Today, plastic surgeons are increasingly faced with the problem of complex abdominal wall reconstruction. Obesity, bariatric surgery, and failed prior herniorrhaphy contribute to high rates of hernia recurrence in these difficult tertiary cases. We reviewed 50 consecutive complex abdominal wall reconstructions to identify the roles of 3 technical variables in successful outcomes: use of mesh, use of a flap buttress to reinforce the fascial repair, and the use of concomitant body-contouring techniques. Six groups were identified based on the presence or absence of each of these variables. Incidence of hernia recurrence and incidence of complications were compared for each group. Patient satisfaction with reconstructive outcome was assessed at follow-up using a 5-point scale. At a mean follow-up of 24 months, we observed an overall hernia recurrence rate of 4.0%, and an overall complication rate of 34%. Tension-free primary fascial repair and mesh repair of tension defects had equivalent recurrence rates (3.3% vs. 5%) and complication rates (40% vs. 25%). Repairs buttressed with flaps and repairs without buttressing had equivalent recurrence rates (3% vs. 6%) and complication rates (38% vs 28%). Repairs with and without body contouring techniques as part of the reconstructive plan had equivalent recurrence rates (7.7% vs. 0%) and complication rates (31.7% vs. 53%). Mean patient satisfaction was 4.8 of 5. Reconstruction of complex and recurrent hernias can be successfully performed. When tension-free primary fascial closure is not possible, an inlay mesh with a soft-tissue buttress leads to a 10-fold reduction in hernia recurrence as compared to historical norms. Concomitant body contouring surgery does not impact recurrence or complication rates and may contribute to reconstructive success.