Download PDF
J Reconstr Microsurg 2022; 38(01): 001-009
DOI: 10.1055/s-0041-1727202
Original Article

Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

Charles W. Patterson
1   Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
,
Patrick A. Palines 
1   Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
,
Matthew J. Bartow
1   Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
,
Daniel J. Womac
1   Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
2   Department of Plastic and Reconstructive Surgery, University Medical Center–LCMC Health, New Orleans, Louisiana
,
Jamie C. Zampell
3   Ochsner Medical Center, Jefferson, Louisiana
,
Charles L. Dupin
1   Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
2   Department of Plastic and Reconstructive Surgery, University Medical Center–LCMC Health, New Orleans, Louisiana
,
Hugo St Hilaire
1   Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
2   Department of Plastic and Reconstructive Surgery, University Medical Center–LCMC Health, New Orleans, Louisiana
,
Mark W. Stalder
1   Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
2   Department of Plastic and Reconstructive Surgery, University Medical Center–LCMC Health, New Orleans, Louisiana
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30–34), II (BMI: 35–39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications.

Results When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91–3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09–5.05, p = 0.03) complications.

Conclusion DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

Keywords

DIEP flap - obesity - breast reconstruction


Publication History

Received: 24 September 2020

Accepted: 15 February 2021

Article published online:
14 April 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 National Center for Health Statistics. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. Hyattsville, MD: February 2020. NCHS Data Brief. No. 360
    PubMed
  • 2 Kim DD, Basu A. Estimating the medical care costs of obesity in the United States: systematic review, meta-analysis, and empirical analysis. Value Health 2016; 19 (05) 602-613
    CrossrefPubMedGoogle Scholar
  • 3 Atisha DM, Alderman AK, Kuhn LE, Wilkins EG. The impact of obesity on patient satisfaction with breast reconstruction. Plast Reconstr Surg 2008; 121 (06) 1893-1899
    CrossrefPubMedGoogle Scholar
  • 4 Lee K-T, Mun G-H. Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flap: a systematic review and meta-analysis. Ann Plast Surg 2016; 76 (05) 576-584
    CrossrefPubMedGoogle Scholar
  • 5 Sinha S, Ruskin O, D'Angelo A, McCombe D, Morrison WA, Webb A. Are overweight and obese patients who receive autologous free-flap breast reconstruction satisfied with their postoperative outcome? A single-centre study. J Plast Reconstr Aesthet Surg 2016; 69 (01) 30-36
    CrossrefPubMedGoogle Scholar
  • 6 Nelson JA, Sobti N, Patel A. et al. The impact of obesity on patient-reported outcomes following autologous breast reconstruction. Ann Surg Oncol 2020; 27 (06) 1877-1888
    CrossrefPubMedGoogle Scholar
  • 7 Kulkarni AR, Katz S, Hamilton AS, Graff JJ, Alderman AK. Patterns of use and patient satisfaction with breast reconstruction among obese patients: results from a population-based study. Plast Reconstr Surg 2012; 130 (02) 263-270
    CrossrefPubMedGoogle Scholar
  • 8 Jeong W, Lee S, Kim J. Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. Breast 2018; 38: 45-51
    CrossrefPubMedGoogle Scholar
  • 9 Butler PD, Wu LC. Abdominal perforator vs. muscle sparing flaps for breast reconstruction. Gland Surg 2015; 4 (03) 212-221
    PubMedGoogle Scholar
  • 10 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 (04) 656-664
    CrossrefPubMedGoogle Scholar
  • 11 Panayi AC, Agha RA, Sieber BA, Orgill DP. Impact of obesity on outcomes in breast reconstruction: a systematic review and meta-analysis. J Reconstr Microsurg 2018; 34 (05) 363-375
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Center for Disease Control. Defining Adult Overweight and Obesity. https://www.cdc.gov/obesity/adult/defining.html . Published 2016. Accessed March 9, 2021
    PubMedGoogle Scholar
  • 13 Kelsey JL, Berkowitz GS. Breast cancer epidemiology. Cancer Res 1988; 48 (20) 5615-5623
    PubMedGoogle Scholar
  • 14 Folsom AR, Kaye SA, Prineas RJ, Potter JD, Gapstur SM, Wallace RB. Increased incidence of carcinoma of the breast associated with abdominal adiposity in postmenopausal women. Am J Epidemiol 1990; 131 (05) 794-803
    CrossrefPubMedGoogle Scholar
  • 15 Huang Z, Hankinson SE, Colditz GA. et al. Dual effects of weight and weight gain on breast cancer risk. JAMA 1997; 278 (17) 1407-1411
    CrossrefPubMedGoogle Scholar
  • 16 Flancbaum L, Choban PS. Surgical implications of obesity. Annu Rev Med 1998; 49 (01) 215-234
    CrossrefPubMedGoogle Scholar
  • 17 Carmichael AR, Bates T. Obesity and breast cancer: a review of the literature. Breast 2004; 13 (02) 85-92
    CrossrefPubMedGoogle Scholar
  • 18 Cleary MP, Grossmann ME. Minireview: obesity and breast cancer: the estrogen connection. Endocrinology 2009; 150 (06) 2537-2542
    CrossrefPubMedGoogle Scholar
  • 19 Hanwright PJ, Davila AA, Hirsch EM. et al. The differential effect of BMI on prosthetic versus autogenous breast reconstruction: a multivariate analysis of 12,986 patients. Breast 2013; 22 (05) 938-945
    CrossrefPubMedGoogle Scholar
  • 20 Srinivasa DR, Clemens MW, Qi J. et al. Obesity and breast reconstruction: complications and patient-reported outcomes in a multicenter, prospective study. Plast Reconstr Surg 2020; 145 (03) 481e-490e
    CrossrefPubMedGoogle Scholar
  • 21 Spear SL, Ducic I, Cuoco F, Taylor N. Effect of obesity on flap and donor-site complications in pedicled TRAM flap breast reconstruction. Plast Reconstr Surg 2007; 119 (03) 788-795
    CrossrefPubMedGoogle Scholar
  • 22 Ochoa O, Chrysopoulo M, Nastala C, Ledoux P, Pisano S. Abdominal wall stability and flap complications after deep inferior epigastric perforator flap breast reconstruction: does body mass index make a difference? Analysis of 418 patients and 639 flaps. Plast Reconstr Surg 2012; 130 (01) 21e-33e
    CrossrefPubMedGoogle Scholar
  • 23 Fischer JP, Nelson JA, Serletti JM, Wu LC. Peri-operative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): a review of 9305 patients from the 2005-2010 ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg 2013; 66 (11) 1504-1512
    CrossrefPubMedGoogle Scholar
  • 24 Ozturk CN, Kundu N, Bernard S, Cooper K, Ozturk C, Djohan R. Breast reconstruction with abdominal-based free flaps in high body mass index population: postoperative complications and impact of weight loss. Ann Plast Surg 2014; 72 (01) 13-22
    CrossrefPubMedGoogle Scholar
  • 25 Timmermans FW, Westland PB, Hummelink S. et al. A retrospective investigation of abdominal visceral fat, body mass index (BMI), and active smoking as risk factors for donor site wound healing complications after free DIEP flap breast reconstructions. J Plast Reconstr Aesthet Surg 2018; 71 (06) 827-832
    CrossrefPubMedGoogle Scholar
  • 26 Ochoa O, Garza III R, Pisano S. et al. Prospective longitudinal patient-reported satisfaction and health-related quality of life following DIEP flap breast reconstruction: relationship with body mass index. Plast Reconstr Surg 2019; 143 (06) 1589-1600
    CrossrefPubMedGoogle Scholar
  • 27 O'Neill AC, Sebastiampillai S, Zhong T, Hofer SOP. Increasing body mass index increases complications but not failure rates in microvascular breast reconstruction: a retrospective cohort study. J Plast Reconstr Aesthet Surg 2019; 72 (09) 1518-1524
    CrossrefPubMedGoogle Scholar
  • 28 Boczar D, Huayllani MT, Forte AJ, Rinker B. Microsurgical breast reconstruction in the obese patient using abdominal flaps: complication profile and patient satisfaction. Ann Plast Surg 2020; 84 (6S): (Suppl. 05) S361-S363
    CrossrefPubMedGoogle Scholar
  • 29 Garvey PB, Villa MT, Rozanski AT, Liu J, Robb GL, Beahm EK. The advantages of free abdominal-based flaps over implants for breast reconstruction in obese patients. Plast Reconstr Surg 2012; 130 (05) 991-1000
    CrossrefPubMedGoogle Scholar
  • 30 Momeni A, Ahdoot MA, Kim RY, Leroux E, Galaiya DJ, Lee GK. Should we continue to consider obesity a relative contraindication for autologous microsurgical breast reconstruction?. J Plast Reconstr Aesthet Surg 2012; 65 (04) 420-425
    CrossrefPubMedGoogle Scholar
  • 31 Modarressi A, Müller CT, Montet X, Rüegg EM, Pittet-Cuénod B. DIEP flap for breast reconstruction: is abdominal fat thickness associated with post-operative complications?. J Plast Reconstr Aesthet Surg 2017; 70 (08) 1068-1075
    CrossrefPubMedGoogle Scholar
  • 32 Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health 2009; 9 (01) 88
    CrossrefPubMedGoogle Scholar
  • 33 Mraz M, Haluzik M. The role of adipose tissue immune cells in obesity and low-grade inflammation. J Endocrinol 2014; 222 (03) R113-R127
    CrossrefPubMedGoogle Scholar
  • 34 Enser M, Avery NC. Mechanical and chemical properties of the skin and its collagen from lean and obese-hyperglycaemic (ob/ob) mice. Diabetologia 1984; 27 (01) 44-49
    CrossrefPubMedGoogle Scholar
  • 35 Xing L, Culbertson EJ, Wen Y, Robson MC, Franz MG. Impaired laparotomy wound healing in obese rats. Obes Surg 2011; 21 (12) 1937-1946
    CrossrefPubMedGoogle Scholar
  • 36 Chang DW, Wang B, Robb GL. et al. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 2000; 105 (05) 1640-1648
    CrossrefPubMedGoogle Scholar
  • 37 Fischer JP, Nelson JA, Sieber B. et al. Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast Reconstr Surg 2013; 131 (05) 681e-692e
    CrossrefPubMedGoogle Scholar
  • 38 Scheflan M, Kalisman M. Complications of breast reconstruction. Clin Plast Surg 1984; 11 (02) 343-350
    CrossrefPubMedGoogle Scholar
  • 39 Wilson JA, Clark JJ. Obesity: impediment to wound healing. Crit Care Nurs Q 2003; 26 (02) 119-132
    CrossrefPubMedGoogle Scholar
  • 40 Lambert DM, Marceau S, Forse RA. Intra-abdominal pressure in the morbidly obese. Obes Surg 2005; 15 (09) 1225-1232
    CrossrefPubMedGoogle Scholar
  • 41 Pierpont YN, Dinh TP, Salas RE. et al. Obesity and surgical wound healing: a current review. ISRN Obes 2014; 2014: 638936
    PubMedGoogle Scholar
  • 42 Jandali S, Nelson JA, Sonnad SS. et al. Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese. Plast Reconstr Surg 2011; 127 (06) 2206-2213
    CrossrefPubMedGoogle Scholar
  • 43 Fischer JP, Cleveland EC, Nelson JA. et al. Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 National Surgical Quality Improvement Program data sets. Plast Reconstr Surg 2013; 132 (04) 750-761
    CrossrefPubMedGoogle Scholar
  • 44 Spitz JA, Bradford PS, Aguilar F, Turin SY, Ellis MF. How big is too big: pushing the obesity limits in microsurgical breast reconstruction. Ann Plast Surg 2018; 80 (02) 137-140
    CrossrefPubMedGoogle Scholar
  • 45 Reddix Jr RN, Tyler HK, Kulp B, Webb LX. Incisional vacuum-assisted wound closure in morbidly obese patients undergoing acetabular fracture surgery. Am J Orthop 2009; 38 (09) 446-449
    CrossrefPubMedGoogle Scholar
  • 46 Mark KS, Alger L, Terplan M. Incisional negative pressure therapy to prevent wound complications following cesarean section in morbidly obese women: a pilot study. Surg Innov 2014; 21 (04) 345-349
    CrossrefPubMedGoogle Scholar
  • 47 Larson KE, Ozturk CN, Kundu N, Cooper KR, Bernard S, Djohan R. Achieving patient satisfaction in abdominally based free flap breast reconstruction: correlation with body mass index subgroups and weight loss. Plast Reconstr Surg 2014; 133 (04) 763-773
    CrossrefPubMedGoogle Scholar
  • 48 Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications after microvascular breast reconstruction: experience with 1195 flaps. Plast Reconstr Surg 2006; 118 (05) 1100-1109
    CrossrefPubMedGoogle Scholar
  • 49 Vyas RM, Dickinson BP, Fastekjian JH, Watson JP, DaLio AL, Crisera CA. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008; 121 (05) 1519-1526
    CrossrefPubMedGoogle Scholar
  • 50 Roostaeian J, Yoon AP, Sanchez IS. et al. The effect of prior abdominal surgery on abdominally based free flaps in breast reconstruction. Plast Reconstr Surg 2014; 133 (03) 247e-255e
    CrossrefPubMedGoogle Scholar
  • 51 Kraft CT, Chao AH. Concurrent ventral hernia repair is effective in patients undergoing abdominally based microsurgical breast reconstruction. J Reconstr Microsurg 2020; 36 (08) 572-576
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Parrett BM, Caterson SA, Tobias AM, Lee BT. DIEP flaps in women with abdominal scars: are complication rates affected?. Plast Reconstr Surg 2008; 121 (05) 1527-1531
    CrossrefPubMedGoogle Scholar
  • 53 Ngaage LM, Hamed R, Oni G. et al. The role of CT angiography in assessing deep inferior epigastric perforator flap patency in patients with pre-existing abdominal scars. J Surg Res 2019; 235: 58-65
    CrossrefPubMedGoogle Scholar
  • 54 Daly LT, Doval AF, Lin SJ, Tobias A, Lee BT, Dowlatshahi AS. Role of CTA in women with abdominal scars undergoing DIEP breast reconstruction: review of 1,187 flaps. J Reconstr Microsurg 2020; 36 (04) 294-300
    Article in Thieme ConnectPubMedGoogle Scholar
  • 55 Blondeel N, Vanderstraeten GG, Monstrey SJ. et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50 (05) 322-330
    CrossrefPubMedGoogle Scholar
  • 56 Garvey PB, Buchel EW, Pockaj BA. et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006; 117 (06) 1711-1719
    CrossrefPubMedGoogle Scholar
  • 57 Haddock NT, Culver AJ, Teotia SS. Abdominal weakness, bulge, or hernia after DIEP flaps: an algorithm of management, prevention, and surgical repair with classification. J Plast Reconstr Aesthet Surg 2020; x: x
    PubMedGoogle Scholar
  • 58 Hembd A, Teotia SS, Zhu H, Haddock NT. Optimizing perforator selection: a multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg 2018; 142 (03) 583-592
    CrossrefPubMedGoogle Scholar
  • 59 Gill PS, Hunt JP, Guerra AB. et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113 (04) 1153-1160
    CrossrefPubMedGoogle Scholar
  • 60 Butler DP, Plonczak AM, Reissis D. et al. Factors that predict deep inferior epigastric perforator flap donor site hernia and bulge. J Plast Surg Hand Surg 2018; 52 (06) 338-342
    CrossrefPubMedGoogle Scholar
  • 61 Masia J, Larrañaga J, Clavero JA, Vives L, Pons G, Pons JM. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg 2008; 60 (01) 29-36
    CrossrefPubMedGoogle Scholar
  • 62 Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 2008; 121 (01) 9-16
    CrossrefPubMedGoogle Scholar
  • 63 Rozen WM, Palmer KP, Suami H. et al. The DIEA branching pattern and its relationship to perforators: the importance of preoperative computed tomographic angiography for DIEA perforator flaps. Plast Reconstr Surg 2008; 121 (02) 367-373
    CrossrefPubMedGoogle Scholar
  • 64 Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg 2010; 63 (09) e674-e682
    CrossrefPubMedGoogle Scholar
  • 65 Kim EK, Kang BS, Hong JP. The distribution of the perforators in the anterolateral thigh and the utility of multidetector row computed tomography angiography in preoperative planning. Ann Plast Surg 2010; 65 (02) 155-160
    CrossrefPubMedGoogle Scholar
  • 66 Sacher M, Kapalschinski RN, Wallner C. et al. Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction. J Plast Reconstr Aesthet Surg 2020; 73 (03) 494-500
    CrossrefPubMedGoogle Scholar
  • 67 Shayan R, Rozen WM, Bernard S, Corlett RJ, Ashton MW, Taylor GI. Perforator dilatation induced by body weight gain is not reversed by subsequent weight loss: implications for perforator flaps. Plast Reconstr Surg 2008; 122 (06) 1765-1772
    CrossrefPubMedGoogle Scholar
  • 68 Macchi V, Tiengo C, Porzionato A. et al. Anatomical remodelling of the anterior abdominal wall arteries in obesity. Clin Hemorheol Microcirc 2014; 57 (03) 255-265
    CrossrefPubMedGoogle Scholar
  • 69 Rifkin WJ, Kantar RS, Daar DA. et al. Obesity and lower extremity reconstruction: evaluating body mass index as an independent risk factor for early complications. J Reconstr Microsurg 2019; 35 (05) 346-353
    Article in Thieme ConnectPubMedGoogle Scholar
  • 70 DelMauro MA, Moon VA. Obesity and the abdominal wall vasculature: correlating BMI with perforator anatomy. J Reconstr Microsurg 2020; 36 (06) 438-444
    Article in Thieme ConnectPubMedGoogle Scholar
  • 71 Scott JR, Sullivan SR, Liu D. et al. Patient body mass index and perforator quality in abdomen-based free-tissue transfer for breast reconstruction. J Reconstr Microsurg 2009; 25 (04) 237-241
    Article in Thieme ConnectPubMedGoogle Scholar
  • 72 Ayhan S, Oktar SO, Tuncer S, Yucel C, Kandal S, Demirtas Y. Correlation between vessel diameters of superficial and deep inferior epigastric systems: Doppler ultrasound assessment. J Plast Reconstr Aesthet Surg 2009; 62 (09) 1140-1147
    CrossrefPubMedGoogle Scholar
  • 73 Mahajan AL, Zeltzer A, Claes KEY, Van Landuyt K, Hamdi M. Are Pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions?. Plast Reconstr Surg 2012; 129 (04) 797-805
    CrossrefPubMedGoogle Scholar
  • 74 Fred HL. Drawbacks and limitations of computed tomography: views from a medical educator. Tex Heart Inst J 2004; 31 (04) 345-348
    PubMedGoogle Scholar
  • 75 Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol 2008; 36 (02) 69-74
    CrossrefPubMedGoogle Scholar
  • 76 Uppot RN. Impact of obesity on radiology. Radiol Clin North Am 2007; 45 (02) 231-246
    CrossrefPubMedGoogle Scholar
  • 77 Adelman RD. Obesity and renal disease. Curr Opin Nephrol Hypertens 2002; 11 (03) 331-335
    CrossrefPubMedGoogle Scholar