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Selective Mesh Placement in DIEP Flap Reconstruction: Insights from a Propensity-Score Matched Analysis
Micaela J. Tobin¹, Noelle Garbaccio¹, Bradley Colarusso¹ , Audrey K. Mustoe¹, Maria Escobar-Domingo¹, Agustin N. Posso¹, Samuel J. Lin¹, Sarah Karinja¹, Bernard T. Lee^1
1Beth Israel Deaconess Medical Center, Wellesley, MA, United States.

Background
Deep inferior epigastric perforator (DIEP) flaps are the gold standard in autologous breast reconstruction (ABR) despite being associated with abdominal donor site morbidity. Some surgeons place mesh during abdominal closure to mitigate this risk of postoperative hernias. Yet, research on this practice's efficacy has been limited by small sample sizes. This study evaluates factors that influence mesh placement in DIEP ABR and assesses the effects of mesh placement on postoperative hernia development and donor site morbidity.
Methods
The TriNetX health database was queried to identify patients who underwent DIEP flap reconstruction with or without abdominal mesh. Cox regression analysis was performed to identify significant covariates influencing mesh placement and postoperative hernia risk. Patients with BMI ≥ 30 were stratified by mesh placement and propensity-score matched by demographics and comorbidities. Risk ratios were calculated to determine five-year hernia rates between the matched cohorts.
Results
Among 12,593 patients who underwent DIEP ABR, 1,100 patients (8.7%) had abdominal mesh placed at the time of surgery. Cox regression demonstrated BMI ≥ 30 and advanced age were significant predictors of postoperative hernias (p<0.0001). ABR patients were more likely to receive mesh if they had BMI ≥ 30 (p<0.0001), prior hernia repairs (p<0.05), tobacco use (p<0.05), or advanced age (p<0.01). After propensity-score matching, mesh placement did not significantly reduce 30-day donor site morbidity or five-year hernia rates in patients with BMI ≥ 30.
Conclusions
These findings suggest that surgeons preferentially place mesh in patients they perceive to be at high risk of postoperative complications. Yet, mesh placement during DIEP reconstruction does not provide the anticipated protective effect against postoperative hernias, even in higher-risk patients. These findings challenge the routine use of mesh during abdominal closure in DIEP ABR and suggest that more targeted approaches to reducing donor site complications are warranted.