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Abdominal Weakness, Bulge Or Hernia After DIEP Flaps: An Algorithm Of Management, Prevention, And Surgical Repair With Classification
Abby Warren, MD1, Avinash Jayaraman, BS1, Yash Kadakia, BS1, Ricardo Garza, BS1, Sami U. Khan, MD2, Nicholas Haddock, MD1, Sumeet Teotia, MD1.
1University of Texas Southwestern, Dallas, TX, USA, 2Stony Brook University, Stony Brook, NY, USA.

PURPOSE - This study analyzes abdominal weakness, hernia and bulge following DIEP flap breast reconstruction. Abdominal wall morbidities are categorized, and an algorithm for management is provided.
METHODS - A retrospective review of 718 patients who underwent abdominal based flap breast reconstruction between 2009 and 2018 was performed. Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. The incidence of abdominal weakness was evaluated by BREASTQ data. Risk factors were analyzed.
RESULTS - Of the 644 patients included, 23 (3.6%) had a bulge or hernia on exam postoperatively. Developing an abdominal wound postoperatively and sacrificing nerves both correlated with an increased incidence of bulge or hernia (p < 0.05). The use of lateral row perforators, keeping the umbilicus, higher BMI and the use of mesh in the initial abdominal wall repair trended towards an increased incidence of bulge or hernia; however, this data was not statistically significant. Seven percent of patients who answered the BREAST-Q reported abdominal weakness. Patients in the umbilicus sacrificing cohort had an increased incidence of weakness (p < 0.05). Abdominal wounds, nerve sacrificing procedures and obesity correlated with an increased incidence of weakness; this data was not statistically significant.
CONCLUSIONS - Following analysis, a classification and algorithm for treatment of abdominal wall morbidity is provided. Abdominal wall morbidity is classified as: type 1 - abdominal weakness; type 2 - smaller, unilateral abdominal bulge; and type 3 - true abdominal hernia or large bilateral bulge. An algorithm of treatment is presented which includes physical therapy and surgical repair recommendations.


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