title: Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese.
abstract: BACKGROUND
  There are national trends of increasing incidence of morbid obesity and autologous breast reconstruction with free tissue transfer from the abdomen. The purpose of this study was to assess the safety and efficacy of free flap breast reconstruction in the morbidly obese population.
  
  
  METHODS
  A retrospective review was conducted on all patients who underwent transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, or superficial inferior epigastric artery flap breast reconstructions between July of 2006 and October of 2008. Data from all patients with a body mass index greater than 40 were compared with those of patients with a body mass index less than 40. A p value less than 0.05 was considered significant. Significant findings were then analyzed in a post hoc fashion to examine trends with increasing body mass index.
  
  
  RESULTS
  Four hundred four patients underwent 612 free flap breast reconstructions during the study period. Twenty-five of these patients (6 percent) had a body mass index greater than 40. The morbidly obese group had significantly higher rate of total flap loss (p = 0.02), total major postoperative complications (p = 0.05), and delayed wound healing (p = 0.006).
  
  
  CONCLUSIONS
  Free flap breast reconstruction in the morbidly obese is associated with a higher risk of total flap loss, total major postoperative complications, and delayed abdominal wound healing. However, the overall incidence of complications is low, making free tissue transfer from the abdomen an acceptable method of breast reconstruction in this patient population.
authors: Philadelphia, Pa. From the Division of Plastic Surgery, University of Pennsylvania Health System.
authors: Shareef
authors: S
authors: Jandali
authors: Jonas A
authors: JA
authors: Nelson
authors: Seema S
authors: SS
authors: Sonnad
authors: David W
authors: DW
authors: Low
authors: Stephen J
authors: SJ
authors: Kovach
authors: Liza C
authors: LC
authors: Wu
authors: Joseph M
authors: JM
authors: Serletti
references: Flancbaum L, Choban PS. Surgical implications of obesity. Annu Rev Med. 1998;49:215–234.
references: Kroll SS, Netscher DT. Complications of TRAM flap breast reconstruction in obese patients. Plast Reconstr Surg. 1989;84:886–892.
references: Moran SL, Serletti JM. Outcome comparison between free and pedicled TRAM flap breast reconstruction in the obese patient. Plast Reconstr Surg. 2001;108:1954–1960.
references: 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;105:1640–1648.
references: 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;119:788–795.
references: Garvey PB, Buchel EW, Pockaj BA, Gray RJ, Samson TD. The deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients. Plast Reconstr Surg. 2005;115:447–457.
references: Selber JC, Kurichi JE, Vega SJ, Sonnad SS, Serletti JM. Risk factors and complications in free TRAM flap breast reconstruction. Ann Plast Surg. 2006;56:492–497.
references: Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. Arch Intern Med. 1998;158:1855–1867.
references: Bouchard C. Obesity in adulthood: The importance of childhood and parental obesity. N Engl J Med. 1997;337:926–927.
references: Hartrampf CR Jr, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient: A critical review of 300 patients. Ann Surg. 1987;205:508–519.
references: Scheflan M, Kalisman M. Complications of breast reconstruction. Clin Plast Surg. 1984;11:343–350.
references: Scheflan M, Dinner MI. The transverse abdominal island flap: Part I. Indications, contraindications, results, and complications. Ann Plast Surg. 1983;10:24–35.
references: Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: A meta-analysis. Ann Intern Med. 2002;136:792–801.
references: Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362:18–26.
references: Reich DL, Bennett-Guerrero E, Bodian CA, Hossain S, Winfree W, Krol M. Intraoperative tachycardia and hypertension are independently associated with adverse outcome in noncardiac surgery of long duration. Anesth Analg. 2002;95:273–277.
references: Farwell DG, Reilly DF, Weymuller EA Jr, Greenberg DL, Staiger TO, Futran NA. Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg. 2002;128:505–511.
references: Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999;91:109–118.
references: Graham JM, Robinson JM, Ashcroft PB, Glennie R. Deep vein thrombosis in ear, nose and throat surgery. J Laryngol Otol. 1976;90:427–432.
references: Aronovitch SA. Intraoperatively acquired pressure ulcers: Are there common risk factors? Ostomy Wound Manage. 2007;53:57–69.
references: Kemp MG, Keithley JK, Smith DW, Morreale B. Factors that contribute to pressure sores in surgical patients. Res Nurs Health 1990;13:293–301.
references: Aronovitch SA. Intraoperatively acquired pressure ulcer prevalence: A national study. J Wound Ostomy Continence Nurs. 1999;26:130–136.
references: McGurk MG, Fan KF, MacBean AD, Putcha V. Complications encountered in a prospective series of 182 patients treated surgically for mouth cancer. Oral Oncol. 2007;43:471–476.
references: Rogers SO Jr, Zinner MJ. The role of perioperative hyperglycemia in postoperative infections. Adv Surg. 2009;43:103–109.