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Page 2 of 9 Alimi et al. Plast Aesthet Res 2020;7:5 I http://dx.doi.org/10.20517/2347-9264.2019.39

Figure 1. Abdominal wall demonstrating mesh planes

[2]
approximately 348,000 hernia repairs were performed in the United States in 2006 . Ventral hernias are
an encapsulating term referring to anterior abdominal wall hernias that include the following: epigastric,
umbilical, spigelian, parastomal, and most incisional hernias. In the United States alone, over 3.4 billion
[1]
dollars are spent on the management of hernias . The standard approach to ventral hernia repair and the
realm of abdominal wall reconstruction is that of repair of the fascial defect with reinforcement of the
abdominal wall with mesh. There are many facets to the completion of a ventral hernia repair, including
approach to repair, mesh type selection, and mesh plane selection. The approach to the repair can be
completed open or through minimally invasive techniques. Presently, minimally invasive techniques utilize
both laparoscopic and/or robotic platforms. The selection of the mesh can be that of a prosthetic or biologic
variety. Finally, the location in which the selected mesh is placed is crucial to the integrity of the repair. The
focus of this review is the latter of these three facets: the choice of mesh and the anatomic location of mesh.

MESH LOCATION
The ideal anatomic location for mesh placement during the repair of ventral hernias or abdominal wall
reconstruction has been debated; however, the most common anatomic locations include: onlay, inlay,
sublay-retromuscular, sublay-preperitoneal, and sublay-intraperitoneal [Figure 1]. Numerous single-
institution studies, reviews, and meta-analysis have been completed on this topic, still without clear
consensus on the ideal location of mesh. The anatomic location of the mesh has an influence on how the
mesh is incorporated with the tissues, the tensile strength of the repair and the abdominal wall, and finally
[3]
the immune reaction between the mesh and the tissue . We strive to summarize the advantages and
limitations of these locations to make an argument for the ideal mesh plane for ventral hernia repair in
abdominal wall reconstruction.

Onlay mesh placement is the placement of mesh on the anterior fascia and is sometimes referred to as a
[4]
premuscular location of mesh . This technique, popularized by Chevrel in 1979, is typically approached in
an open fashion with the placement of mesh over the anterior fascia following closure of the fascial defect.
The key tenets of this approach include the reapproximation of the linea alba and fixation of mesh to the
anterior fascia, which requires the creation of lipocutaneous flaps and the sacrifice of the periumbilical
umbilical perforator vessels. The key to the onlay mesh is based on Chevrel’s exploration of human cadavers
anterior and posterior rectus sheaths. In his 1997 study on cadaveric specimen, Chevrel describes the burst
strength of the anterior rectus sheath above the arcuate line to be the strongest portion of the abdominal
wall which forms the basis for the onlay approach. He suggests that the strongest reinforcement for the
abdominal wall is the combination of the native strength of the anterior rectus sheath in combination with
[5]
the strength of polypropylene mesh .