Breast Reconstruction with Free Tissue Transfer from the Abdomen in the Morbidly Obese

Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia, Pa 19104, USA.
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 06/2011; 127(6):2206-13. DOI: 10.1097/PRS.0b013e3182131c93
Source: PubMed

ABSTRACT There are national trends of increasing incidence of morbid obesity and autologous breast reconstruction with free tissue transfer from the abdomen. The purpose of this study was to assess the safety and efficacy of free flap breast reconstruction in the morbidly obese population.
A retrospective review was conducted on all patients who underwent transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, or superficial inferior epigastric artery flap breast reconstructions between July of 2006 and October of 2008. Data from all patients with a body mass index greater than 40 were compared with those of patients with a body mass index less than 40. A p value less than 0.05 was considered significant. Significant findings were then analyzed in a post hoc fashion to examine trends with increasing body mass index.
Four hundred four patients underwent 612 free flap breast reconstructions during the study period. Twenty-five of these patients (6 percent) had a body mass index greater than 40. The morbidly obese group had significantly higher rate of total flap loss (p = 0.02), total major postoperative complications (p = 0.05), and delayed wound healing (p = 0.006).
Free flap breast reconstruction in the morbidly obese is associated with a higher risk of total flap loss, total major postoperative complications, and delayed abdominal wound healing. However, the overall incidence of complications is low, making free tissue transfer from the abdomen an acceptable method of breast reconstruction in this patient population.

  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to (1) determine risk factors predictive of delayed abdominal healing; (2) determine characteristics that perpetuate progression to chronic abdominal wounds and describe the resultant morbidity; and (3) identify outcomes and cost following two treatment strategies-conservative wound care and early reoperative primary closure. Patients were identified from a database of abdominally based free flaps performed from January of 2005 through July of 2012. One thousand two hundred eighteen abdominal donor sites were reviewed, and 167 cases (13.7 percent) of delayed abdominal wound healing were identified. Obesity (p < 0.0001), smoking (p = 0.043), bilateral reconstruction (p = 0.006), preoperative chemotherapy (p = 0.006), and abdominal mesh (p = 0.028) were independently associated with delayed healing. Initiation of chemotherapy p < 0.0001), wet-to-dry wound care (p = 0.001), negative-pressure wound therapy (p = 0.002), and flap type (p = 0.047) were predictive of chronic wounds, and such wounds generated higher rates of hospital readmission (p = 0.009), mesh complications (p < 0.001), and hernia/bulge (p = 0.006). Patients who underwent delayed primary wound closure were more likely to have a well-healed abdomen within 1 month (90.9 percent versus 24.2 percent; p < 0.0001), resulting in lower cost, fewer hospital readmissions, lower rates of scar revision, and lower rates of mesh complications/hernia/bulge. Chronic abdominal wounds were associated with abdominal wall sequelae, including hernia. Early reoperative primary wound closure has been successfully and selectively implemented, resulting in improved patient outcomes. Risk, III.
    Plastic &amp Reconstructive Surgery 01/2015; 135(1):14-23. DOI:10.1097/PRS.0000000000000805 · 3.33 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Although we practice in an era of high flap success rates following microsurgical breast reconstruction, complications can still occur. Several studies have evaluated the impact of risk factors on microvascular outcomes in the setting of a particular type of patient or with a particular type of flap. However, few studies that have evaluated a consecutive series of high-risk patients will all types of microvascular breast reconstruction. Our goal was to gain a better understanding of the relationship between risk factors and complications in order to provide useful information for patients and surgeons considering free flap breast reconstruction in high-risk patients. We performed a retrospective review of all patients who underwent microsurgical breast reconstruction by the senior author (M.Y.N) from July 2005 July 2010. Patient records were analyzed for risk factors (age, BMI, smoking history, medical history, adjunct therapies, timing of reconstruction, type of reconstruction), and complications (hematoma, seroma, infection, wound dehiscence, pulmonary embolism (PE), deep venous thrombosis (DVT), pneumonia, fat necrosis, leech use, partial flap loss, total flap loss). Statistical methods were employed to determine statistically significant relationships. A total of 352 patients underwent 490 microvascular breast reconstructions during the study period. Active smoking was found to be a statistically significant risk factor for seroma [P<0.0001; odds ratio (OR) =36; 95% confidence interval (CI), 5.9-193.9], infection (P=0.0081; OR =4.3; 95% CI, 1.3-14.1), and pneumonia (P<0.0001; OR =17.1; 95% CI, 3.3-89.9). Unilateral reconstruction was found to be a statistically significant factor for fat necrosis (P=0.0083; OR =4; 95% CI, 1.4-11.4). Additionally, BMI was found to be a statistically significant risk factor for infection (P<0.00001). This study corroborates findings from previous studies. Tobacco use was demonstrated to be a significant risk factor for infection, seroma, and pneumonia. Obesity was demonstrated to be a significant risk factor for infection. Unilateral reconstruction was demonstrated to pose additional risk for fat necrosis compared to bilateral reconstruction. Patients who choose to have microsurgical breast reconstruction should be informed of the complication profile associated with certain risk factors.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Studies show that obesity is a risk factor for complications after expander/implant breast reconstructions. However, reports vary on the precise threshold of body mass index (BMI) as a predictor of heightened risk. We endeavored to link BMI as a continuous variable to overall complications in a single-surgeon series of expander-implant reconstructions. Methods: From 399 patients undergoing expander-implant reconstruction, 551 breasts were stratified to normal weight, overweight, and obese groups for analysis and comparison with previous studies. Logistic regression was performed to predict changes to risk profile per increment of BMI. Results: Complication rates for obese and overweight patients were significantly greater than for normal weight patients, that is, 21.1% and 24.0% versus 10.4%, respectively (P < 0.005). A unit increase in BMI predicted a 5.9% increase in the odds of a complication occurring, and 7.9% increase in the odds of reconstruction ending in failure. Conclusions: By expanding the analysis of BMI to include patients who do not meet the traditional definition of obesity (BMI >= 30 kg/m(2)), we demonstrated that simply overweight patients (25 <= BMI < 30 kg/m(2)) had an elevated complication rate. Moreover, through regression analysis, we established that BMI as a continuous variable predicts outcomes from expander-based breast reconstruction.
    Annals of Plastic Surgery 07/2014; 73(1):19-24. DOI:10.1097/SAP.0b013e318276d91d · 1.46 Impact Factor