Comparing autologous breast reconstruction in high vs. low body mass index patients

Breast reconstruction has been shown to significantly improve quality of life (QoL) for women who must undergo mastectomy. Between the implant-based and autologous-based reconstruction, autologous-based reconstruction has demonstrated better outcomes in both QoL and overall satisfaction as reported by the BREAST-Q. For patients desiring autologous reconstruction, a woman's weight and body habitus can affect not only the pre-operative planning, but also outcomes in terms of both complications as well as overall satisfaction. Here, we present our cohort that has been stratified by body mass index (BMI) and compare how BMI can influence flap selection as well as complications.

After institutional review board approval, a retrospective review in a REDCap database-guided analysis was conducted of patients who underwent autologous reconstruction with longitudinal follow-up at a single academic institution from 2013 to 2024. Patients were then stratified into BMI categories as outlined by the Centers for Disease Control (CDC) including healthy (18.5≤ BMI <25 kg/m²), overweight (25≤ BMI <30 kg/m²), and obese (BMI ≥30 kg/m²). Data were then obtained and the subgroups were compared. Statistical significance was set at a P value less than 0.05 for all tests. Pearson Chi-squared tests were used to compare flap types, categorical comorbidities, and complications across the groups, and one-way analysis of variance (ANOVA) was used to compare average length of surgery.

A total of 957 patients were identified who fit the inclusion criteria, with 239 patients sorted into the healthy (18.5≤ BMI <25 kg/m²) subgroup, 348 patients into the overweight (25≤ BMI <30 kg/m²) subgroup, and 370 patients into the obese (BMI ≥30 kg/m²) subgroup. There were significant differences in comorbid conditions between the groups including diabetes and hypertension (P<0.05), with the incidence of these comorbidities increasing from healthy to overweight to obese subgroups. The rate of multi-flap procedures was significantly higher in the Healthy subgroup (33.9%) as compared to the overweight (23.3%) and obese (11.6%) subgroups (P<0.05). There was a significant difference in the type of flaps used between the subgroups (P<0.05), as well as in the incidence of deep inferior epigastric perforators (DIEPs), profunda artery perforators, and lumbar artery perforators between the subgroups (P<0.05). There was a significant difference found for incidence of flap site infection (P<0.05), seroma (P<0.05), and wound (P<0.05), as well as in overall donor site complications (P<0.05) between the subgroups, with a greater incidence occurring within the obese subgroup as compared to the overweight or healthy subgroups.

In this retrospective cohort study, we found that patients with healthy BMI are more likely to undergo multi-flap or non-abdominally based flap reconstruction and less frequently rely on DIEP flaps than women of overweight or obese BMI. Furthermore, patients with obese BMI are more likely to have post-operative complications at either the breast or donor site. A deeper look into perioperative data and complications will help understand other differences between the subgroups in terms of surgical efficacy and safety.