title: The differential effect of BMI on prosthetic versus autogenous breast reconstruction: a multivariate analysis of 12,986 patients.
abstract: BACKGROUND
  The comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes.
  
  
  METHODS
  Utilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups.
  
  
  RESULTS
  Of 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue expander, pedicled TRAM, and free flap reconstructions (OR = 1.09, OR = 1.05, OR = 1.10, respectively; p < 0.05). Medical complications were higher in obese patients undergoing tissue expander and pedicled TRAM reconstructions (p = 0.001 and p < 0.001), but no significant difference was observed in latissimus and free flap reconstruction patients. Compared with obese tissue expander recipients, obese patients reconstructed using autologous tissue had higher rates of reoperations (12.8% versus 9.1%), overall morbidity (18.0% versus 9.5%), surgical (12.7% versus 8.3%), and medical complications (9.0% versus 2.2%).
  
  
  CONCLUSIONS
  The NSQIP database allows for evaluation and comparison of reconstructive outcomes in the obese population. Increased BMI was associated with higher morbidity in autologous reconstruction than tissue expander reconstruction. Among autologous procedures, latissimus flaps experienced the lowest captured 30 day morbidity.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Hanwright
authors.forename: Armando A
authors.initials: AA
authors.lastname: Davila
authors.forename: Elliot M
authors.initials: EM
authors.lastname: Hirsch
authors.forename: Seema A
authors.initials: SA
authors.lastname: Khan
authors.forename: Neil A
authors.initials: NA
authors.lastname: Fine
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
authors.forename: John Y S
authors.initials: JY
authors.lastname: Kim
mesh_terms: D000328:Adult; D015992:Body Mass Index; D001943:Breast Neoplasms / Q000601:surgery*; D005260:Female; D058752:Free Tissue Flaps / Q000009:adverse effects / Q000637:transplantation; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects* / Q000379:methods; D008875:Middle Aged; D015999:Multivariate Analysis; D064827:Myocutaneous Flap / Q000009:adverse effects / Q000637:transplantation; D009765:Obesity / Q000150:complications*; D011475:Prosthesis Failure / Q000209:etiology; D011655:Pulmonary Embolism / Q000209:etiology; D017568:Rectus Abdominis / Q000637:transplantation; D012086:Reoperation; D012189:Retrospective Studies; D018805:Sepsis / Q000209:etiology; D064171:Superficial Back Muscles / Q000637:transplantation; D015625:Tissue Expansion Devices / Q000009:adverse effects; D020246:Venous Thrombosis / Q000209:etiology
keywords: BMI; Body mass index; Breast reconstruction; Complication; DIEP; Deep inferior epigastric perforator; Flap; Implant; Microvascular; NSQIP; National Surgical Quality Improvement Program; Pedicle; TRAM; Tissue expander; Transverse rectus abdominis myocutaneous