ASPS: Obese Women Have More Breast Reconstruction Complications

SAN FRANCISCO, Oct. 19 -- Breast reconstruction surgery in extremely obese women after a mastectomy is associated with a high rate of complications, said researchers here.

About 40% of all extremely obese patients -- a body mass index (BMI) greater than 35 -- who had breast reconstruction over 15 years wound up with had complications such as fat necrosis, flap loss, or delayed wound healing, said Elisabeth S. Beahm, M.D., of the University of Texas M. D. Anderson Cancer Center in Houston.

This compared with about 30% of those with a BMI less than 35, she told the American Society of Plastic Surgeons meeting.

"Just because someone is overweight doesn't mean they should not be entitled to undergo breast reconstruction after mastectomy," said Dr. Beahm. "Feeling 'whole' can be an integral part of recovery from cancer, yet significant concerns have been raised about the wisdom of doing breast reconstruction in very obese patients due to a high complication rate."

It may be better in many cases for extremely obese patients to lose weight before reconstruction is attempted, she said.

Obese patients tend to have higher complication rates with autologous flaps at both the donor and the recipient site, which has led some researchers to recommend the use of implants in such patients instead, Dr. Beahm said.

Yet because of the size and shape of their breasts, there are only limited implant options available for these patients and some surgeons will refuse to operate on them, or will limit treatment options for breast reconstruction in the morbidly obese, she noted.

To determine where to draw the line, Dr. Beahm and colleagues conducted a retrospective review of breast reconstruction outcomes in obese patients from the beginning of 1990 to the end of 2004. They looked at patients in four categories based on BMI: 25 to 29.9, 30 to 34.9, 35 to 39.9, and greater than 40.

The patients were matched by age and type of reconstructive surgery to normal weight patients (BMI of less than 24.9). The procedures included autologous flaps from the lower abdominal wall (transverse rectus myocutaneous, deep inferior epigastric, and superficial inferior epigastric flaps), latissimus dorsi flaps with and without implants, and implant-only methods.

The outcomes analysis included assessment of complications including:

• Fat necrosis.
• Total or partial flap loss.
• Delayed wound healing at donor and/or recipient sites.
• Abdominal wall complications in transverse rectus myocutaneous flap patients, such as chronic pain, bulge, hernia, or infection.
• Length of hospital stay.
• Medical complications such as pulmonary embolus and deep vein thrombosis.

The investigators also considered the prevalence of premorbid conditions such as diabetes and coronary artery disease, as well as overall aesthetic outcome.

If the record contained information about the decision-making process for the type of reconstruction, such as indications for or against immediate or delayed reconstruction, that information was also taken into account.

The authors found that the BMI among 3,518 patients in the study ranged from 15.2 to 59.9. They also noted a trend toward an annual increase in the mean BMI of the patients treated, from 24.2 in 1990 to 26.8 by the end of 2004.

All patients with a BMI lower than 35 had comparable complication rates, but among patients with a BMI of 35 or greater, the complication rates were significantly higher for each type of surgery.

The most frequent complications for obese patients were edema and infection at both the reconstructive site and the flap donor site. In abdominal flap procedure, hernia and bulge were much more common among obese than normal weight patients.

Overall, 39% of extremely obese women experienced complications from breast reconstruction surgery, compared with 30.9% of women with a BMI less than 35.

The rates by procedure for women with a BMI of 35 or greater versus those with a BMI of less than 35 were:

• Transverse rectus myocutaneous procedures: 50% versus 33%.
• Implants: 33.3% versus 22.5%.
• Latissimus dorsi procedures: 40% versus 33%.

No P values were given for the significance of the differences in the various rates.

"While complications increased with patients with a BMI over 35 and approached 100% in those with a BMI over 40, there was no linear correlation in this relationship," Dr. Beahm and colleagues wrote.

They noted that in a focused study of patients treated from 2000 to 2005, patients with a BMI 35 or greater were less satisfied in general and were deemed to have lower overall aesthetic outcomes.

"While it's very difficult to tell a patient she needs to wait for breast reconstruction, patient safety is our primary concern," said Dr. Beahm. "We must not compromise the oncologic imperative in breast cancer. Each case must be individualized. Morbidly obese patients need to work with their plastic surgeons and carefully assess risk factors. Patients may be best served by deferring breast reconstruction until they have achieved and maintained a lower BMI through exercise and nutrition."