Background and Aims Aggressive fibromatosis (AF) is a rare clonal myofibroblast proliferative disease derived from deep soft tissues. This study aims to analyze and summarize the case characteristics and clinicopathologic features of patients with abdominal wall AF admitted to 21 medical centers in Hunan province, to enhance the current knowledge and investigate the factors associated with the recurrence of abdominal wall AF.Methods The clinical data and follow-up results of 148 patients with abdominal wall AF recruited consecutively from 21 medical centers in Hunan province between January 1, 2010 and September 30, 2022 were reviewed. The general characteristics, treatment method, risk factors for postoperative recurrence, and prognosis of patients were analyzed.Results Among 148 patients with abdominal wall AF, 15 cases (10.1%) were males, and 133 cases (89.9%) were females with a median age of 31 (3-72) years old; there were 142 cases (95.9%) with primary disease and 6 cases (4.1%) with recurrent disease; 71 cases (48.0%) had a history of abdominal surgery. Among the female patients, 111 cases (83.5%) had a history of pregnancy, and 57 cases (42.9%) had a history of cesarean section. All patients were confirmed with AF by postoperative pathological examination. Pathological diagnosis obtained by fine needle puncture before surgery in 16 patients (10.8%), which in 8 cases (50.0%) were consistent with the postoperative results. Immunohistochemical staining was performed in 100 patients (67.6%). Among them, 32 cases (32.0%) had Ki-67 >5%, 56 cases (56.0%) had β-catenin (+), and 42 patients (42.0%) had vimentin (+). All 148 patients with AF underwent radical resection of abdominal wall tumors. Among them, 72 cases underwent abdominal wall repair by direct suture after tumor resection, 72 cases underwent mesh implant for abdominal wall strengthening, and 4 cases underwent abdominal wall reconstruction with a musculocutaneous flap or pedicled tensor fascia lata musculocutaneous flap. Follow-up was obtained through telephone calls and clinic visits in 127 patients (85.8%), and the median follow-up time was 3.6 (0.9-12.3) years. During follow-up, recurrence occurred in 11 patients (11/127, 8.7%), including three re-recurrent cases. Recurrent AF and positive surgical margins were risk factors for postoperative recurrence (both P<0.05). Postoperative wound infection and wound dehiscence or incisional hernia were observed in none of them, and no tumor metastasis or death occurred.Conclusions Abdominal wall AF predominantly affects young female adults with a pregnancy history. There is a certain recurrence rate after radical resection. Surgeons should strive to achieve negative surgical margins, especially for those with recurrent AF, for whom specialized care with an individualized treatment plan from an experienced hernia and abdominal wall surgery center is recommended.