Effect of Prophylactic Mesh and Placement Plane on Abdominal Wall Outcomes Following DIEP Flap Reconstruction

Abstract

Background/Objective: The deep inferior epigastric perforator (DIEP) flap is the most widely used autologous option for breast reconstruction. Donor-site morbidity, particularly abdominal wall weakness or bulge, remains a recognized complication. Prophylactic mesh has been proposed to reduce these risks, but the optimal plane of mesh placement has not been established. This study examines abdominal wall outcomes in patients undergoing DIEP flap reconstruction with and without prophylactic mesh, as well as across different planes of mesh placement. Methods: A retrospective review of patients who underwent DIEP flap reconstruction (2021–2025) at a single institution was performed. Patients were grouped by mesh type and location. Demographic data and postoperative outcomes were collected. Significance was set at p<0.05. Results: A total of 250 patients underwent DIEP flap reconstruction, including 150 with prophylactic mesh (retrorectus, n=81; overlay, n=69) and 100 without mesh. When analyzed by mesh use overall, patients with mesh had a significantly lower rate of abdominal bulge compared with those without mesh (2.7% vs. 9%, p=0.027). Subgroup analysis by plane of mesh trended towards significance demonstrating lowest rate of bulge in the retrorectus group (1.2%) compared with overlay mesh (4.3%) (p=0.06). Rates of infection and hernia were similar among groups. (p=0.6) Conclusion: Prophylactic mesh placement during DIEP flap reconstruction is associated with a significantly lower risk of abdominal bulge compared with no mesh. Retrorectus placement demonstrated the lowest rates of donor-site complications.