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Are Flaps Really Better Than Implants For Breast Reconstruction In Obese Females? - An Analysis Of 89,514 Women Undergoing Breast Surgery From The ACS-NSQIP Database
Mohamud A. Qadi, BS1, Pablo A. Baltodano, MD1, José M. Flores, MPH2, Sashank Reddy, MD, PhD1, Nicholas B. Abt, BS1, Karim A. Sarhane, MD, MScs1, Francis M. Abreu, BS3, Carisa M. Cooney, MPH1, Gedge D. Rosson, MD1.
1Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA, 3Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Baltimore, MD, USA.
PURPOSE: To determine data-driven recommendations for breast reconstruction in obese women. Obesity is a known risk factor for postoperative morbidity after mastectomy with/without reconstruction. Current evidence support the use of flaps over implants for reconstruction in this population. We searched for the reconstruction strategy associated with the lowest 30-day postoperative overall-morbidity, surgical-site morbidity, and reconstruction-failure rates in the obese population.
METHODS: We analyzed all females undergoing mastectomy with/without reconstruction from 2005-2011 in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases.1 Data included demographic, preoperative, and perioperative factors. Patients were stratified by body mass index (BMI), all the overweight (BMI≥25, WHO definition) and obese females (BMI≥30, WHO definition) were identified, and multivariable regression was used to compare 30-day postoperative overall-morbidity, surgical-site morbidity, and reconstruction failure rates between breast-reconstruction procedures. Predefined outcomes included: cardiac, respiratory, neurological, urinary, venous thromboembolism, wound, and prosthesis/flap failure complications. Confidence intervals estimate 95% precision.
RESULTS: 89,514 women underwent mastectomy or breast reconstruction and had NSQIP BMI data, including: 65,827 (73.5%) mastectomy-only, 19,124 (21.4%) immediate breast reconstruction (IBR), and 4563 (5.1%) delayed breast reconstruction (DBR) patients. Overweight was independently associated with higher postoperative overall-morbidity in the mastectomy-only (OR_adjusted=1.12; 95%CI:1.04-1.22, p=0.004) and IBR groups (OR_adjusted=1.34; 95%CI:1.16-1.55, p<0.001), while trending towards significance in the DBR group (OR_adjusted=1.41; 95%CI:0.95-2.11, p=0.08). Obesity was independently associated with higher overall-morbidity in all groups (OR_adjusted=1.91; 95%CI:1.24-2.94, p<0.03). Additionally, multivariable comparison of 30-day postoperative morbidity rates of flaps vs. implants (using tissue expanders as the reference group) in the 6,427 obese patients undergoing reconstruction, showed that flap reconstructions were associated with higher overall-morbidity (OR_adjusted=1.49; 95%CI:1.31-1.71, p<0.001), higher surgical-site morbidity (OR_adjusted=1.41; 95%CI:1.16-1.72, p=0.001), and higher reconstruction failure rates (OR_adjusted=2.74; 95%CI:2.01-3.75, p<0.001) than implant based reconstructions (Table 1).
CONCLUSION: Our study supports that obesity is associated with higher postoperative morbidity, but more importantly, it brings attention to the overweight population and to a dose response effect of BMI on postoperative morbidity. During the first 30 postoperative days, flap based reconstructions are associated with higher overall-morbidity, surgical-site morbidity, and reconstruction-failure rates compared to implant based reconstructions. The health care cost implications of the higher 30-day postoperative morbidity associated with flap based reconstruction warrant further investigation.
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