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O’Connor et al. Plast Aesthet Res 2019;6:26 I http://dx.doi.org/10.20517/2347-9264.2019.38 Page 7 of 9

no substitute for good technique when closing the linea alba, utilizing small bites and adequate myofascial
[40]
release to bring the midline together with minimal tension . Mesh fracture has also been associated with
SSI, which weakens the fascial layers and in turn places mechanical stress on the mesh. Mesh fixation with
sutures, staples, and tacks has not been associated with fracture, although this was previously thought to
be a possible source. Failures around the mesh are most commonly found at the site of transfascial fixation
sutures, which pull through and weaken the abdominal wall, or due to inadequate mesh-tissue overlap in
all directions.

[24]
Maloney et al. reviewed a large hernia database to determine risk factors for recurrence after component
separations. There was a higher risk of SSO with ACS leading to a higher overall recurrence rate; however,
on univariate analysis, there was no difference between anterior and posterior component separations, and
no association with smoking status, steroid use, diabetes, or peripheral vascular disease. There was, however,
an association with BMI greater than 35, use of absorbable mesh, SSO, SSI, and failure to close the fascia.
The exact effect of BMI on recurrence after hernia repair is difficult to ascertain due to heterogeneity in
[41]
the literature, although an increase in hernia recurrence has consistently been found with BMI > 30-35 .
Interestingly, recurrence was not associated with the size of the defect as long as the fascia was closed,
reinforcing the importance of adequate myofascial release and midline closure technique.

Unfortunately, recurrent hernia itself is a risk factor for recurrence of subsequent repairs, meaning that
many patients enter a vicious cycle of multiple failed repairs. The risks of complete mesh excision can be
significant, often requiring extensive lysis of adhesions with risk of bowel injury. In addition, if the mesh
is well incorporated, there is a risk of destruction of the native abdominal wall components, making
[35]
subsequent repairs more difficult. In the aforementioned review of the AHSQC database, Kao et al. also
compared partial vs. complete mesh excision in clean cases such as excision for pain or recurrent hernia.
In these cases, there was no difference in SSO, SSI, SSOPI, or reoperation in patients who only underwent
partial excision of the mesh. This suggests that, in the case of small recurrence without any infection, it
is reasonable to repair the hernia without complete excision of previous mesh. If the recurrent defect is
through the mesh, primary repair should be performed with permanent suture bites through the previous
mesh to reestablish its continuity. Defects above or lateral to the mesh can be repaired with underlay or
sublay technique either laparoscopically or open. Mesh fractures larger than 2 cm should be treated with
explantation and repeat repair with permanent mesh to prevent layering of mesh in the abdominal wall.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: O’Connor SC, Carbonell AM

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Sean C. O’Connor, M.D. has no disclosures. Alfredo M. Carbonell, D.O. has received honoraria from W.L.
Gore and Associates, Ethicon Inc. and Intuitive.

Ethical approval and consent to participate
Not applicable.