title: Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets.
abstract: BACKGROUND
  Obesity is a growing epidemic in the United States (US) affecting more than 33% of adults. We aimed to use the World Health Organization (WHO) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP database from 2005 to 2010.
  
  
  METHODS
  We reviewed the 2005 to 2010 ACS-NSQIP databases identifying encounters for Current Procedural Terminology (CPT) codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominis myocutaneous [pTRAM], free TRAM, and latissimus dorsi flap with or without implant). Patients were classified and compared based on WHO obesity criteria: nonobese (body mass index [BMI] = 20 to 29.9 kg/m(2)), class I (BMI = 30 to 34.9 kg/m(2)), class II (BMI = 35 to 39.9 kg/m(2)), and class III (BMI > 40 kg/m(2)).
  
  
  RESULTS
  During the study period 15,937 breast reconstructions were performed. The majority of reconstructions were immediate reconstructions (85.0%) and implant-based (79.1%). The incidence of obesity was 27.1%, with 16.3% defined as class I obese, 6.9% defined as class II obese, and 4.0% defined as class III obese. The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions, higher American Society of Anesthesiologists (ASA) physical status (p < 0.001), longer operative times (p = 0.0001), and greater lengths of hospital stay (p = 0.0001). Progressively higher BMIs were associated with higher rates of complications, including wound (p < 0.001), medical (p < 0.001), infections (p < 0.001), major surgical (p < 0.001), graft and prosthesis loss (p < 0.001), and return to the operating room (p < 0.001).
  
  
  CONCLUSIONS
  This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large, prospective multicenter dataset. Increasing obesity is associated with increased perioperative morbidity. Data derived from this cohort study can be used to risk-stratify patients, enhance risk counseling, and advocate for institutional reimbursement in obese patients undergoing breast reconstruction.
authors.affiliation: Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. Electronic address: John.Fischer2@uphs.upenn.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Fischer
authors.forename: Jonas A
authors.initials: JA
authors.lastname: Nelson
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Kovach
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Serletti
authors.forename: Liza C
authors.initials: LC
authors.lastname: Wu
authors.forename: Suhail
authors.initials: S
authors.lastname: Kanchwala
mesh_terms: D000328:Adult; D015992:Body Mass Index; D001943:Breast Neoplasms / Q000150:complications* / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D016462:Mammaplasty / Q000009:adverse effects*; D008408:Mastectomy; D008875:Middle Aged; D009765:Obesity / Q000150:complications*; D012307:Risk Factors; D016896:Treatment Outcome
keywords: ACS-NSQIP; American College of Surgeons National Surgical Quality Improvement Program; BMI; CPT; Current Procedural Terminology; OR; TRAM; WHO; World Health Organization; body mass index; odds ratio; transverse rectus abdominis myocutaneous