COSMETIC

Concomitant Abdominoplasty and Umbilical

Hernia Repair Using the Ventralex Hernia Patch
Ryan M. Neinstein, M.D.
Alan Matarasso, M.D.
David L. Abramson, M.D.
New York and Great Neck, N.Y.; and
Englewood, N.J.
Background: Patients requesting abdominoplasty often have concomitant um-
bilical hernias and may request simultaneous treatment. The vascularity of
the umbilicus is potentially at risk during these combined procedures. In this
study, the authors present a technique for treating umbilical hernias at the
time of abdominoplasty surgery using the Ventralex hernia patch.
Methods: A total of 11 female patients with a mean age of 39.4 years (range,
28 to 51 years) undergoing abdominoplasty with umbilical hernia repair with
the Ventralex patch were included.
Results: The mean body mass index was 27.6 kg/m2 (range, 20 to 34 kg/m2).
No vascular compromise of the umbilicus was seen. The hernia repair did not
alter the abdominoplasty results. One patient had transient umbilical swelling
postoperatively that resolved within 6 months postoperatively.
Conclusion: The authors present a series of umbilical hernia repairs in ab-
dominoplasty patients using a minimal access incision by means of the rectus
fascia and the Ventralex patch that is fast and reliable and preserves the blood
supply to the umbilicus.  (Plast. Reconstr. Surg. 135: 1021, 2015.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

U
mbilical hernias are relatively common
findings, particularly in the postpartum
patient seeking abdominal contouring sur-
gery. Patients may be unaware of their presence or
they may consider them to be an unsightly “outie”
belly button.1 The concern over appearance of
the umbilicus and the implications of a hernia
may cause the patient to request simultaneous
repair during consultation. The exact incidence
in which hernias would resolve with abdomino-
plasty alone is unknown.
The umbilicus is located at the midline at the
level of the iliac crest. It can be displaced superiorly
by pregnancy and inferiorly by ascites (Tanyol sign).2
The fascial opening or umbilical ring at the base of
the umbilicus exists to allow passage of the umbilical
vessels from mother to fetus. After birth, the opening
From private practice; Manhattan Eye, Ear, and Throat
Hospital, North Shore Long Island Jewish Health System;
Lenox Hill Hospital; Mount Sinai School of Medicine; and
the Department of Plastic Surgery, Englewood Hospital and
Medical Center.
Received for publication February 21, 2014; accepted July
28, 2014.
Presented at the 41st Annual Meeting of the Canadian
Society for Aesthetic Plastic Surgery, in Toronto, Ontario,
Canada, September 19 through 20, 2014.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001135
closes spontaneously as the rectus abdominis mus-
cles grow toward each other. Complete peritoneal
and fascial layer fusion is complete in 85 to 90 per-
cent of children by 5 years of age.3 Umbilical hernias
in adults are acquired. They have a 3:1 incident ratio
in women compared with men, regardless of race.
These hernias are associated with increased intraab-
dominal pressure caused by obesity, abdominal dis-
tention, liver cirrhosis, ascites, and pregnancy.4
When patients present for abdominal contour-
ing surgery, assessing the umbilicus for abnormali-
ties is a component of the physical examination.
Patients may have a protuberance caused by a
hernia, or bulge above, below, or to the side of
the umbilicus. Patients may state that they have
an outie belly button, which is usually caused by
the presence of a hernia. These are typically not
tender without provocation. Preoperative imag-
ing and general surgery consultation can be orga-
nized at the discretion of the surgeon.
Treatment for symptomatic umbilical hernias is
surgical. There are many different approaches and
techniques described for abdominal hernia repairs.
Disclosure: The authors have no conflicts of inter-
est and no funding was provided for the preparation
of this article. The authors have no financial interest
in the patch mentioned in this article.

www.PRSJournal.com 1021

In the classic open repair, after supraumbilical skin
incision, a vertical or curvilinear incision is made over
the sac, and the dissection is carried down until the
sac is identified. The sac is then dissected to its fas-
cial attachments. Once the fascia has been cleared,
the hernia sac is either inverted and the fascia closed
with nonabsorbable suture or the sac is excised and
the fascia is then closed.5 Increasing evidence sug-
gests that the use of prosthetic mesh should be the
preferred method of hernia repair, because recur-
rence rates after primary herniorrhaphy are high. In
a recent prospective, randomized, controlled trial,
the recurrence rate after primary open repair was
11 percent compared with 1 percent in mesh repair
with a mean follow-up of 64 months.6
The ideal mesh material is durable, easy to
handle, and resistant to infection; would adhere
to the abdominal wall but not to bowel; and would
resist an inflammatory response.7 Meshes can be
divided into biological and synthetic. Biological
meshes are typically reserved for contaminated
or infected wounds.8 Synthetic meshes are either
woven monofilaments or those with expanded
polytetrafluoroethylene. Adhesions are lower with
expanded polytetrafluoroethylene; however, the
grafts are susceptible to a higher rate of infection.
During abdominoplasty surgery, the umbilicus
is traditionally circumscribed to free it from the sur-
rounding skin. Thus, if traditional techniques for her-
nia repair are used, the sole remaining blood supply
to the umbilicus by means of its stalk is interrupted
and umbilical ischemia or necrosis may ensue. This
has led surgeons to consider staging repair or avoid-
ing repair during an abdominoplasty. Some hernias
appear to be improved or ameliorated with plica-
tion of the rectus diastasis during abdominoplasty.
Recently, a midline infraumbilical incision through
the linea alba was described as a technique for repair-
ing umbilical hernias during abdominoplasty.9 We
present a technique of umbilical hernia repair that
spares long intraabdominal incisions and also incor-
porates the Ventralex hernia patch (C. R. Bard, Inc.,
Covington, Ga.) (Fig. 1). The patch is a composite
expanded polytetrafluoroethylene/polypropylene
mesh. Polypropylene allows tissue ingrowth and thus
incorporation of the patch into the abdominal wall.
The expanded polytetrafluoroethylene side is placed
in contact with the abdominal viscera and minimizes
adhesion. Two polypropylene straps facilitate place-
ment, positioning, and fixation (Fig. 1).10
PATIENTS AND METHODS
A series of 11 healthy American Society of
Anesthesiologists class 1 female patients (>18 years
1022
Plastic and Reconstructive Surgery • April 2015
Fig. 1. Ventralex hernia patch.
of age) undergoing abdominoplasty with umbili-
cal hernia repair with the Ventralex patch were
included. The mean age of the patients was 39.4
years (range, 28 to 51 years). The mean body mass
index was 27.6 kg/m2 (range, 20 to 34 kg/m2). All
patients were postpartum, with no stated desire
for future pregnancies. The surgical technique
and size of the patch were recorded. Patients were
followed up to 1 year postoperatively and all com-
plications were recorded.
Surgical Technique
The senior authors (A.M. and D.L.A.) use dif-
ferent abdominoplasty techniques. One senior
author (A.M.) premarks the abdominal pannus to
be excised with the patient in the standing and sit-
ting positions. We have incorporated a bendable
ruler (Staedtler Mars GmbH & Co. KG., Nurem-
berg, Germany) that maintains its memory, which
allows for a mirrored ellipse to be easily drawn on
both sides of the umbilicus. This supplements our
preoperative markings. Superwet liposuction of the
flanks and abdomen is performed as indicated. The
abdominoplasty proceeds by circumscribing and
freeing the umbilicus. The pannus is then prepared
for preexcision in a vest-over-pants fashion. This
maneuver is accomplished by incising the upper
limb of the ellipse to the level of the rectus fascia
while beveling the cut inward at a 45-degree angle.
The upper abdominal flap is then undermined in
a narrow tunnel resembling an inverted V, preserv-
ing the lateral intercostal blood supply and possibly
the predominant Huger zone 1 blood supply. Dis-
section is performed by scalpel and electrocautery.
Huger11 zone 2 is undermined discontinuously with
liposuction. The operating room table is flexed
and the upper skin flap is pulled over the pannus
to the proposed lower skin marking to verify that it
Volume 135, Number 4 • Ventralex Hernia Patch

reaches the lower skin incision line. The lower skin

incision is then made and the pannus is excised en
bloc from side-to-side. The rectus muscle diastasis
is marked with ink in a long vertical ellipse from
xiphoid to pubis. The section above and below the
umbilicus is closed with a running 0 looped nylon
suture (Johnson & Johnson, Inc., New Brunswick,
N.J.). Additional layers of buried interrupted 2-0
Nurolon (Johnson & Johnson) sutures are used.
Final lower abdominal skin closure is performed in
two layers (2-0 polydioxanone, then 3-0 polydioxa-
none) with absorbable barbed sutures (Quill SRS;
Angiotech, Inc., Vancouver, British Columbia, Can-
ada). Drains and abdominal binders are placed.12,13
The other senior author (D.L.A.) does not precut
the abdominal pannus on its superior margin and
performs minimal liposuction of the abdominal
flap and flanks. He uses a barbed nonabsorbable
suture for rectus plication.
Mesh Insertion
Various approaches to the umbilical hernia
have been used. In the majority of cases, the defect
was exposed using an approach from the side of
the umbilicus (Fig. 2). The hernia was dissected
and divided. The contents of the sac are then
reduced into the abdomen. The patch is folded
in half and held in position with a clamp. It is
important to ensure that the expanded polytetra-
fluoroethylene is facing out. The patch is placed
intraperitoneally (Fig. 3). The memory technology
allowed it to open and lie flat against the abdomi-
nal wall (Fig. 4). The two polypropylene position-
ing straps are then sutured onto the margin of the
defect with an interrupted 2-0 absorbable braided
suture. In one patient, a patch fixation technique
was used.10 The mesh is sutured to the fascia at the
3-, 6-, 9-, and 12-o’clock positions. Alternatively, the
Fig. 3. Intraoperative view showing the technique for insetting
the mesh, ensuring that the expanded polytetrafluoroethylene
side is facing externally. The straps are than pulled vertically and
fixed to the defect edge.
patch can be inserted from a peri-umbilical inci-
sion prior to commencing the abdominoplasty.
RESULTS
Patches come in various sizes. All of our patients
had medium size patches placed (6.4 × 6.4 cm).
The hernia approach was the same in all patients.
The hernia repair did not affect the results of the
abdominoplasties. One patient had a four-point
patch fixation technique. All others had the straps
of the mesh fixed to the defect edge. There was
no incidence of umbilical ischemia or necrosis.
No patients had clinical evidence of hernia recur-
rence. One patient had transient swelling of the
umbilicus that resolved within 6 months of surgery.
Ultrasound of the area showed soft-tissue swelling
but no evidence of recurrence. All patients stated
that they were pleased with the aesthetics of their
umbilicus postoperatively along with their abdomi-
noplasty (Fig. 5). We noted that in some cases the

Fig. 2. Intraoperative view showing a lateral approach to the

umbilical hernia sac, with the umbilical stalk intact. A plastic Fig. 4. Intraoperative view after hernia repair and mesh fixation. The
button is sewn to the top of the umbilicus.  rectus muscle diastasis has been repaired with a two-layer plication.

1023

Fig. 5. Before and after pictures of two women undergoing umbilical hernia repair with the Ventralex hernia patch in conjunction
with abdominoplasty (patients of D.L.A.).
patch caused less mobility of the umbilical stalk,
resulting in tethering of the stalk.
DISCUSSION
Combining umbilical hernia repair with
abdominoplasty can potentially lead to vascular
compromise of the umbilical stalk.14–16 In some
circumstances, plication of the rectus diastasis
may be enough to ameliorate the appearance of
the hernia. Supplementing the plication with a
components separation technique17 may decrease
the recurrence rate of hernias.18
The Ventralex patch has been shown to be
a viable long-term option for midline ventral
hernia repairs. In one study of 51 patients, only
one recurrence and three minor wound compli-
cations were observed at 1 month.10 A prospec-
tive study of 101 patients showed recurrence and
complication rates of only 2 percent at a mean
follow-up of 28.5 months.19 Interestingly, in cases
of reoperation, the device has been found to
become stiff, shrunken in size, and sometimes
flipped.20 It has been thought that the patch fixa-
tion technique may reduce long-term recurrence.
1024
Plastic and Reconstructive Surgery • April 2015
Conceptually, when the straps are pulled tightly,
the patch may “potato chip curl,” exposing the
layer that is meant for adhesion.21 This phenome-
non was not found in this study. One patient who
experienced persistent swelling had the fixation
technique implemented.
This study is limited by the small sample size
and a 1-year follow up. The advantages of this tech-
nique are its simplicity and effectiveness in hernia
repair while preserving the umbilical blood sup-
ply. The mesh has an average cost of $800.
CONCLUSIONS
Umbilical hernias can be seen in patients con-
sidering abdominoplasty surgery. The primary
concern for the surgeon is the potential for vascu-
lar compromise during simultaneous hernia and
abdominoplasty surgery. We report a method of
concomitant hernia repair and abdominoplasty
using the Ventralex hernia patch.
David L. Abramson, M.D.
42A East 74th Street
New York, N.Y. 10021
plasticsurgerydoc@yahoo.com
Volume 135, Number 4 • Ventralex Hernia Patch
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