Selecting Patients for Autologous Free Flap Breast Reconstruction in Body Mass Index >35: Stratifying Surgical Risk Factors for Patient Inclusion or Exclusion

Abstract

INTRODUCTION: Morbid obesity presents numerous challenges in autologous breast reconstruction. Along with considering other medical comorbidities, body mass index (BMI) alone can serve as an overall denominator in the decision-making process to offer or decline reconstruction. METHODS: Retrospective chart review was performed on N = 350 patients who underwent bilateral breast reconstruction using deep inferior epigastric perforator flaps (n = 654 flaps). Patients were divided into 2 groups: patients with BMI <35 (group 1; N1 = 273 patients; n1 = 508 flaps) and patients with BMI ≥35 (group 2; N2 = 77 patients; n2 = 146 flaps). Comorbidities including age, BMI, hypertension, diabetes mellitus, autoimmunity, smoking status, previous deep venous thrombosis (DVT)/PE, and previous abdominal surgery were tracked. Donor site complications including wounds, infection, seroma, hematoma, and DVT/PE and abdominal bulge were tracked. Flap losses and hospital stays were accounted. All data were collected using a centralized REDCap database. Analysis was performed with SPSS: continuous variables were analyzed with t tests, and binary variables were analyzed with chi-square, or Fischer’s exact test for subgroups with n < 5. RESULTS: Age, comorbidities, and medical histories were equivalent between groups, except for diabetes mellitus: group 2 (21%) had a significantly higher rate of diabetes mellitus than group 1 (7%; P < 0.01). Rates of infections requiring intravenous antibiotics (P = 0.056), seroma requiring operation (P = 0.750), hematoma requiring operation (P = 0.356), and DVT/PE (P = 0.512) were equivalent between groups. Rate of wound complications requiring operative repair was higher in group 2 (16%) than in group 1 (7%; P = 0.013). Surgical intensive care unit stay after flap procedure was equivalent between groups (group 1 = 2.22 days; group 2 = 2.32 days; P = 0.180). Total hospital stay was equivalent between groups (group 1 = 4.00 days; group 2 = 4.21 days; P = 0.091). Rates of abdominal bulge were equivalent between groups (group 1 = 4%; group 2 = 6%; P = 0.361). Umbilicus was sacrificed significantly more in group 2 (46%) than in group 1 (10%; P < 0.01). Flap loss was significantly higher in group 2 (4/146, 3%) than in group 1 (3/508, 0.6%; P = 0.026). Overall combined flap loss was 1%. DISCUSSION: In our study, offering deep inferior epigastric perforator flaps to patients with BMI >35 seems to have a 5-fold increase in flap loss. Despite attempting to decrease wound complications in higher BMI patients by sacrificing umbilicus, operative intervention for postoperative wound complications is still more than twice that of lesser BMI patients. This could be accounted by 3 times higher diabetes mellitus encountered in our higher BMI group. Based on individual practice patterns, patients with BMI >35 can be educated of their higher risks in consideration as a candidate for free flap breast reconstruction.