Evaluating the Impact of Prior Abdominal Surgeries and Mesh Use on Abdominal Wall Morbidity after Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

Abstract

Background: Abdominal wall hernia and bulge rates after DIEP flap breast reconstruction range from 2-33%. Mesh use after DIEPs is controversial and criteria for determining at-risk patients remains poorly defined. Previous abdominal surgery may increase the risk of abdominal morbidity after DIEPs. However, it is unclear if mesh use would reduce hernia/bulge rates in this population, and how prior abdominal surgery depending on surgical approach (minimally invasive or open) affects abdominal wall morbidity. This study evaluates how different types of previous abdominal surgery and mesh use impact the incidence of post-DIEP abdominal morbidity. Methods: A retrospective review of all patients with a history of prior abdominal surgeries who underwent DIEP flap reconstruction after mastectomy at a single academic tertiary center from January 2005 to December 2022 was performed. Demographics, BMI, comorbidities, type of prior abdominal surgeries, closure technique for abdominal incision, mesh use, and mesh type were documented. Incidences of post-operative abdominal wall hernia and bulge were combined into a single complication and recorded for each patient. Results: Of the 198 patients who underwent DIEP flap reconstruction and had a prior history of abdominal surgery, 43 (21.7%) had only minimally invasive abdominal surgery, 48 (24.2%) had a Pfannenstiel C-section scar, and 115 (58.1%) had open abdominal surgery. Average length of follow up was 21.6 months (SD, 22.0). 10 (5.1%) patients overall developed post-DIEP abdominal wall hernia/bulge requiring operative intervention. Comparing patients who did and did not develop hernia/bulge showed no significant differences in age, BMI, diabetes, use of mesh, or type of prior abdominal surgery (p>0.05). There was significantly higher use of permanent mesh use in patients who developed hernia/bulge compared to those who did not (40.0% vs 13.3%, p=0.029). In regression analysis controlling for age, BMI, diabetes, type of abdominal surgery, mesh use and mesh type, permanent mesh use was associated with a 1.75x increased odds of hernia/bulge (p=0.036). Interestingly, 17 patients (54.8%) with permanent mesh use had previous minimally invasive surgery only. Conclusion: Our data shows that the type of prior abdominal surgery does not significantly impact the occurrence of post-DIEP abdominal wall morbidity. However, the correlation of permanent mesh with worse abdominal sequalae suggests inherent fascial characteristics that influence surgeons’ intraoperative decisions regarding mesh use which were not captured retrospectively. This highlights the need for future prospective investigations with long-term follow-up data to explore the effects of various mesh types in mitigating abdominal morbidity after DIEP surgery.