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Potential Risk Factors for Worsening Abdominal Well-Being after Abdominal Flap Breast Reconstruction: There's No Such Thing As a Free Tummy Tuck
Meredith L. Meyer, MD1,2, Ricardo J. Bello, MD, MPH1, Charalampos Siotos, MD1, Mohamad E. Sebai, MBBS1, Rachael M. Payne, BS1, Michele A. Manahan, MD1, Justin M. Sacks, MD, MBA1, Carisa M. Cooney, MPH1, Gedge D. Rosson, MD1.
1Johns Hopkins University, Baltimore, MD, USA, 2Inova Fairfax Medical Center, Falls Church, VA, USA.

Purpose: Patient-reported lower satisfaction with the abdomen preoperatively is a strong predictor of undergoing a DIEP flap. This may suggest that patients have specific expectations regarding their postoperative donor site outcomes. Whether these expectations are actually met has not been well documented. Therefore, we evaluated physical well-being of the abdomen before and after flap-based breast reconstruction to determine potential predictors for decreased postoperative abdominal well-being.
Methods: We retrospectively analyzed a prospectively-maintained institutional breast reconstruction registry, selecting patients who underwent abdominally-based autologous flap breast reconstruction from 2010 to 2015. Our primary outcome was the Physical Well-being of the Abdomen (PWA) domain from the Breast-Q, measured preoperatively and at 6- and 12-month follow-up visits after final reconstruction. We classified patients into 2 groups: those who experienced a clinically-important worsening of PWA (wPWA group) from baseline to 12-month follow-up (defined as a decrease of > 7 points) and those who did not (control group). We used Chi-squared test, t-test, and Wilcoxon rank-sum test to examine potential predictors of decreased PWA. We then fitted a multivariable logistic regression model including variables with p<0.2 in a univariate analysis to estimate which variables may be potential risk factors for worsened PWA.
Results: We identified 142 women who met inclusion and exclusion criteria. Of these, 74 (52%) experienced a clinically-important worsening of PWA, whereas 68 (48%) did not. The wPWA group experienced an average decrease in PWA of 25 points compared to baseline (95% CI[22-28] p<0.001). The control group experienced an average increase in PWA of 8 points compared to baseline (95% CI[5-10] p<0.001). Based on univariate analysis, we fitted a predictive multivariable logistic regression model (Table 1) including race, depression, hypertension, BMI, bilateral reconstruction, baseline PWA, and baseline RAND-36 general health scores (of p<0.2). This analysis showed an association between a higher baseline PWA (p<0.001) and race (p=0.009) with higher odds of decreased PWA at the 12-month follow-up. A higher baseline RAND-36 general health score, bilateral reconstruction (versus unilateral), and a lower BMI demonstrated a trend for clinically-important worsening of PWA.
Conclusions: Our results show that more than half of flap-based breast reconstruction patients experienced clinically-important worsening of abdominal well-being pre- to post-final breast reconstruction. This is at odds with the often-misleading notion of obtaining a “free” abdominoplasty in conjunction with breast reconstruction. Patients with higher preoperative abdominal well-being Breast-Q scores, lower BMI, and higher RAND-36 general health scores tend to have worsened well-being of the abdomen after flap-based breast reconstruction. Our finding that African-American patients and those classified under “Other” races are independently associated with significant worsening of PWA may be due to confounding factors that should be explored in larger, prospective studies. Clinicians may use these findings to identify patients at higher risk of worsened postoperative abdominal well-being and appropriately counsel them regarding realistic post-operative expectations.
Table 1: Multivariable logistic regression model for potential risk factors for clinically important worsening of physical well-being of the abdomen.
VariableOR95% CIp-value
Baseline Breast-Q Physical Well-being of Abdomen1.071.031.11<0.001
Baseline RAND-36 General health1.021.001.050.051
Bilateral reconstruction1.980.884.440.099
Body-Mass Index0.930.851.010.075
Hypertension0.480.181.270.140
Smoking status1.470.713.060.300
Diabetes1.760.2313.160.584
Depression0.630.241.710.368
RaceWhiteReference0.009
African American3.931.2911.96
Asian0.350.034.79
Other8.371.1262.54


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