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Page 4 of 14 Knapp et al. Plast Aesthet Res 2020;7:7 I http://dx.doi.org/10.20517/2347-9264.2019.69

Weight loss counseling should be a routine component of preoperative visits for those patients with BMI > 35.
This counseling involves review of specific dietary modifications, exercise regimen, dietician consult, and
establishment of realistic weight loss goals. A reasonable rate of weight loss entails 0.5 kg or one pound
per week with a 15-30-pound deficit over 3-6 months. Even with the support of a multidisciplinary clinical
team, successful weight loss is greatly variable. Should the patient not meet weight loss goals with dietician
support, the date of surgery may be postponed and a referral may be placed to bariatric surgery for
evaluation.

In cases where the patient elects to proceed with a weight loss operation, the literature remains split
regarding timing of hernia repair. A study using NSQIP data for all VHRs showed an increased risk
of infection at 30 days with concurrent VHR and bariatric surgery (sleeve gastrectomy or Roux-en-Y);
[21]
however, the increased risk did not exceed that expected of dual procedures . Thus, the authors of
the review advocated for a combined approach to minimize the morbidity of two otherwise separate
procedures. We would agree that, with a relatively small ventral hernia in a patient undergoing a
laparoscopic sleeve gastrectomy, the benefit of concurrent repair would outweigh separate anesthetic
events. However, in our experience, patients undergoing a gastric bypass or who require AWR have
improved outcomes after they experience the full scope of benefit from bariatric surgery, including, but not
limited to, metabolic, endocrine, and hormonal changes, weight distribution, cardiopulmonary enhancement,
and increased mobility. In general, we recommend waiting until the patient’s weight has plateaued (typically
18-24 months post-bariatric surgery), and then scheduling a definitive hernia repair 3-4 months later.

Smoking
Tobacco smoking widely increases the risk of postoperative complications in most procedures, and hernia
repair is without exception [22-25] . A recent study using NSQIP data examined 30-day outcomes in patients
undergoing elective hernia repairs and showed that current smokers were at increased risk of reoperation,
[26]
readmission, death, wound, and pulmonary complications . Several studies examining the effects of
smoking have found an increase in wound infection rate after hernia surgery and have identified smoking
as an independent risk factor for the development of incisional hernia after abdominal surgery [23,27,28] .
Smoking has a multifactorial detrimental effect on wound healing due to its reduction of oxygen tension
levels in the blood and tissue, disruption of microvasculature, and alteration in surgical site collagen
deposition [29-31] . VHR and AWR involve several components that may compromise wound healing and
promote infection such as undermined skin flaps, myofascial advancement flaps, mesh products, reduction
of chronically incarcerated hernia contents, and other concurrent gastrointestinal operations such as
fistula take-downs. These factors are compounded with problems associated with active tobacco use,
further motivating smoking cessation prior to surgery. Establishing the timing of the “last” cigarette is
key as smoking cessation at least one month prior to an operation has been shown to reduce the risk of
[25]
complications . A prospective trial showed that infection rates of compliant patients quickly approach
[25]
those of nonsmokers after four weeks of abstinence . A systemic review and meta-analysis confirmed
the benefit of smoking cessation on postoperative outcomes and showed that the magnitude of the benefit
[32]
rises significantly with each week of cessation up to the four-week mark . While the debate continues
regarding nicotine replacement in the preoperative setting due to concern for vasoconstriction and
impaired healing, several studies maintain it has no impact on surgical outcomes [29,33] .

For all patients who desire elective complex VHR at our institution, we require a minimum of 30 days
smoking cessation preoperatively with allowance for nicotine replacement formulations as needed. Urine
cotinine (metabolite of nicotine with a longer half-life) is checked at least 2 weeks prior to surgery to allow
rescheduling in case of positive testing. Of note, the use of nicotine-replacement products can result in a
positive urine cotinine test. If there is serious concern about a patient’s ongoing smoking status, a urine
anabasine level can be checked, which is an alkaloid only present in tobacco and not in any replacement
[34]
products .