Divulge the bulge: an international survey of abdominal donor site morbidity in free autologous breast reconstruction.

The frequency of donor-site complications following abdominal free-flap breast reconstruction remains controversial. Consensus on strategies to minimize morbidity is underdeveloped. An online survey was distributed to surgeons practicing free-flap breast reconstruction worldwide. Contact information was obtained via (1) official website listings/directories of US Plastic Surgery residencies/fellowships and (2) first/last authors of PubMed-indexed publications relating to free autologous breast reconstruction over the past decade. Questions related to practice environment, surgical volume/preferences, complications, mesh-use, referrals and perceptions of interventions for decreasing abdominal complications. Statistics were performed using non-parametric Kruskal-Wallis H test. The response rate was 26% (140/537). The majority of respondents came from the United States (100, 71%), and reported an academic practice environment (120, 86%). Fifty-six percent reported bulge rates ≥3% and sixteen percent reported bulge rates ≥10%. Most (93%) reported 0-2% hernia incidence. Those performing fewer surgeries were more likely to use mesh (p=.034) and report higher bulge incidence (p=.002). US surgeons performed a lower fraction of deep inferior epigastric perforator (DIEP) flaps (p<.001) and were more likely to believe that mesh use lowered complication risk (p<.001). Bulge and hernia incidence were associated with an increased proportion of non-DIEPs performed and mesh use (p=.004 and p=.024). Most respondents (54%) 'never' or 'rarely' had patients see occupations/physical therapy postoperatively. Bulge and abdominal muscle weakness are under-recognized donor site complications following free-flap breast reconstruction. Low surgical volume, non-DIEP reconstruction and mesh use may be associated with higher complication rates. Current practice patterns to reduce morbidity vary widely both domestically and internationally.