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Singh et al. Plast Aesthet Res 2020;7:39 I http://dx.doi.org/10.20517/2347-9264.2019.76 Page 7 of 13

for transplantation. Performing panniculectomy in advance will allow patients to be better optimized for
transplantation and allow them to heal without the influence of immunosuppression. However, this staged
approach may add cost relative to simultaneous panniculectomy and transplant. It should be acknowledged
that, while the pre-transplant panniculectomy patients are often not pharmacologically immunosuppressed,
they are still relatively immunosuppressed due to their end-stage organ dysfunction.

[15]
Ngaage et al. discussed panniculectomy at the time of living donor renal transplantation. In their study,
panniculectomy was performed prior to standard oblique muscle cutting incisions such as a Gibson or
Rutherford-Morison incision for transplantation. Among 58 patients with an average BMI of 35.2 who
underwent simultaneous panniculectomy and renal transplant, the authors noted comparable rates of
wound complications when compared to panniculectomy without transplant. Furthermore, there was no
significant difference in allograft complications compared to the standard two-staged procedure, nor was
[15]
there a significant difference in length of hospital stay .
[15]
In the single-stage operation by Ngaage et al. , the reconstructive surgeon mobilizes, undermines, and
reflects the redundant soft tissue, exposing entirely the underlying fascia. This exposure provides access to
the abdominal fascia and then facilitates closure of the defect. Simultaneous panniculectomy appears to
be performed without a significant increase in wound healing morbidity even though these single-stage
[15]
patients must face the challenge of healing after induction and maintenance of immunosuppression . It
is noteworthy that the study by Ngaage et al. did not have homogeneous immunosuppressive regimens,
[15]
which may have skewed the interpretation of wound complication rates.

Use of mesh in post-transplant incisional hernia repair
The optimal type of mesh to use in hernia repair - and hernia prevention - is widely debated. However,
there has recently been a greater shift towards the use of biologic mesh over synthetic mesh. Biological
materials such as human acellular dermal matrix (HADM) and porcine acellular dermal matrix (PADM)
have multiple advantages over their synthetic counterparts. Biologic mesh provides a scaffold that allows
cellular and vascular ingrowth, thus benefitting from possible incorporation into native abdominal
[9]
wall tissue . The vascularization of acellular dermal matrix (ADM) assists the immune system in
combating bacterial contamination. Furthermore, ADM has low antigenic potential and elicits a milder
host inflammatory response compared to synthetic mesh. This allows for a less adhesiogenic environment
[16]
in comparison to prosthetic mesh, making ADM desirable for intraperitoneal use . ADM also contains
[16]
collagen cross-linkages, which provide strength and resistance to mechanical stress . Among popular
acellular dermal matrices (AlloDerm, FlexHD, Strattice, Neoform, and DermACELL), AlloDerm (a HADM)
[17]
has been shown to be more effective against bacterial growth. This was supported by Fahrenbach et al.
who showed that AlloDerm was resistant to penetration with S. aureus and S. pyogenes. However, AlloDerm
contains more elastin than its porcine equivalent; thus, it is more prone to stretching and can lead to
recurrence, bulging and weakness when used in the abdominal wall. Generally speaking, non-crosslinked
17
porcine ADM has been found to be beneficial in higher risk patients, including the transplant population.

Multiple studies have shown that mesh implantation during incisional hernia repair can decrease the risk
[2,5]
of hernia recurrence without increasing risk for infection in the transplant population .A study published
by our group compared clinical outcomes of incisional hernia repair in 87 patients receiving solid organ
transplants in which PADM, HADM, or synthetic mesh was utilized. We found that patients whose
hernias were repaired using synthetic mesh had a significantly higher incidence of wound infection, hernia
[1]
recurrence, and mesh removal . Another study observing 104 patients undergoing renal, liver, or pancreas
transplants had a statistically significant odds ratio of 11 and 8.7, respectively, for wound infection and
mesh removal when comparing HADM with synthetic mesh . It is important to note that neither of these
[18]
studies was blinded, therefore inherent selection bias is possible in both.