a substantial breast that could be reconstructed from the skin and flap. And back when I was a resident, what they would tell the women was, Hey, this is great because you kind of get your breast reconstruction and a tummy tuck at the same time.

(11:39):

That was the way it was built. And I was like, that’s kind of cool. You get to get a tummy tuck, that’s cool. But actually now in retrospect, now that I know better, not that cool, what they were doing was, so let’s say you only had one breast that needed reconstruction. So the cancer surgeon would do the mastectomy, take out the cancer, the breast tissue, the lymph nodes, whatever you need, and the plastic surgeon would come in and do a big scar on the bottom, like a tummy tuck, scar of your abdominal wall, find the muscle, take that muscle and the overlying skin and fat, cut it off and then bring it up here. But you need blood flow, right? These things need to have blood flow to live. Your tissue needs blood flow to lip. So whatever blood flow fed that piece of muscles, fat and skin, they would take that main blood vessel and they would really cool implant it under microscopic surgery into one of the blood vessels in the arm or going to your heart somewhere like that.

(12:51):

Very, very complicated surgery, a lot of complications with it. So then you’re thinking, okay, from an abdominal wall standpoint, what happens to the belly? You’re now missing muscle. Exactly. So that’s where they’re like, oh, you get a tummy tuck. I mean basically they cut out a chunk of muscle, so they have to close you. And in doing the closure, you were tighter because you had to take that gap where you took out the muscle, you had to close it, so you’re deformed and you’re tighter. And a lot of women lost abdominal wall function. They were disabled from it. And that as a hernia surgeon, I would be treating their hernias. So you would think, yeah, why don’t all of them get hernias? And thank you. Hello from Light of Hope, some ladies from the TRAM DIEP flap complications and hope ask questions. So yeah, thank you for joining me.

(13:57):

I think a lot of people from the DIEP flap and TRAM flap complications group are on this site. So I hope I get to answer all this. So okay, going to the tramp flap. So it was deforming and functionally was not good for the women. They all thought they were going to get this fantastic tummy tuck, but in fact they were recovering from their breast surgery. Now they also have to at the same time recover from a tummy tuck, couldn’t get out of bed, couldn’t use their arms. Very disabling, difficult recovery, 12 to 16 hours of surgery. I remember this. I was a resident, but a lot of these operations were happening and the goal was to do well, but the plastic surgeons started to now gain more experience and say, okay, TRAM flap, there must be a better way. And what they learned was you don’t really need the muscle part of the flap.

(15:02):

You need the skin and the fat because what’s breast tissue? There’s no muscle and breast tissue, it’s skin tissue and fat tissue and breast glands, but the breast glands are out. So the surgeons said, okay, well let’s figure out how we can do this flap without involving the muscle. Now why didn’t they do that the first time? Well, because, and again, I’m not a plastic surgeon, I’m just explaining to you my knowledge, the muscle is where the vessels are. So remember you have to take these flaps from let’s say your abdominal wall and then you implant the vessels into let’s say your arm or chest area so that you get blood flow to it well, whereas a blood flow, the blood flow comes with the muscle, so the blood flow comes with the muscle. Originally they thought that the muscle has to go with the blood flow as part of the flap. Now they figured out, let’s think of better ways. So now what they do is they take the vessels, but they don’t take the muscle. That’s called the DIEP flap, DIEP. And these are all acronyms.

(16:23):

These are all acronyms. Give me a second. So stands for TRAM stands for transverse rectus adominis myocutaneous flap DIEP stands for deep inferior epigastric perforator flap, DIEP. And then that seems to be a more commonly performed procedure. So similar operation, you have kind of a tummy tuck scar, low transverse, low abdominal incision all the way across the belly. And then technically there’s no muscle that is used for the flaps. It’s just skin and fat. But what’s key is, and why I get involved in these complications is what they do is they take the blood vessels, but they have to go cut through the fascia and through the muscle to get to the blood vessels. Does that make sense? And in doing so, they can injure a nerve or they may see a nerve in their way and cut that nerve and that can cause a pretty severe damage to the muscle.

(17:44):

Remember the whole goal was not to touch the muscle because they’re like, okay, TRAM flap, you need to rectus muscle with it. That seems pretty disabling. Let’s do better. We’ll do the deep flap. But deep flap is though technically what is transplanted into the breast region for example, is skin fat. In order to get to the blood flow that feeds that skin and flap, they have to cut through the muscle and therefore the cutting through the muscle can either cause an actual hernia, right? Cutting any muscle can cause a hernia or those are easy to fix. It’s just a hernia. I mean, it’s not just a hernia, but it’s just a hernia. It gets much more complicated when there’s no hernia, but there’s what we call a denervation. So the nerve to the muscle is injured during the process of getting going through the muscle to cut the vessels out.

(18:48):

Does that make sense? And depending on where you take these vessels, the nerves may or may not be associated with the vessels. You may have heard of a term called neurovascular bundle. A neurovascular bundle means there’s the nerve and the vasculature, the artery vein all together as one bundle. If that’s what you need and you cut the neurovascular bundle, you’re just there for the vessels, artery vein, but you’re also getting the nerve. So part of it is because it’s just a very difficult operation. There aren’t enough surgeons that do a lot of them really well. Part of the other reason for complications is anatomically it can be difficult to get to these arteries and veins and just getting to it can cause nerve injury and then they’re just good surgeons and bad surgeons. So all of that put together has made it that lately. So I’ve been treating TRAM flaps complications and TRAM flap complications and DIEP flap complications for years.

(20:05):

In fact, my very first operation, not technical operation, my very first non-elective operation when I started at my job in 2008, no one even knew who the hell I was, but my first day was a complication from a flap, a pedicle TRAM flap. It was a what a great story. I tell this story often. That was a bad complication. The complication was not a hernia, it was actually bowel obstruction from that operation. My point is I’ve been dealing with this. I think my very first one was 2008, at least that I remember. Anyway, so let me know if you have any questions about this. Now, why do they use the abdominal wall? Because most people have a lot of skin and fat in the abdominal wall and it’s kind of a nice area to be able to have a scar. The DIEP flap actually is somewhat better recovery, not technically taking out any muscle. So the recovery should be easier.

(21:22):

There’s less of a blood flow issue to skin and fat compared to muscles. So the rate of the flap not failing from a vessel blood flow issue is pretty good. There’s not as much disability from it. Now if you’re thin and you don’t really have much skin and fat around the lower abdomen, you can’t get a TRAM flap or sorry, you can’t get a DIEP flap. If you have thick muscles, you can probably still get a TRAM flap, but it wouldn’t be very good. And then if you’ve had prior surgeries in the abdominal wall, let’s say you had colostomy a bunch of different abdominal operations, trauma surgery, then you’re probably also not a good candidate for these operations because number one, there may be a lot of scar tissue involved in the skin and fat they want to remove, but more importantly, number two, the blood flow to that may have been disrupted from the prior trauma surgery or colostomy colectomy. So that’s why not everyone will be getting a tramp flap or a DIEP flap. So how do they do other flaps? Well, a lot of times they do it from the sides. So they do what’s called a latisimus dorsi flap.

(22:52):

There are some surgeons that prefer those. It does kind of affect you get physical therapy, it can affect the function at your shoulder level, but you don’t have any issues with hernias or denervation issues. All of those are gone, and if you’re one of those and have a lot of that kind of, what’s it called, that fat that boulders around your bra, that kind of under arm or back fat, then those co lateral chest wall flaps actually work really well for breasts instead of a deep flap or tramp flap. So I’m happy to answer any questions. Let’s see what’s going on. So the patient that I saw this past week, yeah, so she was interesting. So I’ve seen there’s two types of deep flap complications. The one’s either hernia or a denervation. Denervation is more common and then depends on how much surgery you’ve had. So if you’ve had deep flaps for both breasts, then both your left and right abdominal skin and fat are involved and you can get denervation. If you only had one breast affected, then you may only have one side of the abdominal wall cut, and then if you have a complication, you only get bulging on one side, which is very deforming.

(24:28):

So that’s kind of one thing. And then these are all complicate operations and things happen. What I don’t like is almost every single patient that I’ve had who’s had a DIEP flap or TRAM flap complication has been told to go away by prior surgeons. It has nothing to do. Be happier. You’ve had this surgery, it doesn’t look that bad, just wear a binder, wear a girdle, do some physical therapy. I guess that seems to somehow physical therapy is going to fix that, never will. It’s really, really disturbing because these women have had, they get years and years of just being gaslit by the surgeons, mostly the surgeons saying, I don’t know what to do with this. Go home. What they should be saying is, I don’t treat these problems. Let me send you to someone who does. Okay, lots of comments here. Hi. I meant to say I hope several of my ladies from the complication group will join. Yes, I hope so too. But you know what you can do after this? You just share this with them. I’m happy to have you share. Like I’ve said, I’m looking for more surgeons to help us in our new journey or bulges or hernias. Yes, you’re welcome.

(25:49):

Okay. I have no more muscles. My rectus and transverse and oblique have been harvested due to complications. I have an abdominal repair every year to repair for removal of old mesh. I have an abdominal repair every year to repair for removal of old mesh. My questions is how to avoid having a turtle body. Turtle body. I don’t know what turtle body means. Does anyone know what a turtle body is? Many of us have been told to learn to live with it. Yes, so that’s what’s wrong. Now, are there ways to fix tram or deep flap complications? Absolutely, I’ve done it multiple times. Are they great operations? No. Can I take you back to exactly how you were before surgery? No.

(26:44):

Well, I take that back. If you’ve had a hernia, yes, so much, yes, but if you haven’t had a hernia and it’s a denervation, which is more the most common complication that I see, then it’s very hard to get you back to normal. The operation basically involves what I’ve covered in prior episodes of hernia attack live. When we deal with flank hernias from let’s say spine surgery or vascular surgery or kidney surgery or your nerves are shot, so that nerve is no longer, I’m sorry, that muscle is no longer healthy and because it’s no longer healthy, no amount of suturing or tightening will hold. You have to use mesh and you have to use permanent mesh. So you have to number one, take that weakened muscle that’s bulging and tighten it. We call that plication. And then number two, you have to then support that plication with a permanent synthetic mesh, which I put very widely and I sew it to areas that don’t stretch. So your rib, your hip bone, your ankle ligament and so on. So it’s a big operation. It’s typically done for younger patients. If you don’t operate, then this bulging will get bigger, heavier, more painful, more taught, more deforming and more difficult to repair because the muscle just gets thinner and thinner and thinner and weaker and weaker.

(28:23):

Okay, talking about turtle shape, I’m more around in the front with no shape. Yeah, you lose your waist and your belly starts bulging and it bulges kind of like, it kind of comes to a peak. I dunno how to explain it, but it’s not like a perfect round bulge. It kind of has a peak to it, and that’s because gravity and so on just keeps pushing, pushing forward, forward and your abdominal muscle doesn’t have the strength to push it back against it to hold your intestines in. For example, I’m having issues and feel something popping out from time to time and it’s really painful. I’m going to get it fixed. The surgeon saw denervation, but how do you know the difference between denervation and the hernia is denervation or pre hernia? Those are two different problems. Thank you for asking because I assumed that I was assuming incorrectly that the definition was clear.

(29:21):

So a hernia as a whole through which tissue like intestine can go through that is an actual mechanical problem. It’s a whole, the hole needs to be closed, draped, whatever. Denervation is a functional problem. There is no hole. The bulging may seem like it’s a hernia. It’s actually no. If you get imaging, let’s say a CAT scan, you’ll see there’s muscle or tissue throughout. There’s no hole through which any thing is going through. However, the muscle has been damaged from a functional standpoint. So what does muscle do? You’ve seen when you cough your diaphragm contracts and your belly contracts when you tuck in your belly, you can tuck in your belly and it contracts, but a natural state, your belly has some trigger to it. It has some quality to it. Now if you lose the blood flow to your muscle, not good, but if you lose the nerve to your muscle, much worse because the nutrition to your muscle comes through the nerves.

(30:36):

If your muscle is not being fed by a nerve, it loses all function. You’ve seen people in wheelchairs who are paraplegic, their muscles are like they’re just skin and bones from the waist down. They’re sitting in a wheelchair, they’re paraplegic, let’s say from a bad fall or car accident. They unfortunate situation, but you’ve seen them, their legs are super thin, their muscle is they had some type of nerve injury in their lower back where everything below from their hip and below doesn’t work with those nerves don’t get muscle. Sorry. If those muscles don’t get nerve feeding them, they lose their function. So paraplegic can’t walk and they lose their girth. It’s not because you’re not using your muscles, you literally don’t have nerve feeding the muscles and that’s why it is. So that’s a difference between hernia and denervation. If you get imaging CAT scan being the best, simplest, and you should do the imaging with and without bare down with and without Val Salva, then you’ll see the disparity in bulging when you’re lying flat and pushing out and you’ll see the muscles starting to thin over time. Can you describe what a McVay relaxing incision is? Yes. Let me finish this and we’ll talk about McVay. McVay is in the groin hernia for femoral hernias.

(32:11):

What is denervation? Yes. So denervation means there’s no denervation like De nerve, without a nerve. So I hope that clears it up. Okay, so you’re round in the front with no shape. So rounding in the front is because you’ve lost the ability of the most to and kind of hold your belly in and so you’re like a balloon in the front. Hope that makes sense. And there’s absolutely a treatment. It’s just not an ideal treatment. Okay, going back to the question, can you just, okay, so let’s not do that yet. Another question. So what I bend over and I feel something pushing out where the pain is, but then it goes away. Is that my intestine pushing against the denervated muscle area? It could be the bulging only lasts for a few minutes, but it really hurts. Yes, it absolutely could be. So when you’re bending, you’re increasing your abdominal pressure.

(33:15):

Coughing is the same, and when you’re bending, you’re pushing things out. Now a normal abdominal wall would hold everything in, but if you have an area of weakness because the muscle is weak because it has no nerve to it, that’s a denervation injury. Okay, going back to the McVay question. So McVay procedure is a tissue-based inguinal hernia repair as described by Dr. McVay, I believe he was an American surgeon long time ago, more than a hundred years ago. He came up with this surgery, no mesh. This is before the times. And the beauty of this is it’s not only good for inguinal hernias, but it’s also good for femoral hernias. So this type of operation can be done for inguinal and or femoral hernias. Now it’s very tight surgery. So what you’re doing is you’re sewing your own tissue down towards your bone to use your tissue to cover the hole instead of mesh to cover the hole.

(34:23):

What can happen is that becomes very tight and because it’s tight, we have to loosen it up somewhere else. Call a relaxing incision to reduce the amount of tightness where your sutures are. If we don’t do that and it’s a tight repair, then the McVay incision or closure with the sutures will pull and you’ll get chronic pain and it pulls a lot in tears. You get a hernia recurrence. So to reduce chronic pain and reduce hernia recurrence, we add a relaxing incision. We do it for shoulder dice or bini and all the other tissue repairs as well. And in doing so, we loosen up one place so it’s not as tense at the incision and therefore has less chronic pain and less hernia recurrence.

(35:15):

Is a lipoma in the inguinal canal considered a hernia and is it treated as such or can it be removed with a scalpel? So good question. A lipoma in the angle canal, technically, okay, if it truly is a lipoma, which 99% of them are not, but if it truly is a lipoma that’s just a fatty mass unrelated to anything else that happens to be in the inguinal canal, some people get in their arms or legs that is not a hernia. But when we say lipoma of the cord, inguinal canal lipoma, et cetera, what we really mean, and unfortunately no one has decided to change this term.

(36:02):

And what we really mean is there’s fat that is communicating into the inguinal canal, but it originates further back around the intestines. So if you have fat that should be around your intestines or in the space behind your muscle and that fat has creeped itself into the inguinal canal, then that’s an inal hernia and we call that cord lipoma or spermatic cord lipoma or lipoma of the inguinal canal. So yes, technically that is a hernia. Now does it need to be addressed? No more than any other hernia needs to be addressed. And then the question is, what do you do if you’ve already had a hernia repair and you still have that lipoma? Well, a lot of times that can either cause bulging or pain or both and therefore cutting it out is a possibility. I was just diagnosed with a ventral wall hernia complex.

(37:07):

I’m pretty nervous status post 2007 TRAM flap. Alright. Yeah. So 2007 is when we were doing these TRAM flaps. We’ve transitioned to a DIEP flap right around that time, more less TRAM flaps were done and more DIEP flaps were done mostly to prevent these complicated abdominal wall hernias and the ability of having this kind of reconstruction. But first the question is, is your hernia related to the TRAM flap or do you just have a hernia? I mean people can have hernias. It doesn’t have to be from the TRAM flap if it’s from the TREM flap. The question is did you have a one-sided TRAM flap or a bilateral two-sided TRAM flap and then was this a pedicle flap or was this a free flap? So if it was a one or two-sided free flap and it’s usually from a lower abdomen, then it’s a very complicated reconstruction.

(38:15):

You cannot be overweight, you must lose weight all the way down as close to your ideal weight as possible and you must use mesh because you don’t really have tissue to help reconstruct that abdominal wall. I have several questions on being an ALT flap thigh to hypogastric region and can issues in this area cause sexual problems off topic, but about phasix mesh, your barrier called amnio fix also, your sentiments or any sprays or sheets that could alter adhesion? Okay, a lot of questions, but going back to the beginning of the hour, I said we talk about flaps not just for breast reconstruction but for reconstruction of any area that needs tissue coverage. So if you were, let’s say in a bad motorcycle accident and you shear it off muscle and skin from your leg or you broke some leg, you have a broken bone and that caused a lot of damage to the muscle, then you can get flops from one part of the body used to cover the other part of the body.

(39:35):

So if this is a flap that’s used from the thigh to the hypogastric region, then it should not cause. So none of these should be causing sexual dysfunction. If you do have sexual dysfunction, it’s either unrelated or you’re having pain in the area or a hernia in the area and that hernia is indirectly causing you to have sexual dysfunction because of the pain, not because you functionally can’t do it. And then phasix mesh, we interestingly, we actually talked about phasic mesh in the OR today that’s what we call a synthetic absorbable mesh. It’s becoming very popular. I’m not a fan of it currently and I don’t use it. I did enroll patients in their clinical trial, but it’s in my mind a very highly inflammatory mesh. The patients that I’ve seen have it placed do have a lot of inflammation from it, and there are patients out there that need it removed.

(40:43):

As a result, it’s supposed to be gone in about 18 months. I’ve been in abdominal areas where two or three years later the mesh is still there. So it seems to be more synthetic than people believe. It acts more like a synthetic than an absorbable. What are your thoughts of having laparoscopic hernia repair? Okay, so laparoscopic hernia repair in general is a great idea. It is not a good idea. I don’t believe for DIEP or TRAM flap denervation because it doesn’t address a problem. You’re treating a derivation, which is a functional weakness of the muscle causing a bulge as if it’s a mechanical problem. It’s a functional problem, but you’re treating it like a mechanical problem and you are putting mesh in it so it doesn’t work. You need to do an open procedure unfortunately. Now the issue that I want to also address with that is that’s my train of thought.

(41:53):

Oh, I was going to give you an analogy. Why not? So what you need to do, it’s kind of like construction, right? So if you have construction, and let’s say you have a wall that’s falling apart, right? Let’s say you have some type of wall, like a brick wall and it’s bowing out and about to collapse. So one way you can do is just put, I don’t know, some trees in front of it. I mean that doesn’t change the fact that you have a wall that’s falling and doesn’t give you any support either. That’s a horrible analogy by the way. I define with a better analogy. Shoot, what’s a good analogy for a hernia versus denervation of the muscle where the nerve to the muscle is injured from let’s say a deep or TRAM flap or DIEP flap I should say.

(42:54):

Well, the best way I think is a functional versus a mechanical problem. I hope that’s helpful. Okay, another question. Oops, where is the McVay incision made into? Which muscle is the incision made? Does it predispose to another hernia where incision is made? No, it doesn’t predispose you to any other hernia. The McVay incision is for inguinal hernia or femoral hernias. So the incision is made in the inguinal or femoral region, basically the lower abdomen and the groin area. So it’s like any other open groin tissue repair, let’s say couple finger breasts above your groin crease is usually where the incision is made. So that’s kind of my discussion about it. I try and talk to my plastic surgery friends. I had a laparoscopic TAR procedure that’s beginning to fail. Yeah, I’ve seen people provide a TAR for these. It is the wrong operation in my mind.

(44:04):

It is not addressing your problem. You have patients with a bulging abdomen that are getting a TAR. A tar is a TAR transversus abdominis release. First of all, you don’t need any releases of any muscles. The last thing you want is more potential for disrupting the abdominal wall. The tar itself, if not done correctly, can cause denervation injury. Why? Because it’s operating in the same plane that the plastic surgeon went to get the blood vessels for your DIEP flap. So they’re the ones already injured, the nerve, the TAR, you can injure it even more because now you’re working in a bigger area. So to do a TAR for a DIEP flap and sorry about all these acronyms, but that’s just the way you’re to do a TAR, which is the type of hernia repair for a DIEP flap, which is the type of breast reconstruction.

(45:07):

Usually tissue problem means you don’t understand what was done, surgery was done and is now has a functional problem. The muscle function is not there. There’s no hole. So to try and close tissue and just lay some mesh in there hoping it’ll stick, won’t stick. Why? Because the muscle itself is not healthy. So putting mesh against it is not going to help. Then what you need to do is actually tighten the muscle, which you don’t do with a TAR. You don’t tighten the muscle, you just close a hole and you actually loosen the muscle. It’s actually the wrong thing because you’re loosening muscle. You need to tighten it. So you may feel fine initially because they start sewing and closing things, but because the overlying where the meshes the overlying muscle to it is not healthy, the mesh is just going to fall into this unhealthy hole.

(46:17):

So when you stand up instead of the mesh acting like a wall, which is what the plan should be with these TARs, what you’re doing when you’re standing is the messages is going to fall into this loosened, weakened muscle from the nerve injury, from the DIEP flap procedure. So laparoscopic surgery, a tar, those are all operations that do not address the problem. It just complicates things. Now you have mesh in you and a space and blah, and now they’ve loosened you up even more and that’s just not cool. Also, this whole idea about the Turkey abdomen or no, not Turkey. What’d you say?

(47:15):

What did you call it? Not Turkey frog, toad. Turtle. Turtle, turtle, okay. This idea, a turtle belly is also true when you do a tar. So when you do a tar, a lot of people, they lose their thank you turtle, they lose their abdominal kind of contour and they become more like a square instead of a flat belly. They have a square belly. So they start bulging a little bit more to the sides and not as much in the middle. And so they kind of get a square look. For women, it’s not a good look. I don’t know if men care, but for women it’s not a good look. And so a lot of these abdominal wall operations, I don’t want to piss off the males, but I feel like these men, they come up with these ideas, which is great, but they don’t understand the, I shouldn’t say men, I should they surgeons.

(48:23):

I feel like these surgeons come up with these ideas as a general surgeon let’s say, but they’ve never operated with or been in the same room as a plastic surgeon. And then what they do is they do this great idea, yeah, we get to close the hole, but look at the belly. Like these women, they end up looking really not that good. So yes, it was minimally invasive and you have three little four little scars, but they don’t look good. Now if you’re morbidly obese and the cont of your abdomen is not as obvious after these operations, then doing a minimally invasive operation is great. But if you are doing a tar in a relatively thin person, what you end up doing is you’re basically releasing the inner girdle. And if you release the inner girdle, you end up getting a tabletop, like a square look to you.

(49:20):

Can that be fixed? Yeah, it can be fixed. Depends on what was done exactly. But you’re square. Yes. That’s what I’m saying. You’re square. And I say this in the meetings and initially everyone thinks I’m the crazy one and then now they’re admitting that yeah, they do kind look square and I mean it’s not that much of a big deal, but I think it’s a big deal. I don’t think you should look square after her repair when you have the option of looking beautiful and flat like a plastic surgery tummy tuck type look, thank you for your wealth of knowledge. But instead of phasix, what would you use? Thanks again. Last question, I promise.

(50:08):

So yeah, there’s a lot of things besides phasix. There’s tons of meshes available out there. Phasix is one of them. Phasix is a synthetic absorbable. There’s synthetic non-absorbable and there’s absorbable synthetics. So there’s a lot of mesh options. Depends on the patient and where you plan you had a TAR. I mean what kind of procedure can be done after a tar? Depends on what your needs are. If your need is to close to address the bulging, that’s one thing. That’s one type of procedure. If the problem is on the sides, if the bulging is in the middle still, then you need a plication. And then on top of the plication get a very wide, what we call onlay mesh. And again, that mesh needs to be secured to areas that are a healthy no more, not only to the unhealthy muscle, very wide overlap and needs to be go to let’s say your bone, your pubic bone, your hip bone and ribs and all that. It’s a big, big operation. Did you have a tar? I thought that’s what you said. I thought you mentioned earlier that you had a tar, but I have seen multiple doctor surgeons present patients that have had nerve damage from a deep flap causing bulging and they use the tar procedure TAR, transversus abdominis release with mesh, which is a hernia repair. It doesn’t address her for that problem, which to me means they don’t understand what was done and what the problem is.

(52:05):

Okay, more questions. What does the Vincera Institute and Dr. Myer mean by dissecting intimate fascia of the rectus muscle in order to bring it down to the pubic plate without tension as part of their sports hernia repair use on patients such as Damien Lillard? Okay, so this is for patients who have rectus adominis disruption. So they’ve basically, like Damien Lillard I think is a basketball player when they have avulsion of the rectus muscle off of the bone or chronic pain because they’ve been tearing it for so much time, they then disconnect the scarring of the rectus muscle to the pubic bone and then they bring down, disconnect the fascia from the muscle and they bring down the muscle to take some tension off of that fascia. I don’t know if you can explain it. It’s complicated, which is why I don’t do those operations. Vincera Institute are the specialists for it. So very complicated series of operations.

(53:27):

Okay, that was pretty intense. A lot of questions and I hope it all made sense. DIEP flap, TRAM flap latisis dorsi side flap thigh flaps, et cetera. I’ve been told there’s a lack of blood supply to my abdomen and I have a high risk of chronic infection and open wound if a repair is done, is it possible to restore blood to the area? So hopefully you’re not using nicotine and you have good oxygenation. The question is can you restore blood flow? So it’s unclear why you have lack of blood flow, but there are ways to help improve it during surgery and after surgery. And if you’ve had a lot of operations areas where there should be blood flow are replaced by scar and that can be part of the problem. What’s your thought on ovatex mesh? I’m a fan of ovatex mesh. I feel it’s a very high quality biologic mesh. I just put one in today in a patient with a mesh infection. The ovatex mesh works really well in those settings. Thanks again following you from Paris. So thank you for following me in Paris. I’ll be there. I’m usually there every year. I have.

(54:58):

So I am a godmother to two beautiful little girls in Paris, so I get to go there every year and do my godmother duties. So thank you for joining us from Paris. I love it. Okay, so that’s all I have for you. I will be back next week. Know that a couple of weeks. It’s the European Hernia Society meeting. I will be in Prague, Czech Republic. Every time I go to these meetings, do know that I live tweet from those. So do follow me on Twitter at or x at Hernia doc and all of these episodes, as you know, catch ’em on YouTube. Or if you like podcasts, download the podcast. It’s really great. You listen to it on the train on your ride home or ride to work wherever you like. So that’s really it. I don’t have much more to add. I would like to thank you all for an amazing session. So join me next week. I will be there. I’ll be here hopefully with a little bit more hydration and a little bit more food. Don’t forget synergy syn. I got the initial one. It has vanilla coconut. It’s pretty, pretty good. All right, I’m going to eat. Have you go on to another event. Still no food. Who’s going to have to do? See you guys. Bye.