Operative Risk Stratification and Reduction in the Obese Female Undergoing Implant Breast Reconstruction

Background: Obesity in combination with breast reconstruction is associated with increased complications¹.  The prevalence of obesity is growing therefore breast reconstruction in the obese patient is becoming the norm rather than the exception.  Our aim is to stratify risks associated with implant-based breast reconstruction complications in this expanding population.

Methods: A review of consecutive obese women (BMI ≥ 30) who underwent mastectomy and implant breast reconstruction over a 10-year period was performed. Patient demographics, co-morbidities, oncologic treatments, reconstructive procedures and their complications were recorded.  

Results:  One hundred fifty-one patients (242 breast reconstructions) were included with a mean follow-up of 28 months.  Average age was 52.8 years and average BMI was 36 (range 30-60). Eighty percent of cases were immediate and 20% delayed reconstructions.  Acellular dermal matrices (ADMs) were utilized in 58% of cases. Twenty six percent of patients included had diabetes with a third of these women achieving perioperative glycemic control.  Eighteen percent of women were active smokers and 34% had a history of radiotherapy in their cancer care.  Major complications developed in 42% of patients and minor complications in 12% of patients. Complication rates were analyzed per breast and included 3% hematoma, 5% seroma, 8% incisional wound breakdown, 11% mastectomy skin flap necrosis and 21% infection.  Twenty six percent of reconstructed breasts required explantation. Completed reconstruction, defined as placement of a permanent implant, was not achieved in 21% of these women.  Seventy percent of the women who did not complete reconstruction did not do so secondary to a complication requiring implant removal. 

Patients with prior radiation were three times as likely to develop an infection (p=0.008, OR 2.3, 95% CI 1.24-4.36) and 2.5 times as likely to undergo explantation (p=0.002, OR 2.46, 95% CI 1.36-4.45). Skin flap necrosis was three times as likely in current smokers (p=0.01, OR 3.15 95% CI 1.29-7.716). Increased rates of incisional wound breakdown were associated with increasing age (p=0.005, OR 1.1, 95% CI 1.07-1.13), smoking (0.0035 OR 4.34, CI 1.62-11.62) and radiation (p=0.023, OR 2.80, 95% CI 1.1-7.46). Reconstructive completion was reduced by the presence of diabetes (OR 2.61, 95% CI 1.13-6.01). Increasing BMI class (WHO obesity class 1-3), delayed breast reconstruction, and use of ADM were not associated with increasing complication rates.

Conclusion: While obesity alone increases implant breast reconstruction complication rates, the presence of additional risk factors, particularly smoking and prior radiation, compounds these rates. Increasing BMI within this subgroup is not associated with further complication risk. Surgical modifications, such as delayed breast reconstruction timing and foregoing the use of ADMs, do not appear to reduce complication rates.  Women who fall into this subgroup of breast reconstruction patients have a significant chance that they may not achieve reconstruction completion and should be counseled regarding this possibility.

1. Fischer JP, et al. Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets. J Am Coll Surg. Oct 2013; 217(4): 656-64.