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Published on: December 5, 2025
Beyond Body Mass Index: Using Abdominal Wall Thickness to Guide Patient Selection for Deep Inferior Epigastric
Joyce Xiaoran Cui1, Eric Zeng1, Mary Lee Duet2
1Wake Forest University School of Medicine, United States.
Introduction:
Body mass index (BMI) limits of 30.0 to 32.7 kg/m2 have been recommended to reduce postoperative complications in autologous breast reconstruction. However, BMI does not accurately represent body composition for all individuals. This study evaluates the relationship between abdominal wall thickness (AWT) and postoperative complication rates using a novel, accessible measuring method.
Methods:
A retrospective chart review of 793 patients (1,310 flaps) who underwent deep inferior epigastric perforator (DIEP) flap reconstruction from November 2017 to May 2024 at two medical sites was conducted. Demographics, medical history, operative course, and postoperative complications were reviewed. Subcutaneous AWT was measured on preoperative computed tomography angiogram at four standardized anatomical landmarks. Patients were stratified by BMI (<25, 25-30, 30-35, and >35) and AWT (<20, 20-40, and >40 mm). Statistical analysis was conducted in R.
Results:
The mean patient age was 50.5 years, and mean BMI was 30.3 kg/m2. BMI was strongly correlated with AWT (r = 0.68, p < 0.001), and both variables were strong predictors for complication rates (p < 0.001, p<0.001). Stepwise increases in wound dehiscence, infection, and fat necrosis were observed across AWT groups. Receiver operating characteristic analysis identified AWT threshold of 26.3 mm for overall complications. AWT and BMI models demonstrated comparable predictive ability for complication rates. Patients with mismatched BMI and AWT highlighted cases where BMI alone underestimated risk.
Conclusion:
AWT may serve as a valuable adjunct tool in determining DIEP flap eligibility, particularly for patients with a high BMI and thin abdominal wall, or vice versa.
