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Microsurgical Breast Reconstruction in the Obese: A Better Option Than Tissue Expander/Implant Reconstruction?

Klement, Kristen A. M.D.; Hijjawi, John B. M.D.; LoGiudice, John A. M.D.; Alghoul, Mohammad M.D.; Omesiete-Adejare, Pamela B.S.

Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 539-546
doi: 10.1097/PRS.0000000000005897
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Background: Obesity has reached epidemic proportions, with 72 million people in the United States classified as obese in 2010. This significant increase in obese patients is reflected in the breast cancer population seeking breast reconstruction. Previous studies demonstrated increased complication rates and decreased satisfaction in obese patients undergoing breast reconstruction. This study aims to directly compare prosthetic and autologous reconstruction in the obese population by evaluating surgical outcomes and patient satisfaction.

Methods: In an institutional review board–approved study, a retrospective chart review was conducted on patients with a body mass index of 30.0 kg/m2 or greater who underwent breast cancer reconstruction after mastectomy with either free tissue transfer from the abdomen or prosthetic reconstruction over a 3-year period. The authors identified 96 patients with 141 reconstructions. Demographic, intraoperative, and postoperative variables were collected. All patients were sent the BREAST-Q questionnaire by means of mail to study the impact and effectiveness of breast surgery from the patient’s perspective. Statistical analysis was completed with Fisher’s exact test, Mantel-Haenszel chi-square test, Pearson chi square test, or Mann-Whitney-Wilcoxon test.

Results: Prosthetic-based breast reconstruction was associated with increased major breast complications (p < 0.001), mastectomy skin flap necrosis (p = 0.009), infection (0.006), and overall reconstructive failure (p < 0.0001) compared with autologous reconstruction. When evaluating the results of the BREAST-Q studies, the autologous reconstruction group had improved satisfaction with breasts (p < 0.0001), satisfaction with outcome (p = 0.01), psychosocial well-being (p = 0.007), and sexual well-being (p = 0.006).

Conclusion: In the obese population, reconstruction with free tissue transfer from the abdomen resulted in decreased complications of the breast reconstruction site and improved patient satisfaction with outcomes compared with prosthetic reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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Milwaukee, Wis.; Murray, Utah; and Chicago, Ill.

From the Department of Plastic Surgery, Medical College of Wisconsin; the Division of Plastic Surgery, Intermountain Healthcare; and the Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine.

Received for publication March 27, 2018; accepted November 12, 2018.

Disclosure:None of the authors has any commercial association that might pose a conflict of interest with information presented in this article.

John A. LoGiudice, M.D., Department of Plastic Surgery, Medical College of Wisconsin, 1155 North Mayfair Road, Suite T2600-South Entry, Milwaukee, Wis. 53202, jlogiudi@mcw.edu

Obesity, defined as a body mass index greater than 30 kg/m2, is reaching epidemic proportions. In 2010, over one-third of U.S. adults, or 72 million people, were classified as obese.1 This significant increase in obese patients is reflected in the breast cancer population seeking breast reconstruction. The plastic surgeon is then faced with a difficult decision, to determine the reconstructive method that will yield the best general and aesthetic outcomes and patient satisfaction.

Obesity is considered a risk factor for surgery given the increased incidence of coronary artery disease, hypertension, diabetes mellitus, obstructive sleep apnea, hyperlipidemia, and venous disease. Obese patients often also have increased anesthesia risk because of their body habitus and its influence on airway control. In addition, obese patients undergoing breast reconstruction are at increased risk for complications including wound dehiscence, skin and fat necrosis, seroma, partial and total flap failure, and overall reconstruction failure. Several studies in the plastic surgery literature compared autologous and prosthetic reconstruction between obese and nonobese patients and found an increased complication rate and a decreased satisfaction rate in the obese group.2–9 The literature offers few comparisons between prosthetic and autologous breast reconstruction in the obese population. A 2012 study by Garvey et al. found increased failure rates with implant-based breast reconstruction when compared with autologous reconstruction in the obese population.9

Autologous reconstruction, most commonly using pedicled or free tissue transfer from the abdomen, has the advantage of producing favorable results that closely mimic the shape, softness, mobility, and warmth of the natural breast. The greatest aesthetic advantage, however, is the availability of tissue in the abdomen in this patient population, which provides a good volume match in the breast that is proportionate to their body habitus. The disadvantage of autologous reconstruction is prolonged operative time, more extensive dissection in the donor site, and the addition of more wounds and potential healing problems and increased risk of fat necrosis and partial flap failure in the thick abdominal flaps. Prosthetic reconstruction, in contrast, is limited by the available size of implants. The maximum implant size is usually small relative to the obese patient’s body habitus, leading to inferior aesthetic outcomes. In addition, prosthetic reconstruction requires multiple operations and has its own risks of skin necrosis, postoperative seroma, hematoma, infection, expander extrusion, and failure. Our study aims to directly compare prosthetic and autologous reconstruction in the obese population by evaluating surgical outcomes and patient satisfaction.

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PATIENTS AND METHODS

In an institutional review board–approved study, a retrospective chart review was conducted on patients who underwent breast cancer reconstruction after mastectomy with either a free tissue transfer from the abdomen or prosthetic reconstruction over a 3-year period from January 1, 2009, to December 31, 2011, at our institution (Froedtert Memorial Lutheran Hospital, Milwaukee, Wis.). A search of billing records by CPT codes was conducted and identified 96 patients. All of the patients were treated at the same institution by the Department of Plastic Surgery, by two different surgeons (J.B.H. and J.A.L.). We excluded patients with a body mass index lower than 30.0 kg/m2.

Free tissue transfer from the abdomen included a deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric artery flap, or a muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flap. Patients underwent preoperative planning with computed tomographic angiography to evaluate the perforators. Anastomosis was performed to the internal mammary artery in the majority of cases. The thoracodorsal vessels were the backup in cases of extensive scarring of the internal mammary vessels from radiation therapy. Arterial anastomosis was hand-sewn and the venous anastomosis was performed using a coupling device (Synovis, Birmingham, Ala.). Two closed suction drains were placed in the abdomen and two were placed in the breast reconstruction. The fascia was closed in one layer with permanent interrupted figure-of eight suture, followed by a three-layer abdominal skin closure.

All implant reconstructions were completed using textured anatomical expanders or Spectrum implants (Mentor Worldwide LLC, Santa Barbara, Calif.). The implants were placed in the submuscular position with cadaveric human acellular dermis from the pectoralis major to the new inframammary fold. Intraoperative tissue expansion was completed with the volume depending on tissue tolerance. Two closed suction drains were used. Postoperative expansion was carried out until 110 percent of the desired volume was achieved. In patients who had undergone radiation therapy, expansion to preoperative breast volume was attempted based on the health of the skin envelope and patient tolerance.

Mastectomy flaps with questionable perfusion were evaluated with intraoperative perfusion mapping with laser-assisted indocyanine green imaging (LifeCell Corp., Bridgewater, N.J.). This imaging was also used to evaluate the perfusion of the abdominal flap before transfer to the chest. All patients received perioperative antibiotics for 23 hours. All patients received deep vein prophylaxis with subcutaneous heparin unless a contraindication existed. In patients with free tissue transfer, this began intraoperatively or immediately postoperatively in the recovery room. In patients with tissue expanders, this began postoperatively; however, a dose was typically held in patients who had an epidural pain catheter.

Variables recorded included age, race, body mass index, comorbidities, and tobacco use at the time of consultation and surgery. Tobacco use, not the duration of abstinence from tobacco use, was documented before consultation or the date of surgery. Breast cancer treatment history was recorded, including stage of breast cancer, radiation therapy, and chemotherapy. Radiation therapy was further classified as before or after reconstruction radiation. Chemotherapy was classified into neoadjuvant and adjuvant therapy.

Postoperative variables included length of hospital stay, readmission, total days until the last drain was removed, total days until the implant device was filled, total number of clinic visits, total number of days of follow-up, and need for reoperation or secondary procedures. Secondary procedures were planned second-stage procedures and included lipofilling for contour abnormalities, nipple reconstruction, contralateral symmetry procedure, flap revision, and implant exchange. Reoperation was defined as an unplanned return to the operating room. Operative complications recorded were seroma of the flap or abdomen, hematoma of the flap, mastectomy skin flap necrosis, fat necrosis, flap compromise, flap thrombosis, flap failure, flap or donor-site infection, delayed healing of the donor site, bulge or hernia, umbilical necrosis, capsular contraction, implant infection, extrusion, and implant failure. Mastectomy skin flap necrosis was further broken down by severity into mild, with observation only; moderate, requiring dressing changes and/or clinic débridement; and severe, requiring a reoperation for débridement. Fat necrosis was defined as a 1 × 1-cm palpable firmness and further classified if this required a reoperation for excision. Flap compromise is a flap that had a change in clinical or Doppler examination that required a reoperation for exploration. Flap failure is a flap that on reoperation was determined to be unsalvageable. Flap, abdominal, or implant infection was further classified by severity into mild, with clinical erythema and warmth requiring oral antibiotics; moderate, requiring admission for intravenous antibiotics; and severe, with operative irrigation and débridement. Delayed healing of the abdomen was defined as mild if the breakdown required only local wound treatment and severe if reoperation was necessary for débridement and closure. Implant extrusion is an implant that is visible and implant failure defines the necessity to completely remove the implant because of complication. Other complications recorded included pneumothorax, transfusion, pulmonary embolism, deep venous thrombosis, urinary tract infection, myocardial infarction, and cerebrovascular accident.

All patients were sent the BREAST-Q questionnaire (Memorial Sloan Kettering Cancer Center and The University of British Columbia 2006, all rights reserved) by means of mail to study the impact and effectiveness of breast surgery from the patient’s perspective.10–12 This is a well-validated survey to evaluate both quality of life and satisfaction. The survey was sent a second time if no response was received within 1 month.

Two analyses were performed: one treating patients as the sample unit (per patient), and a second where each flap was treated as an independent measurement (per flap). No separate analysis was performed for immediate versus delayed reconstruction. The Mann-Whitney-Wilcoxon test was used to compare continuous measures between flap/implant groups, and the chi-square test, Fisher’s test, or Mantel-Haenszel chi-square trend test was used for categorical and ordinal measures. Exact calculations for chi-square p values were used where needed because of small expected cell counts in some tables. For survey data, groups were compared using the Mann-Whitney-Wilcoxon test. The analysis was performed using SAS version 9.3 (SAS Institute, Inc., Cary, N.C.).

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RESULTS

The prosthetic reconstruction cohort consisted of 43 patients and 59 reconstructions, compared to 53 patients and 82 flaps in the autologous reconstruction group. The groups were similar with regard to age, body mass index, and race (Table 1). Although the prosthetic reconstruction group had more comorbidities, when looking at individual comorbidities, there were no differences. No patients were smoking at the time of reconstruction in either group. There were no differences in breast cancer stage or chemotherapy administration; however, there was more postoperative radiation therapy in the implant group (48.8 percent versus 0 percent; p < 0.0001). There was no difference in mastectomy weight in either group (p = 0.15). The majority of patients had immediate reconstruction; however, there was significantly more delayed reconstruction in the autologous group (29.1 percent versus 2.3 percent; p < 0.001). There was no difference in the choice of unilateral versus bilateral reconstruction (p = 0.22). Follow-up averaged 337 days in the prosthetic reconstruction group and 370 days in the autologous reconstruction group (p = 0.54) (Table 1).

Table 1. - Patient Characteristics by Reconstructive Type
Characteristics Implant Flap
Immediate (%) Delayed (%) Immediate (%) Delayed (%)
No. of patients 42 1 27 26
Age, yr
 Median 49 54 51 50.5
 Range 27–74 26–68 32–71
BMI, kg/m2
 Median 34.4 44 33.2 32.7
 Range 30.1–56.3 30.3–39.4 30.2–40.2
Race
 Caucasian 35 (83.3) 1 (100) 25 (92.6) 24 (92.3)
 African American 5 (11.9) 0 (0) 1 (3.7) 2 (7.7)
 Asian 0 (0) 0 (0) 1 (3.7) 0 (0)
 Hispanic 2 (4.8) 0 (0) 0 (0) 0 (0)
Comorbidities 34 (81.0) 1 (100) 13 (48.2) 18 (69.2)
 Diabetes 9 (21.4) 0 (0) 5 (18.5) 0 (0)
 Pulmonary 5 (11.9) 0 (0) 3 (11.1) 3 (11.5)
 Cardiac 8 (19) 0 (0) 2 (7.4) 4 (15.4)
 Hypothyroidism 11 (26.2) 0 (0) 4 (14.8) 9 (34.6)
 History of thromboembolism 6 (14.3) 0 (0) 3 (11.1) 2 (7.7)
 HTN 19 (45.2) 1 (100) 9 (33.3) 13 (50)
Smoking
 At consultation 1 (2.4) 0 (0) 0 (0) 2 (7.7)
 At surgery 0 (0) 0 (0) 0 (0) 0 (0)
Stage
 0 3 (7.1) 0 (0) 4 (14.8) 1 (4.4)
 1 8 (19) 9 (20.9) 12 (44.4) 4 (4.4)
 II 14 (33.3) 0 (0) 5 (18.5) 7 (30.4)
 III 15 (35.7) 0 (0) 2 (7.4) 9 (39.1)
 IV 1 (2.4) 0 (0) 0 (0) 0 (0)
 Prophylactic 1 (2.4) 0 (0) 4 (14.8) 2 (8.7)
 Bilateral breast cancer 5 (9.4) 2 (7.4) 3 (11.5)
Radiation therapy
 None 19 (45.2) 1 (100) 16 (30.2) 7(13.2)
 Preoperative 2 (4.8) 0 (0) 9 (17) 19 (73.1)
 Postoperative 20 (47.6) 0 (0) 0 (0) 0 (0)
Chemotherapy
 None 11 (25.6) 1 (100) 15 (55.6) 7 (13.2)
 Preoperative 10 (23.3) 0 (0) 0 (0) 4 (7.6)
 Postoperative 19 (44.2) 0 (0) 12 (44.4) 15 (28.3)
Length of follow-up, days 339 (117–1012) 190 370 (64–1233) 0.54
Laterality
 Unilateral 26 (60.5) 1 (100) 14 (51.9) 12 (46.2)
 Bilateral 16 (37.2) 0 (0) 13 (48.2) 14 (53.9)
Mastectomy weight for immediate reconstruction, g 972.8 859.9
B
MI, body mass index; HTN, hypertension.

Table 2 shows the different reconstructive groups. The majority of prosthetic reconstructions (76.3 percent) were completed with a staged tissue expander to implant, and the majority of autologous reconstructions were completed with a DIEP flap (69.5 percent). Patients in the autologous reconstruction group had a longer length of stay during initial hospitalization (4.7 days versus 2.2 days; p < 0.0001). However, the prosthetic group had more readmissions (30.2 percent versus 11 percent; p = 0.02). There were more reoperations in the prosthetic implant group (48.8 percent versus 37.7 percent), but this did not reach statistical significance. There was no difference in time until drains were pulled; however, prosthetic reconstruction groups had more postoperative clinic visits (7 versus 5.2; p < 0.0001) (Table 3).

Table 2. - Reconstruction Types
Reconstruction No. (%)
Flap type
 DIEP 57 (69.5)
 MS-TRAM 22 (26.8)
 SIEA 3 (3.66)
Implant
 Staged tissue expander 45 (76.3)
 Spectrum implant 14 (23.7)
M
S, muscle-sparing; SIEA, superficial inferior epigastric artery.

Table 3. - Postoperative Outcomes by Patient
Characteristics Implant Flap
Immediate (%) Delayed (%) Immediate (%) Delayed (%)
No. of patients 42 1 27 26
Length of stay, days 2.3 ± 0.8 1 4.7 ± 0.8 4.7 ± 1
Readmission 13 (31) 0 4 (15)* 2 (8)*
Reoperation 21 (50) 0 14 (51.9) 6 (23.1)
Postoperative drain, days 25.7 ± 11.1 17 26 ± 12 22 ± 11
Visits 7.1 ± 2.8 6 5.7 ± 3.1 4.8 ± 2.4
*
p = 0.56 between flap immediate vs. delayed.
p = 0.005 between flap immediate vs. delayed.

The rate of major complications (overall) per reconstruction was higher in the flap immediate versus delayed groups (14.6 versus 2.4; p = 0.004) (Table 4). Likewise, reoperation per patient was higher in the flap immediate versus delayed group (51.9 versus 23.1; p = 0.005) (Table 3). It appears that a significant number of complications in the flap immediate group are related to mastectomy skin flap compromise. There was no difference in average follow-up in these subgroups.

Table 4. - Postoperative Breast Outcomes by Reconstruction Type and Timing
Characteristics Implant Flap
Immediate (%) Delayed (%) Immediate (%) Delayed (%)
No. of patients 42 1 42 40
Major complication 28 (47.5) 0 (0) 12 (14.6)* 2 (2.4)*
Seroma 6 (10.2) 0 (0) 4 (4.9) 1 (1.2)
Hematoma 0 (0) 0 (0) 1(2.4) 0 (0)
Mastectomy skin flap necrosis
 Mild 9 (15.3) 0 (0) 6 (14.3) 0 (0)
 Moderate 0 (0) 0 (0) 2 (4.8) 0 (0)
 Severe 18 (30.5) 0 (0) 10 (23.8) 1 (2.5)
Infection
 Mild 12 (20.3) 0 (0) 10 (12.2) 1 (2.5)
 Moderate 2 (3.4) 0 (0) 0 (0) 1 (2.5)
 Severe 8 (13.6) 0 (0) 3 (3.7) 0 (0)
Failure 14 (23.7) 0 (0) 0 (0) 0 (0)
*
p = 0.004 between flap immediate vs. delayed.

When comparing clinical outcomes per breast reconstruction site, the prosthetic reconstruction group had increased major complications (p < 0.0001), mastectomy skin flap necrosis (p = 0.009), and infection (p = 0.006). Of the 18 patients with severe mastectomy skin flap necrosis, nine were treated for infections. In the mild mastectomy skin flap necrosis group, three of nine were treated for infection. Overall reconstruction failure was significantly higher in the prosthetic reconstruction group (23.7 percent) than in the autologous reconstruction group (1.2 percent) (p < 0.0001) (Table 4). Reconstructive failure in the implant group was caused by implant exposure and/or infection. Of the 14 implant-based breast reconstructions that failed, nine eventually had autologous reconstruction, but these flap numbers were not included in this series.

The overall fat necrosis rate was 31.6 percent in the DIEP flap group and 13.6 percent in the muscle-sparing TRAM flap group, but this was not statistically significant (p = 0.07). The fat necrosis rate requiring operative débridement was 10.5 percent in the DIEP flap group and 13.6 percent in the muscle-sparing TRAM flap group, but this was not statistically significant (p = 0.35). Donor-site complications for the autologous reconstruction group are shown in Table 5, which shows that 52.8 percent of patients experienced a donor-site complication, most commonly delayed healing or donor-site infection. Only 7.5 percent of patients experienced a bulge or hernia.

Table 5. - Donor-Site Outcomes by Patient
Characteristic No. (%)
Any donor-site complication 28 (52.8)
Any major donor-site complication 12 (22.6)
Bulge/hernia 4 (7.5)
Donor healing 15 (28.3)
 Mild 10 (18.8)
 Severe 5 (9.4)
Umbilical necrosis 4 (7.5)
Fascial dehiscence 1 (1.9)
Seroma 5 (9.4)
Donor-site infection 14 (26.4)
 Mild 12 (22.6)
 Moderate 0 (0)
 Severe 2 (3.8)

Medical complications were rare in the postoperative period (Table 6). The most common was a urinary tract infection in 7 percent of the prosthetic reconstruction group and transfusion in 3.8 percent of the autologous reconstruction group. Deep venous thrombosis occurred in one patient per group.

Table 6. - Medical Complications by Patient
Implant (%) Flap (%)
No. of patients 43 53
Other complications
 Pneumothorax 0 (0) 1 (1.9)
 Transfusion 0 (0) 2 (3.8)
 Pulmonary embolism 1 (2.3) 0 (0)
 Deep venous thrombosis 1 (2.3) 1 (1.9)
 Urinary tract infection 3 (7.0) 0 (0)
 Myocardial infarction 0 (0) 0 (0)
 Cerebrovascular accident 0 (0) 0 (0)

Results of the BREAST-Q questionnaire showed improved overall satisfaction in the autologous reconstruction group versus the implant group (Table 7). The autologous reconstruction group also showed increased satisfaction with breasts (p < 0.0001), satisfaction with outcome (p = 0.01), psychosocial well-being (p = 0.007), and sexual well-being (p = 0.006). There was no statistical significance between the immediate versus delayed flap respondents.

Table 7. - BREAST-Q Scores by Reconstructive Method per Patient
BREAST-Q Category Implant (n = 16) Flap (n = 35)* 95% Median-Difference CI p
Satisfaction with Breasts 54 (0–91) 78 (52–100) 31 (15–43) <0.001*
Satisfaction with Outcome 67 (0–100) 86 (47–100) 16 (0–33) 0.01*
Psychosocial Well-being 63 (26–100) 94 (53–100) 18 (8–34) 0.007*
Sexual Well-being 39 (0–100) 67 (32–100) 30 (15–49) 0.0006*
Physical Well-being: Chest 74 (36–100) 79 (49–100) 7 (−3–17) 0.21
Physical Well-being: Abdomen 89 (47–100)
Satisfaction with Nipples 35 (35–89) 85 (0–100) 20 (−34–65) 0.21
Satisfaction with Information 74 (43–100) 85 (60–100) 9 (0–25) 0.09
Satisfaction with Surgeon 100 (53–100) 100 (58–100) 0 (0–0) 0.81
Satisfaction with Medical Staff 100 (59–100) 100 (28–100) 0 (0–0) 0.24
Satisfaction with Office Staff 100 (100–100) 100 (40–100) 0 (0–0) 0.18
Overall Satisfaction 68.5 (37–96.2) 85.1 (60.2–99.2) 14 (4.6–21.6) 0.002*
*
No statistical difference immediate vs. delayed flap reconstruction.

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DISCUSSION

Obesity has long been considered a relative contraindication to both pedicled and free TRAM flap breast reconstruction because of increased incidences of fat necrosis, flap loss, and infection.2–4,13–15 Vyas et al. reviewed 279 patients undergoing free flap breast reconstruction and found bilateral reconstruction and obesity to be significant risk factors for donor-site complications.16 Chang et al. compared 64 obese patients with 654 normal or overweight patients who underwent free TRAM flap breast reconstruction.3 Obesity was found to be an independent predictor of both flap and donor-site complications. They noted a nearly two-fold increase in donor-site complications in obese patients compared with nonobese patients (19.8 percent versus 11.1 percent). In a review of 1170 expander/implant reconstructions by McCarthy et al., obesity was an independent risk factor for perioperative complications. Obese patients were two times more likely to have complications and seven times more likely to have reconstruction failure compared to nonobese patients. This study found a 25 percent complication rate in the obese patients.5 Jandali et al. reviewed their experience with autogenous reconstruction in morbidly obese patients (body mass index ≥ 40 kg/m2) and showed an increased risk of total flap loss, total major postoperative complications, and delayed abdominal wound healing in the morbidly obese compared with the rest of the patients.6 The literature contains few direct comparisons between prosthetic and autologous reconstruction in the obese population. Recently, Garvey et al. published results of 990 reconstructions in 700 patients, and although there were more overall complications in the flap group, there were more failures in the implant group.9

Although these studies have shown higher complication rates in the obese population when compared to those with a normal body mass index, this procedure can still be performed safely. Although 17.1 percent of patients had a major breast reconstruction complication and 22.6 percent had a major donor-site complication, only 7.5 percent of patients had a medical complication postoperatively, and the total reconstructive failure rate was 1.2 percent. This compares to a 47.5 percent overall major breast reconstruction complication rate in the prosthetic reconstruction group, with reconstructive failure occurring in 23.7 percent of patients.

Clearly, mastectomy skin flap necrosis had a major impact on this failure rate in the implant group. Likewise, in the immediate flap group, mastectomy skin flap necrosis influenced the reoperation rate and contributed to the overall complication rate compared with the delayed flap group. The authors used a variety of approaches to minimize the impact of mastectomy skin flap compromise on the reconstruction. A low threshold for radical skin débridement because of compromise to perfusion of skin flaps based on clinical examination or intraoperative vascular angiography has decreased the rate of severe mastectomy skin flap necrosis. Underfilling of tissue expander devices has also been used to facilitate healing of mastectomy skin flaps that might be vulnerable. Patients undergoing prosthetic reconstruction had more postoperative clinic visits and higher readmission rates.

Atisha et al. studied the impact of obesity on patient satisfaction after breast reconstruction with expander/implant and TRAM flaps among 262 patients. Patient body mass index had a significant effect on aesthetic satisfaction, particularly among patients undergoing expander/implant procedures. Compared with normal weight individuals, obese patients with expanders/implants were significantly less satisfied aesthetically. However, there was no significant difference between obese and normal-weight patients in aesthetic satisfaction with TRAM flap reconstruction.14

Reconstruction with autologous tissue more closely approximates the natural breast, especially by providing a good volume match of the reconstructed breast to the patient’s body habitus. Implant reconstruction can be inferior aesthetically, as the maximum size implant often appears small relative to the body habitus. An alternative to abdominally based reconstruction in this population, the latissimus dorsi flap (and variants), has been avoided by the authors because of the volumetric constraints inherent in this flap. Combining the latissimus dorsi flap with an implant adds inherent liability to the reconstruction, both short and long term, in the form of infection and need for future exchange.17 Using the well-validated BREAST-Q survey, we were able to evaluate patient satisfaction with reconstructive outcomes. Obese patients receiving autologous reconstruction were significantly more satisfied overall, especially with regard to their breasts, outcomes, psychosocial well-being, and sexual well-being.

There are limitations of our study. In a retrospective chart review, all complications may not be captured; however, we have follow-up that averages 1 year in both groups, and we maintain a close relationship with the surgical, radiation therapy, and medical oncologists who continue to follow these patients long term. The BREAST-Q survey was only administered postoperatively and not obtained at a fixed time point. The survey was administered between 1 and 3 years postoperatively. A study on patient satisfaction with autologous tissue breast reconstruction by Zhong et al. demonstrated that satisfaction scores improved during the initial postoperative period.18 The earliest survey in our study was administered at 1 year postoperatively, at which time the patients should have achieved stable postoperative healing. Our overall survey response rate was only 55 percent, 67 percent in the autologous reconstruction group and 41 percent in the prosthetic reconstruction group. The literature shows an average mail survey response rate of 60 percent.19 The lower response rate in the prosthetic reconstruction group could increase our nonresponder bias. Future studies could be conducted with prospectively obtained data with both preoperative and postoperative surveys at a fixed time point.

Our study did have a significantly higher rate of postreconstruction radiation therapy in the implant reconstruction group (48.8 percent versus 0 percent). Further analysis of the 14 reconstructive failures, however, revealed that nine of the failures occurred before adjuvant chemotherapy or radiation therapy had started. The majority of these failures were attributable to severe mastectomy skin flap necrosis that resulted in infection.

With one-third of women in the United States classified as obese, the plastic surgeon is confronted with determining the best breast reconstructive method for this population with regard to outcomes, safety, and patient satisfaction. Breast reconstruction in the obese population using free tissue transfer from the abdomen compared with prosthetic reconstruction has decreased complications of the breast reconstruction site, decreased overall reconstructive failure, and improved patient satisfaction. Although this population may have increased complication and failure rates when compared to normal body mass index patients, obese patients can safely undergo free autologous tissue breast reconstruction with better aesthetic outcomes and patient satisfaction than those undergoing implant-based reconstruction.

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ACKNOWLEDGMENTS

This work was supported by resources of the Department of Plastic Surgery, Medical College of Wisconsin. The authors give special thanks to the statistical assistance from Daniel Eastwood in the Medical College of Wisconsin Biostatistics Department. This service is supported by funds from the Division of Biostatics, Department of Population Health, and the Clinical Translational Science Institute of Southeast Wisconsin. The authors also are grateful to Beth at Medical Wordsmith for assistance in the preparation of this article. For BREAST-Q information and permission to use, contact MAPI Research Trust, Lyon, France (e-mail: PROinformation@mapi-trust.org; website: www.mapi-trust.org).

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