Use of Patient Body Mass Index as a Rationing Tool in Breast Reduction Surgery

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Sir: Breast reduction surgery, although regarded as a low-priority cosmetic procedure by most National Health Service trusts, has been shown to result in high patient satisfaction and better quality of life.1 Most health trusts have set the upper body mass index limit of between 26 (overweight) and 30 (obese) as a selection tool for patients considering surgery. It remains unclear whether these limits are based purely on operative complications or as a rationing tool. Our aim was to assess whether overweight patients with a body mass index greater than 26 have higher complication rates after breast reduction and should thus be excluded from surgery. Two hundred six consecutive patients in one tertiary plastic surgery center who underwent breast reduction surgery were reviewed retrospectively. Of all patients, 38 percent had a body mass index less than 26 and 62 percent had a body mass index of 26 or more (range, 21 to 32; mean, 26.3) (Fig. 1). Mean age was 36 years (range, 14 to 65 years). The most common risk factors were the use of oral contraceptive pills (26 percent) and smoking (22 percent). Most operations (82 percent) were performed using the inferior pedicle technique, half of which were performed by a consultant.Fig. 1.: Distribution of body mass index among the 206 patients in the study.Overall, 72 complications were noted in 56 patients, with wound infection, wound breakdown, hematoma, and fat necrosis accounting for 89 percent of the complications. Twenty-eight of the complications were in the lower body mass index group (35 percent) and 44 were in the higher body mass index group (35 percent) (Table 1). There was no statistically significant difference between the two groups (p > 0.05). In addition, there was no difference in length of hospital stay (mean, 2.5 days) or postoperative follow-up noted (p > 0.05).Table 1: Incidence of Major Complications in Patients with a BMI < 26 and a BMI between 26 and 32Obesity is becoming one of the fastest growing public health problems, with 32 percent of women in the United Kingdom being overweight and 23 percent obese. Our study is the largest to date investigating the risk of postoperative complications following breast reduction surgery in patients with a body mass index of less than 26 and in those with a body mass index between 26 and 32. It confirms that overweight patients are not at increased risk of any complications, and the length of hospital stay and postoperative follow-up are not prolonged as a result. Our study, however, did not have patients with a body mass index greater than 32. The literature investigating the postoperative complication rates after breast reduction surgery in relation to body mass index is sparse and shows contradicting outcomes. Platt et al.,2 in a study of 30 patients, noted an increased wound breakdown rate in those with a body mass index greater than 26.3 (10 percent versus 33 percent; p < 0.05). Similarly, Zubowski et al.3 found a statistically significant increase in local complications in obese patients (11.3 percent versus 7.2 percent). However, Wagner and Alfonso,4 in a study of 186 patients, found that obese patients achieved as much symptom relief and with similar complication rates as the nonobese group. Breast reduction surgery is becoming increasingly restricted by the National Health Service, with variability in rationing across the United Kingdom. Reasons for restriction of surgery should be clear and based on good clinical evidence; otherwise, it represents inequality in the provision of health care. This study showed that overweight patients did not suffer from a higher rate of postoperative complications following breast reduction surgery. Overweight patients are not at increased risk of surgical complications after breast reduction surgery, and a body mass index less than 26 should not be used as a rationing tool with which to restrict surgery. Sujatha Tadiparthi, M.R.C.S. S. H. Liew, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery Whiston Hospital Liverpool, United Kingdom