“Retrorectus mesh use in deep inferior epigastric perforator (DIEP) flaps to reduce abdominal morbidity”

Background: Deep inferior epigastric perforator (DIEP) flaps provide a durable, autologous breast reconstruction option, but can lead to post-operative abdominal bulges and hernias. There is no current standardization in practice for fascial closure or mesh placement. Bioprosthetic poly-4-hydroxybutyrate (P4HB) mesh allows for temporary abdominal support without the long-term risks of permanent mesh. Methods: A retrospective chart review was conducted of a single surgeon’s patients who underwent DIEP flaps from 2020-2024. During the study period the primary surgeon began using retrorectus bioprosthetic mesh prior to fascial closure. Abdominal bulge was a clinical diagnosis made by the attending surgeon, and any patient with concern for a hernia received post-operative imaging. Analysis was conducted with R and included Fisher’s exact test, Shapiro-Wilk’s test, Mann-Whitney U test, and t-tests. Results: This study included 118 patients, 59 with mesh and 59 without mesh, with similar baseline patient demographics. There was a 5.1% bulge rate in the group with mesh compared to 18.6% in those without mesh (p=0.04). There was no significant difference in hernia rates, with the base rate remaining low for these patients (p=1.0). There were no statistically significant differences in the rates of seroma or infection between the groups (p=1.0). Conclusions: There was a three-fold decrease in the rate of abdominal bulge after DIEP flap surgery with retrorectus P4HB mesh. True hernia risk remains low in these patients. Retrorectus mesh placement is a straightforward and quick addition to DIEP flap harvest and may help to reduce the abdominal morbidity of this surgery.