Rectus Abdominis Fascia Plication Within DIEP Flap Breast Reconstruction: Impact on Abdominal Wall Morbidity and Patient Satisfaction Evaluated with the BREAST-Q

<b>Background</b>: The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction, but donor site morbidity, such as abdominal bulging, remains a concern. Rectus fascia plication is a recognized treatment for rectus abdominis diastasis, yet its role in DIEP closure is scarcely evaluated. This study investigates whether plication reduces abdominal morbidity and improves patient satisfaction. <b>Methods:</b> A multicenter retrospective case-control study was performed on women who underwent unilateral DIEP breast reconstruction between 2018 and 2024. Patients were allocated to the plication or control group according to operative notes. Outcomes included abdominal complications, postoperative bulging (clinically and photographically assessed), and patient-reported satisfaction using the BREAST-Q. Standardized postoperative photographs were also rated by blinded expert surgeons. <b>Results</b>: Sixty-two patients met the inclusion criteria: 25 with fascia plication and 37 without. Groups were comparable in demographics and surgical details, though diastasis was more prevalent in the plication group (4.1 cm vs. 0 cm, <i>p</i> < 0.0001). Plication did not increase early or late complications. Abdominal bulge occurred in 16.2% of controls and 0% of the plication group (<i>p</i> = 0.0727). Logistic regression confirmed a significant protective effect (OR = 0.095, 95% CI 0.001-0.87, <i>p</i> = 0.034). BREAST-Q "Physical well-being: abdomen" scores were higher with plication (35.7 ± 18.0 vs. 23.0 ± 17.2, <i>p</i> = 0.0316), which was confirmed by multivariate analysis. Expert photographic assessments showed no significant differences. <b>Conclusions</b>: Rectus fascia plication during DIEP flap breast reconstruction is safe, improves abdominal well-being, and reduces postoperative bulging, especially in patients with preoperative diastasis. This additional step may represent a simple and effective strategy to enhance donor site outcomes.