When doing a tummy tuck, known as abdominoplasty, one of the best parts of the surgery is when I corset the abdominal muscles back together.
How do we fix the muscles? We don’t actually sew the muscles. What we sew is the covering over the muscles called fascia. We are fixing the diastasis, which is a fancy term for the separation of the rectus abdominis muscle, your “six pack” muscle, which always separates with pregnancy. How much diastasis you have varies from person to person—how tall are you? how many pregnancies did you have? how big did you get? how strong was your core before? etc.
The whole idea for this blog came from a current patient. She is in some mommy blog chat room, and people are peppering her with questions about her tummy tuck. And a big question that keeps recurring is “Does your doctor use mesh?” For me, that answer is almost always no. Then she asked why not?
Fixing the abdominal muscles is a key part in your result after a tummy tuck. Not only does it help give you back a defined waistline, but it also helps with the integrity of your core, and it is the muscle repair which likely is the cause of improving issues with low back pain or urinary incontinence.
When doing the muscle repair, all plastic surgeons do not do it the same way. In my own practice, how I do the muscle repair evolved, and I am happy with the technique I now use. How surgeons differ:
- How many layers of repair? (I do two.)
- What type of suture? Permanent or dissolving? (I use permanent)
- Interrupted or running? (I used to do one layer interrupted, and one layer running, but I stopped doing a running suture and converted to doing two layers of interrupted sutures because if one part of a running suture loosens, the whole thing loosens. Think of it as interrupted sutures =buttons vs. a zipper = a running suture. If your zipper busts, the whole thing unzips. If a button busts, the other buttons are still intact and holding. )
- Do you use mesh? (I have done so rarely- I only use if the integrity of the tissue is poor, so it can’t hold my sutures. In that case, I use mesh just like you would use backing when sewing tulle- it keeps the stitches from ripping through the tissue.)
So why don’t I love to use mesh?
I did a PubMed search on mesh to see what the current scientific literature is out there. Most of the articles were discussing the difference between artificial mesh and biologic mesh (cadaver dermis) and when they used mesh (usually large diastasis or ventral hernias). This is an area where there is not a clear consensus on what people do. Biologic mesh disappears over time, as it is converted essentially into scar tissue. There is some thought that Biologic mesh loses its reinforcement strength over time.
- What is the pro of using mesh? Well, if your tissue stretched with pregnancy and didn’t bounce back, the tissue likely has some weakness. The mesh adds an extra layer of oomph to the tissue to help it hold its tightening and closure.
- What is the con of using mesh? Mesh is a foreign object. It can encapsulate, get infected, cause a seroma (a collection of fluid), cause fistulas (little tunnel connections to other areas). It adds cost to the procedure. In super thin patients, there is a risk the mesh could be visible.
The biggest reason I don’t use mesh simply is I haven’t found I need to. I looked at my numbers recently of tummy tucks and have done a significant number of tummy tucks. I have operated on tall and short, fat and skinny, blown out and not so blown out bellies. I have not needed mesh. I get strong closures of the muscle. Perhaps it is technique- I spend a lot of time closing the muscle fascia. I do tons of interrupted sutures and two layers of them, going from the pubic bone up to the rib cage. I think many points of closure is key. I subscribe to simple physics- the more points of contact, the less stress on any given point. Imagine you have a shirt with two layers of buttons spaced super close together. You now try to rip open the shirt. You are more likely to rip the fabric than the buttons. If I found the tissue was not able to hold sutures, I would use mesh. That issue though is super rare.
Also in general I am a fan of natural. For facial volume loss I like fat transfer—replace what you lost with your own fat. I don’t like to put in chin and cheek implants. I avoid foreign objects when I can. They can have all sorts of issues—infection, rejection, encapsulation, seroma. They add cost. They add another layer of something that can go awry.
If I needed the mesh, I would understand its use. But after doing hundreds and hundreds of these cases, my experience is I am regularly able to get strong closures without it. If your surgeon is using it, I guess I would ask why? And what issues have they seen? I have been in practice for 20 years now. If there were long term issues of not using mesh for my diastasis repairs, I would think I would have seen and heard from my patients about it by now.