Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA.
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The association between body mass index (BMI) and surgical complications has been of great interest in recent years given the rise of obesity worldwide. Current evidence shows that there is a strong correlation between obesity and the rate of complications following breast reconstruction, such as wound dehiscence, superficial wound infection, and graft or flap loss. Although malnutrition has been identified as a risk factor for poor wound healing and the effects of reconstruction, no articles have examined the impact of low BMI on the outcomes of breast reconstruction.
The authors present a retrospective study involving 4,676 prosthetic or autologous breast reconstruction patients (136 of which were underweight) recorded on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database between 2006 and 2011. The authors show that underweight patients undergoing autologous reconstruction have higher total and surgical complication rates, but lower reoperation and medical complication rates whereas, underweight patients undergoing prosthetic reconstruction have higher medical complication rates, but lower reoperation, total and surgical complication rates. However, none of these findings are statistically significant on multivariate analysis.
Despite the great efforts by the authors to answer the very important question of whether low BMI has impact on breast reconstruction, there are certain limitations that readers should consider when interpreting the results of this study. Firstly, the spectrum of breast cancer therapy produces a varied range in complication rates and types: simple mastectomy (4-5.72%),[4,5] skin-sparing mastectomy (15.1-64.2%),[6,7] and nipple-sparing mastectomy (12.4-22%).[8,9] Each modality has benefits and short falls, and some of the complications might be enhanced by a low BMI and poor nutrition such as skin flap necrosis, with the rate reported as 0-6.3% for skin-sparing mastectomy, and 5.2-9.5% for nipple-sparing mastectomy,[9,10] or nipple-necrosis with the rate reported as 4.4-9.2%[8,9,11] in nipple-sparing mastectomy. Given the heterogeneity in complications rates, it would have been interesting to see if the effect of the type of mastectomy was a confounding factor in the results. Furthermore, breast conservation therapy (BCT) accounts for the majority of breast cancer treatment in the United States and the readers have to be mindful that the conclusions drawn by this article do not apply to partial breast reconstruction. Therefore, future research warrants inclusion and analysis of each type of breast cancer therapy modality.
Secondly, the stratification of patients into prosthesis and autologous categories does not take into account the heterogeneity of complications among the different types of breast reconstruction procedures. It is known that the rates of complications differ among patients who undergo pedicled flaps (58.5-67.9%) and those who undergo free flaps (17.7-26.9%).[13,14] Furthermore, it is known that patients’ BMI can have an impact on the rates of complications like skin flap necrosis, wound dehiscence, and graft and prosthesis loss.[2,15] Even within each type of reconstruction, there is a variation among the selected flap. For example, a meta-analysis by Wang et al. revealed a lower rate of fat necrosis (RR 0.502) and a higher rate of abdominal hernias (RR 2.354) in muscle-sparing transverse rectus abdominismyocutaneous (TRAM) flap than in deep inferior epigastric perforator flap. Therefore, it is challenging to group pedicled flaps (e.g. latissimusdorsi, or TRAM) with free flaps (e.g. TRAM, muscle-sparing TRAM, DIEP), because variation in complication rates exists among them, and each complication may be affected differently by low BMI. Unfortunately, ACS-NSQIP does not allow distinguish between specific free flap procedures, since all free flap reconstructions are grouped under the same CPT code, making it impossible to perform subgroup analysis. These limitations restrict the authors’ ability to accurately assess the impact of low BMI in breast reconstruction, since too much variation exists between breast reconstruction modalities. Therefore, future research warrants inclusion and analysis of each type of breast reconstruction modality. Most importantly, the authors omitted in the analysis, certain key complications like hematoma, seroma, fat necrosis, nipple necrosis, skin flap necrosis, and donor site complications, which are known issues of breast reconstruction procedures[1,15,16] and whose incidence could be affected by the patient’s BMI. The ACS-NSQIP dataset tracks certain complications for only 30 days and unfortunately does not include some very important and most relevant complications. A lack of data may have resulted in an under-reporting of complications in this study. Also, Epelboym et al. reported discordance in 27.3% of the time in complication reporting by the ACS-NSQIP including: missed complications, reported complications that did not occur, and misclassification of postoperative events. Once again, readers have to mindful of these significant limitations when drawing conclusions.
As illustrated by the authors, the small sample size confirms that breast reconstruction in patients with low BMI is not very common and an attempt to establish the etiology of being underweight unfortunately did not reach statistical significance. A patient with low BMI does not necessarily entail malnourishment. In fact, an obese patient may well be malnourished despite the high BMI. Studies have shown that malnourished patients often require longer hospitalizations, have more postoperative complications, and have delayed wound and fracture healing compared with well-nourished patients.[19,20] For this reason, all patients regardless of their BMI should be evaluated for their nutritional status, and ensure adequate preoperative calorie, protein, vitamin, and mineralintake. This helps optimization of the patient’s nutritional status and minimization of postoperative complications.
Low BMI is a poorly discussed topic and the limited number of eligible patients makes it challenging to obtain statistically significant results. We commend the authors for this study and we believe it provides a great starting point for debate. But because of the limitations (mostly dictated by the ACS-NSQIP data), we feel that definitive conclusions cannot be drawn from this study, but look forward to future research to evaluate the impact of low BMI in the varied spectrum of breast reconstruction.
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Conflicts of interest
There are no conflicts of interest.
1. Wang XL, Liu LB, Song FM, Wang QY. Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction. Aesthetic Plast Surg 2014;38:681-91.DOIPubMed
2. Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanchwala S. Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets. J Am Coll Surg 2013;217:656-64.DOIPubMed
3. Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg 2006;117:S42-58.DOIPubMed
4. El-Tamer MB, Ward BM, Schifftner T, Neumayer L, Khuri S, Henderson W. Morbidity and mortality following breast cancer surgery in women: national benchmarks for standards of care. Ann Surg 2007;245:665-71.DOIPubMedPMC
5. De Blacam C, Ogunleye AA, Momoh AO, Colakoglu S, Tobias AM, Sharma R, Houlihan MJ, Lee BT. High body mass index and smoking predict morbidity in breast cancer surgery: a multivariate analysis of 26,988 patients from the national surgical quality improvement program database. Ann Surg 2012;255:551-5.DOIPubMed
6. Kim Z, Kang SG, Roh JH, Park JH, Lee J, Kim S, Lim CW, Lee MH. Skin-sparing mastectomy and immediate latissimusdorsi flap reconstruction: a retrospective analysis of the surgical and patient-reported outcomes. World J Surg Oncol 2012;10:259.DOIPubMedPMC
7. Omranipour R, Bobin JY, Esouyeh M. Skin sparing mastectomy and immediate breast reconstruction (SSMIR) for early breast cancer: eight years single institution experience. World J Surg Oncol 2008;6:43.DOIPubMedPMC
8. Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. Breast reconstruction following nipple sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg 2013;132:1043-54.DOIPubMed
9. Colwell AS, Tessler O, Lin AM, Liao E, Winograd J, Cetrulo CL, Tang R, Smith BL, Austen WG Jr. Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg 2014;133:496-506.DOIPubMed
10. Piper M, Peled AW, Foster RD, Moore DH, Esserman LJ. Total skin-sparing mastectomy: a systematic review of oncologic outcomes and postoperative complications. Ann Plast Surg 2013;70:435-7.DOIPubMed
11. Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature. Plast Reconstr Surg 2013;131:969-84.DOIPubMed
12. Kummerow KL, Du L, Penson DF, Shyr Y, Hooks MA. Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg 2015;150:9-16.DOIPubMed
13. Spear SL, Newman MK, Bedford MS, Schwartz KA, Cohen M, Schwartz JS. A retrospective analysis of outcomes using three common methods for immediate breast reconstruction. Plast Reconstr Surg 2008;122:340-7.DOIPubMed
14. Garvey PB, Buchel EW, Pockaj BA, Casey WJ 3rd, Gray RJ, Hernández JL, Samson TD. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006;117:1711-9.DOIPubMed
15. Davies K, Allan L, Roblin P, Ross D, Farhadi J. Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction. Breast 2011;20:21-5.DOIPubMed
16. Hanwright PJ, Davila AA, Hirsch EM, Khan SA, Fine NA, Bilimoria KY, Kim JY. The differential effect of BMI on prosthetic versus autogenous breast reconstruction: a multivariate analysis of 12,986 patients. Breast 2013;22:938-45.DOIPubMed
17. Kantak NA, Koolen PG, Martin C, Tobias AM, Lee BT, Lin SJ. Are patients with low body mass index candidates for deep inferior epigastric perforator flaps for unilateral breast reconstruction? Plast Reconstr Surg 2015;135:44-5.DOI
18. Epelboym I, Gawlas I, Lee JA, Schrope B, Chabot JA, Allendorf JD. Limitations of ACS-NSQIP in reporting complications for patients undergoing pancreatectomy: underscoring the need for a pancreas-specific module. World J Surg 2014;38:1461-7.DOIPubMed
19. Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition 2012;28:1022-7.DOIPubMed
20. Koval KJ, Maurer SG, Su ET, Aharonoff GB, Zuckerman JD. The effects of nutritional status on outcome after hip fracture. J Orthop Trauma 1999;13:164-9.DOIPubMed