Retrorectus Mesh Use in Deep Inferior Epigastric Perforator Flaps to Reduce Abdominal Morbidity

Deep inferior epigastric perforator (DIEP) flaps provide a durable, autologous breast reconstruction option, but can lead to postoperative 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.

A retrospective chart review was conducted of a single surgeon's patients who underwent DIEP flaps from 2020 through 2024. During the study period, the primary surgeon began using retrorectus bioprosthetic P4HB mesh before fascial closure. Abdominal bulge was a clinical diagnosis made by the attending surgeon, and any patient with concern for a hernia received postoperative imaging. Analysis was conducted with R and included the Fisher exact test, Shapiro-Wilk test, Mann-Whitney U test, and t tests.

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 with 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 rates of seroma or infection between the groups ( P = 1.0).

There was a 3-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 reduce the abdominal morbidity of this surgery.