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Patient Selection For DIEP Flap Breast Reconstruction In The Obese Population: Stratifying Surgical Risk Factors For Patient Inclusion Or Exclusion
Avinash P. Jayaraman, B.A.1, Ryan M. Dickey, M.D.1, Julie L. Cooper, B.S.1, Yash Kadakia, B.A.1, Ricardo Garza, B.S.1, Sami U. Khan, M.D.2, Nicholas T. Haddock, M.D.1, Sumeet S. Teotia, M.D.1.
1UT Southwestern, Dallas, TX, USA, 2Stony Brook University, Stony Brook, NY, USA.

PURPOSE: Morbid obesity presents numerous challenges in autologous breast reconstruction. Along with considering other medical comorbidities, BMI alone can serve as an overall denominator in the decision-making process to recommend reconstruction
METHODS: Retrospective chart review was performed on N = 316 patients who underwent breast reconstruction using DIEP flaps (n=581 flaps). Patients were divided into two groups: patients with BMI < 35 (Group 1, N1=240 patients, n1=438 flaps), and patients with BMI ≥ 35 (Group 2, N2=76 patients, n2=143 flaps). Comorbidities including age, BMI, hypertension, diabetes, autoimmunity, smoking status, previous DVT/PE, and previous abdominal surgery were tracked. Donor site complications including wounds, infection, seroma, hematoma, and DVT/PE, and abdominal bulge were tracked. Flap losses, hospital stay, and completion of reconstruction (receipt of either nipple tattoo or nipple reconstruction) were tracked. Data was collected using a centralized REDCap database. Analysis was performed with SPSS: continuous variables were analyzed with t-tests, and binary variables were analyzed with Chi-Square (χ2). Univariate & multivariate analyses were used to control for group differences.
RESULTS: Age, comorbidities, and past medical histories were equivalent between groups, except for diabetes (Group 1 = 7%, Group 2 = 21%, p<.01) and prior abdominal surgery (Group 1 = 73%, Group 2 = 84%, p=.046). Rates of wounds requiring operation (p=.228), infections requiring IV antibiotics (p=.892), seromas requiring operation (p=.422), hematomas requiring operation (p=.580), pneumothorax (p=.538), DVT (p=.837), and PE (p=.315) were equivalent. Post-op SICU stay (p=.385) and total hospital stay (p=.173) were equivalent. Completion of reconstruction was significantly lower in Group 2 (49%) than in Group 1 (73%), p<.01. Flap loss was significantly higher in Group 2 (3/143, 2.1%) than in Group 1 (3/438, 0.68%), p<.01. Overall flap loss was 6/581 (1.03%).
CONCLUSION: In our study, DIEP reconstruction in BMI ≥ 35 is associated with three-fold increase in flap loss, and lower likelihood of finishing the reconstruction process. This could be accounted by higher rates of diabetes and prior abdomininal surgery in Group 2, though this was controlled in our analysis. Rate of flap loss was still quite low in Group 2 (2.1%), and this is markedly lower than published rates of implant failure in obese patients (~10-15%). Based on individual practice patterns, patients with BMI ≥ 35 can be educated of their higher risks in consideration as a candidate for free flap breast reconstruction while keeping in mind that there is still a higher likelihood of success when compared to implants.

Table 1. Patient Characteristics and Comorbidities.
Group 1 N1 = 240 pts; n1 = 438 flaps (BMI < 35)Group 2 N2 = 76 pts; n2 = 143 flaps (BMI ≥ 35)p-value
BMI (kg/m2)29.138.7<.001*
Age (years)51.351.7.776
Hypertension83/240 (35%)33/76 (43%).164
Diabetes17/240 (7.1%)16/76 (21%)<.01*
Autoimmune21/240 (8.8%)3/76 (3.9%).168
History of DVT/PE7/240 (2.9%)6/76 (7.9%).057
Current/Former Smokers67/240 (27%)20/76 (26%).785
Prior Abdominal Surgery175/240 (73%)64/76 (84%).046*
Prior Chest Radiation90/240 (38%)34/76 (45%).260

Table 2. Post-Op Complications.
Group 1 N1 = 240 pts; n1 = 438 flaps (BMI < 35)Group 2 N2 = 76 pts; n2 = 143 flaps (BMI ≥ 35)p-value
Flap Loss3/438 (0.68%)3/143 (2.1%).024*
At Least One Donor Wound (abdominal or umbilical)16/240 (6.7%)11/76 (14%).228
At Least One Donor Infection (abdominal or umbilical)7/240 (2.9%)4/76 (5.3%).892
Abdominal Seroma5/240 (2.1%)1/76 (1.3%).422
Abdominal Hematoma3/240 (1.5%)0/76 (0%).580
Hernia/Bulge8/240 (3.3%)4/76 (5.3%).693
Pneumothorax4/240 (1.7%)2/76 (2.6%).538
DVT1/240 (0.41%)0/76 (0%).837
PE4/240 (1.7%)1/76 (1.3%).280

Table 3. Other Post-Operative Outcomes.
Group 1 N1 = 240 pts; n1 = 438 flaps (BMI < 35)Group 2 N2 = 76 pts; n2 = 143 flaps (BMI ≥ 35)p-value
Procedure Time (mins)506566<.01*
Completion of Reconstruction175/240 (73%)37/76 (49%)<.01*
Hospital Course Unplanned Return to OR19/240 (7.9%)6/76 (7.9%).853
Post-Flap SICU Stay (nights)2.232.33.385
Post-Flap Total Hospital Stay (nights)4.084.24.173
Number of Revision Surgeries1.521.45.606


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