Introduction: The increase in surgical risks for obese patients is well known, and obesity is generally considered a contraindication for pedicled as well as free TRAM flap reconstruction. It is also believed that marked obesity represents an absolute contraindication for TRAM flap reconstruction and is associated with unacceptably high rates of flap and donor site morbidity.

Purpose: The purpose of our study was to determine the complication rates in our obese and markedly obese patient population who have undergone breast reconstruction using either transverse rectus abdominis myocutaneous (pedicled and free) or latissimus dorsi (LD) flap. Our patient population is comprised of a number of obese and markedly obese patients referred from a large, indigent Southeast Texas catchment area.

Methods: The records of 157 women who had undergone autologous tissue breast reconstruction in the past 12 years were reviewed to determine the effect of morbid obesity on patient satisfaction and complication rate. The patients were divided into four groups- ideal body weight (body mass index 19-24), overweight (25-26), obese (27-34), and markedly obese (greater than or equal to 35). Events listed as complications included fat necrosis requiring revision, seroma or hematoma requiring evacuation, hernia, partial or complete flap loss, and systemic complication such as deep venous thrombosis.

Results: The complication rate for all patients receiving autologous reconstruction was 21%. In the ideal body weight group(n=59), the complication rate was 14%; overweight group (n=16), 6%; obese group (n=59), 25%;and morbidly obese group (n=23), 32%. Pedicled TRAM complication rates were lower than free TRAM rates in the obese and markedly obese groups, and pedicled TRAM rates ranged from an expected lower rate (7%) in the ideal body weight category to a higher rate among the markedly obese (22%). For patients undergoing LD reconstruction, there were few complications in the ideal and overweight categories, but higher rates in the obese population (17%). Patient satisfaction rates were higher with TRAM flap thatn LD reconstruction regardless of weight group or presence of complication.

Conclusion: Our review suggest that the TRAM flap is a viable option for breast reconstruction and that obesity or marked obesity is not necessarily a contraindication (with understanding of possible complications and proper patient education). This is in contrast to previously published series with higher reported rates and populations with generally lower BMI's. Perioperative management and surgical procedure may be adapted to this patient group enabling optimal breast reconstruction in cases that may have been denied in the past.
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