ABSTRACT
Dealing with excess skin in the context of a massive hernia ideally requires a combined general and plastic surgical approach, which should exist at every stage of the patient's journey. When addressing the soft tissues, the problem must always be considered in three dimensions, as a two-dimensional solution to a three-dimensional problem will inevitably result in failure or, at best, a suboptimal outcome. The hernia contents act as a biologic tissue expander and the external forces transmitted through the skin result in mechanical and biologic creep. In patients who undergo combined high-risk surgical procedures with large incisions, the risk of surgical wound problems is already high and the addition of smoking simply adds another unacceptable, and modifiable, risk. The midline incision is the standard technique and is preferable in the majority of patients due to the presence of a pre-existing midline scar and is especially useful for hernias that are centred above the umbilicus.
