Retrorectus Polyglactin Mesh Reduces the Risk of Bulge in DIEP Flap Donor Sites: A Propensity Score-Matched Study

Hernia and bulge are recognized complications after deep inferior epigastric perforator (DIEP) flap harvest. The authors evaluated retrorectus placement of absorbable polyglactin mesh as a low-cost strategy to reduce hernia and bulge and introduced a sliding-scale estimator for individualized hernia risk with and without mesh use.

The authors conducted a retrospective, single-center cohort study of patients who underwent DIEP flap breast reconstruction from March of 2018 to September of 2023. Donor-site outcomes, including hernia and bulge, were compared between patients with and without retrorectus polyglactin mesh placement. Propensity score matching and multivariable logistic regression were used to adjust for baseline differences and identify predictors of hernia and bulge. To individualize hernia risk assessment, the authors developed and validated a sliding-scale estimator.

Among 330 patients undergoing DIEP flap reconstruction, 108 (33%) received retrorectus polyglactin mesh. After propensity score matching, polyglactin mesh placement was associated with significantly lower postoperative bulge (1.2% versus 9.3%, P =0.017). Multivariable analysis identified age, lateral perforator harvest, and number of medial perforators as independent predictors of hernia, whereas polyglactin mesh placement was the only significant predictor of reduced bulge risk. A logistic regression model with Lasso regularization (area under the curve = 0.97) was used to develop a nomogram estimating individualized hernia risk with and without polyglactin mesh.

Retrorectus polyglactin mesh reduces bulge after DIEP flap harvest, whereas hernia risk is driven by age, prior open surgery, and perforator dissection. When retrorectus polyglactin mesh is used to reduce donor-site morbidity, a validated nomogram can aid in estimating personalized risk and guiding surgical decision-making.