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DOI: 10.1055/s-0038-1627449
Impact of Obesity on Outcomes in Breast Reconstruction: A Systematic Review and Meta-Analysis
Address for correspondence
Publikationsverlauf
24. August 2017
07. Dezember 2017
Publikationsdatum:
06. März 2018 (online)
- Patients and Methods
- Results
- Discussion
- Conclusion
- References
Abstract
Background Increased rates of both breast cancer and obesity have resulted in more obese women seeking breast reconstruction. Studies demonstrate that these women are at increased risk for perioperative complications. A systematic review was conducted to assess the outcomes in obese women who underwent breast reconstruction following mastectomy.
Methods Cochrane, PUBMED, and EMBASE electronic databases were screened and data were extracted from included studies. The clinical outcomes assessed were surgical complications, medical complications, length of postoperative hospital stay, reoperation rate, and patient satisfaction.
Results Out of 33 studies met the inclusion criteria for the review and 29 provided enough data to be included in the meta-analysis (71,368 patients, 20,061 of whom were obese). Obese women (body mass index > 30 kg/m2) were 2.29 times more likely to experience surgical complications (95% confidence interval (CI) 2.19–2.39; p < 0.00001), 2.89 times more likely to have medical complications (95% CI 2.50–3.35; p < 0.00001), and had a 1.91 times higher risk of reoperation (95% CI 1.75–2.07; p < 0.00001). The most common complication, wound dehiscence, was 2.51 times more likely in obese women (95% CI 1.80–3.52; p < 0.00001). Sensitivity analysis confirmed that obese women were more likely to experience surgical complications (risk ratio 2.36, 95% CI 2.22–2.52; p < 0.00001).
Conclusions This study provides evidence that obesity increases the risk of complications in both implant-based and autologous reconstruction. Additional prospective and observational studies are needed to determine if the weight reduction prior to reconstruction reduces the perioperative risks associated with obesity.
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Keywords
plastic surgery - breast reconstruction - obesity - breast surgery complication - breast cancerObesity has reached global epidemic proportions and is imposing a significant public health concern. The most recent data by the World Health Organization (WHO), which defines obesity as having a body mass index (BMI) of ≥30 kg/m2, states that 13% of the world's adult population is obese.[1]
Obesity rates are even higher in women with 40% of the global female population being overweight and 15% obese.[1] Additionally, breast cancer is on the rise, accounting for ∼30% of all newly reported cancer cases in women.[2] [3] Consequently, it is likely that the proportion of women seeking breast reconstruction in the obese population will increase,[4] and it is imperative to evaluate the efficacy of available reconstructive techniques in these patients, as well as the rates of complications associated with these procedures.
It is well known that obese women have an increased risk for perioperative complications in various surgical procedures, including breast reconstruction.[5] The higher risk of medical complications in these patients creates unique challenges to health care systems.[6] Research suggests that obese women are also more likely to experience complications in both autologous and prosthetic breast reconstruction, with obese women demonstrating complication rates of 25% in comparison to 14% in nonobese individuals.[7]
Although it is believed that a high BMI (>30 kg/m2) increases the risk of complications in breast reconstruction, a detailed comparison of the risks associated with the available reconstructive options has been elusive. Improved understanding of the effects of weight on surgical outcomes will enable health care professionals to identify the best strategy for each individual patient to minimize adverse effects. This review seeks to analyze and summarize the literature to provide a better understanding of the risks associated with breast reconstruction in obese women.
Patients and Methods
Selection Criteria
This review was conducted in line with the Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0.[8] A protocol was published a priori[9] and the review was registered on the Research Registry UIN: reviewregistry191 (http://www.researchregistry.com). Cochrane, PUBMED, and EMBASE electronic databases were screened from their inception to 1 June 2016 using the keywords: obesity, weight, BMI, breast reconstruction, breast autologous tissue flap, breast free flap, transverse rectus abdominis myocutaneous (TRAM) flap, free muscle-sparing TRAM flap, pedicled TRAM flap, deep inferior epigastric perforators (DIEP) flap, latissimus dorsi myocutaneous (LDM) flap, superficial inferior epigastric artery flap (SIEA), breast tissue expander, and breast implant. The search format was tailored to the syntax of each database.
The inclusion criteria were cohort studies, case series, randomized controlled trials, and case–control studies reporting on breast reconstruction outcomes in obese women (BMI > 30 kg/m2) who underwent mastectomy for the treatment of breast cancer. The following surgical interventions were considered: prosthetic implants, including acellular dermal matrix use and tissue expander, and autologous reconstruction, including LDM flaps, pedicled, free and muscle sparing TRAM flaps, SIEA flaps, and DIEP flaps. These interventions were selected on the basis of the fact that they are the most commonly used reconstructive techniques, allowing us to set some limits to our search strategy. Given the inclusion of generic terms like breast reconstruction, we feel that the search strategy would be comprehensive. The inclusion and exclusion criteria are listed in [Table 1].
Abbreviations: DIEP, deep inferior epigastric perforators; LDM, latissimus dorsi myocutaneous; SIEA, superficial inferior epigastric artery flap; TRAM, transverse rectus abdominis myocutaneous.
The article selection process was a two-stage process completed by two reviewers (AP and BAS). Data were extracted into Microsoft Excel 2011 (Microsoft, Redmond, WA). First, the citation, title, and abstracts of studies from the search were independently screened to identify potentially relevant studies. The full manuscripts of articles that passed through this stage were then assessed for eligibility. Any inconsistency between the two reviewers was resolved by a third reviewer who was consulted to achieve consensus (DPO).
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Quality Assessment
The grading of recommendation assessment, development, and evaluation (GRADE) guidelines were used to assess the methodological quality of the studies.[10]
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Statistical Analysis
This meta-analysis was performed using RevMan (Review manager V5.2.6) in line with the Cochrane Collaboration and the Quality of Reporting of Meta-analyses guidelines.[11] The risk ratio (RR) were calculated using the fixed-effects model and heterogeneity was quantified using the I 2 and χ2 statistics with the corresponding p-values.
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Subgroup Analysis
Surgical complications were subdivided into wound infection and dehiscence, hematoma, seroma, fat necrosis, partial and total flap failure, and hernia occurrence. Additional analyses were performed to investigate the difference between surgical complication occurrence in implant versus autologous reconstruction and the difference between the nonobese population, and obesity Class I (30–34.9 kg/m2), II (35–39.9 kg/m2), and III (>40 kg/m2) as defined by WHO.[12]
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Sensitivity Analysis
A sensitivity analysis was performed to assess whether the outcomes were altered when the analysis was restricted to higher quality studies.
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Results
Primary Studies Included in the Literature Review
A search of PUBMED yielded 102 articles and Embase yielded another 146 potentially relevant publications. No additional articles were identified from the Cochrane database ([Fig. 1]). Of the 248 studies identified, 125 were excluded on the basis of their title, and 79 were based on their abstract. Full manuscripts were evaluated for 44 publications but only 33 fulfilled the entry criteria.[7] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] Eleven papers were excluded because: (a) they did not provide appropriate numerical data necessary for statistical analysis[45] [46] [47] [48] [49] [50] and (b) they used the same patient population in different studies.[51] [52] [53] [54] [55] In cases utilizing the same population with an overlapping study period, only the study with the largest number of patients was included.
![](https://www.thieme-connect.de/media/jrm/201805/thumbnails/10-1055-s-0038-1627449-i170214-1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
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Main Study Characteristics and Methodological Quality Assessment
Of the 33 included studies only three were prospective ([Table 2]). All studies were case series and had a level of evidence (LoE) of 4 as defined by the Oxford Centre for Evidence-Based Medicine.[56] No randomized controlled trials were found. Eighteen studies were specifically designed to investigate the effect BMI has on breast reconstruction,[7] [13] [15] [16] [17] [18] [19] [23] [25] [26] [30] [31] [32] [33] [38] [42] [43] [44] whereas 15 studies investigated general risk factors, one of which was obesity.[14] [20] [21] [22] [24] [27] [28] [29] [34] [35] [36] [37] [39] [40] [41] Numerical data for meta-analysis could be extracted from 29 papers, six of which investigated prosthetic reconstruction,[7] [13] [14] [22] [27] [28] 22 investigated autologous reconstruction,[15] [18] [19] [20] [21] [23] [25] [26] [29] [30] [31] [32] [33] [34] [35] [36] [37] [39] [40] [41] [42] [43] and five looked at both.[16] [17] [24] [38] [44] Two studies presented data only from obese patients, comparing morbidly with nonmorbidly obese patients, but were included in our meta-analysis as the prevalence of complications in these studies was not significantly different from that in other studies.[30] [31] Fourteen of 29 studies were of low or very low quality on the GRADE scale. Fifteen studies that were comparative were deemed moderate quality.[13] [15] [17] [18] [23] [25] [26] [30] [31] [32] [33] [34] [36] [39] [42]
Study |
Year |
Country[a] |
Type of study |
Reconstructive technique |
No. of patients |
Outcomes |
---|---|---|---|---|---|---|
Huo et al |
2016 |
USA |
Retrospective |
Autologous |
549 |
Surgical |
Sinha et al |
2016 |
Australia |
Retrospective |
DIEP, msTRAM, SIEA |
29 |
Surgical, medical, reoperation, satisfaction |
Alipour et al |
2015 |
Iran |
Retrospective |
TRAM |
14 |
Surgical, reoperation |
Massenburg et al |
2015 |
USA |
Retrospective |
Pedicled and free TRAM, LD |
2,433 |
Surgical, medical |
Mennie et al |
2015 |
UK |
Retrospective |
Pedicled and free TRAM, DIEP |
208 |
Reoperation |
Selber et al |
2015 |
USA |
Retrospective |
ADM |
94 |
Surgical |
Fischer et al |
2014 |
USA |
Retrospective |
TRAM, DIEP, SIEA |
272 |
Surgical, medical, length of stay |
Fischer et al |
2014 |
USA |
Retrospective |
Implant, TE, pedicled and free TRAM, LD |
4,321 |
Surgical, medical, reoperation |
Nelson et al |
2014 |
USA |
Prospective |
Autologous |
57 |
Surgical, medical, reoperation |
Nguyen et al |
2014 |
USA |
Retrospective |
TE, implant |
175 |
Surgical, reoperation |
Ozturk et al |
2014 |
USA |
Retrospective |
TRAM |
63 |
Surgical, medical, reoperation |
Wink et al |
2014 |
USA |
Retrospective |
Implant |
374 |
Surgical, medical, reoperation |
Fischer et al |
2013 |
USA |
Retrospective |
Implant |
3,741 |
Surgical, medical, reoperation |
Fischer et al |
2013 |
USA |
Retrospective |
TE |
2,390 |
Surgical, reoperation |
Hanwright et al |
2013 |
USA |
Retrospective |
TE, pedicled and free TRAM, LD flap |
3,636 |
Surgical, medical, reoperation |
Ireton et al |
2013 |
USA |
Retrospective |
Pedicled TRAM |
21 |
Surgical |
Garvey et al |
2012 |
USA |
Retrospective |
Implant, TE, msTRAM, DIEP, SIEA |
700 |
Surgical, reoperation |
Momeni et al |
2012 |
USA |
Retrospective |
DIEP, msTRAM, SIEA |
28 |
Surgical, medical, length of stay |
Ochoa et al |
2012 |
USA |
Retrospective |
DIEP |
258 |
Surgical |
Yezhelyev et al |
2012 |
USA |
Retrospective |
LDF |
103 |
Surgical |
Seidenstuecker et al |
2011 |
Germany |
Prospective |
DIEP, msTRAM |
79 |
Surgical |
Appleton et al |
2010 |
Canada |
Retrospective |
DIEP |
39 |
Surgical, medical |
Rossetto et al |
2010 |
Brazil |
Retrospective |
TRAM |
39 |
Surgical |
Wan et al |
2010 |
USA |
Retrospective |
DIEP, msTRAM |
103 |
Surgical |
Atisha et al |
2007 |
USA |
Retrospective |
Implant, TE, pedicled and free TRAM |
47 |
Satisfaction |
Greco et al |
2007 |
USA |
Retrospective |
Autologous |
62 |
Surgical, reoperation |
McCarthy et al |
2007 |
USA |
Retrospective |
Implant, TE |
110 |
Surgical |
Mehrara et al |
2006 |
USA |
Retrospective |
Free TRAM |
85 |
Surgical, medical, reoperation |
Selber et al |
2006 |
USA |
Retrospective |
Free TRAM |
80 |
Surgical |
Spear et al |
2005 |
USA |
Retrospective |
TRAM |
30 |
Surgical, medical |
Moran et al |
2001 |
USA |
Retrospective |
TRAM |
114 |
Surgical, medical |
Kulkarni et al |
2001 |
USA |
Retrospective |
Implant, autologous |
53 |
Satisfaction |
Chang et al |
2000 |
USA |
Prospective |
Free TRAM |
64 |
Surgical |
Abbreviations: ADM, acellular dermal matrix; DIEP, deep inferior epigastric artery perforator; LD, Latissimus Dorsi; MS, muscle-sparing; SIEA, superficial inferior epigastric artery; TE, tissue expander; TRAM, transverse rectus abdominis myocutaneous.
a Institution of lead author.
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Definitions of Outcome Measures
Surgical Complications
This outcome was reported in 30 studies.[7] [13] [14] [15] [16] [17] [18] [19] [20] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [39] [40] [41] [42] [43] Wound infection was investigated in 25 studies,[7] [13] [15] [16] [17] [18] [20] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [35] [39] [40] [41] [42] [43] wound dehiscence in 12,[13] [16] [17] [18] [20] [22] [24] [27] [28] [30] [32] [36] abdominal hernia in 14,[15] [18] [23] [29] [30] [31] [34] [36] [37] [39] [40] [41] [42] [43] hematoma in 17,[7] [13] [15] [17] [18] [22] [26] [29] [30] [32] [33] [35] [39] [40] [41] [42] [43] seroma in 18,[7] [13] [15] [17] [18] [22] [23] [25] [26] [29] [30] [31] [32] [33] [34] [35] [41] [42] flap failure in 23,[7] [15] [16] [17] [18] [19] [20] [22] [23] [24] [25] [26] [29] [30] [31] [32] [33] [34] [35] [40] [41] [42] [43] and fat necrosis in 17 studies.[15] [17] [18] [23] [25] [26] [29] [30] [31] [32] [35] [37] [39] [40] [41] [42] [43]
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Medical Complications
Medical complications were reported in 14 studies.[16] [18] [20] [23] [24] [25] [26] [27] [28] [31] [35] [40] [42] [43] Ten studies included deep venous thrombosis (DVT) in their definition[16] [18] [20] [23] [24] [26] [27] [40] [42] [43] and seven studies included pulmonary embolism (PE).[16] [18] [20] [23] [24] [27] [42] Four studies included any National Surgical Quality Improvement Program-defined endpoints such as PE, myocardial infarction, pneumonia, urinary tract infection, sepsis, stroke, and coma in their definition.[16] [20] [24] [27]
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Length of Postoperative Hospital Stay
This was reported in four studies which defined the length of stay in days.[23] [26] [31] [43] All four studies were limited to autologous reconstruction.
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Reoperation
This was reported in 12 studies.[13] [16] [18] [21] [24] [25] [26] [27] [28] [30] [39] [40] Reoperation was defined in numerous ways, for example, two studies defined it as unplanned return to the operating room within 30 days.[24] [27] One study provided four reasons for reoperation: tissue expander explantation, tissue expander exchange, conversion to autologous reconstruction, and ultimate failure of reconstruction.[13] Another focused on hernia repair.[21] For the purpose of this study, any reason for return to the operating room was classified as reoperation.
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Patient Satisfaction
Patient satisfaction was reported in three studies[18] [38] [44] and two of these assessed it using the BREAST-Q, a module measuring postreconstruction satisfaction on six subscales: (1) satisfaction with breasts; (2) psychosocial well-being; (3) sexual well-being; (4) physical well-being with respect to chest/abdomen donor site; (5) satisfaction with outcome; and (6) satisfaction with information provision.[18] [44] The third study used a module, which assessed (1) general satisfaction with the treatment process including information provision, decision making and surgery and (2) aesthetic satisfaction in terms of breast contour and softness.[38]
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Results for the Overall Meta-Analysis
The 29 studies that were analyzed involved 71,368 patients, including 20,061 obese patients. [Tables 3], [4], and [5] summarize the results of the primary outcomes of interest. Overall, obese women were more likely to experience surgical (RR 2.29, 95% CI 2.19–2.39; p < 0.00001) and medical complications (RR 2.89, 95% CI 2.50–3.35; p < 0.00001) and had a higher chance of returning to the operating room (RR 1.91, 95% CI 1.75–2.07; p < 0.00001).
Abbreviations: CI, confidence interval; RR, risk ratio.
Heterogeneity Chi[2] =637.13, df = 25 (p < 0.00001); I 2 = 96%.
Test for overall effect: Z = 35.94 (p < 0.00001).
Abbreviations: CI, confidence interval; RR, risk ratio.
Heterogeneity Chi[2] =49.16, df = 4 (p < 0.00001); I 2 = 92%.
Test for overall effect: Z = 14.27 (p < 0.00001).
Abbreviations: CI, confidence interval; RR, risk ratio.
Heterogeneity Chi[2] =49.44, df = 8 (p < 0.00001); I 2 = 84%.
Test for overall effect: Z = 15.24 (p < 0.00001).
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Subgroup Analysis
[Table 6] shows the subgroup analysis for surgical complications. Obese women were more likely to experience fat necrosis (RR 1.65, 95% CI 1.31–2.07; p < 0.0001), seroma (RR 1.96, 95% CI 1.57–2.45; p < 0.00001), partial flap failure (RR 1.60, 95% CI 1.06–2.41; p = 0.03), total flap failure (RR 1.97, 95% CI 1.34–2.91; p = 0.0006), wound dehiscence (RR 2.51, 95% CI 1.80–3.52; p < 0.00001), wound infection (RR 2.34, 95% CI 2.03–2.69; p < 0.00001), and hernia (RR 1.67, 95% CI 1.15–2.43; p = 0.007). No significant difference was found for the occurrence of hematoma.
Abbreviations: CI, confidence interval; RR, risk ratio.
Subgroup analysis for type of reconstruction ([Tables 7] and [8]) showed that obese women were more likely to experience surgical complications during both implant (RR 2.64, 95% CI 2.25–3.09; p < 0.00001) and autologous reconstruction (RR 2.59, 95% CI 2.27–2.55; p < 0.00001).
Abbreviations: CI, confidence interval; RR, risk ratio.
Heterogeneity Chi[2] =598.15, df = 18 (p < 0.00001); I 2 = 97%.
Test for overall effect: Z = 29.70 (p < 0.00001).
Abbreviations: CI, confidence interval; RR, risk ratio.
Heterogeneity Chi[2] =48.97, df = 4 (p < 0.00001); I 2 = 92%.
Test for overall effect: Z = 12.01 (p < 0.00001).
Subgroup analysis for surgical complications in the different classes of obesity was based on four studies, two of which looked at flap complications[23] [32] and two at implant failure.[27] [28] Class II obese patients (RR 1.84, 95% CI 1.56–2.17; p < 0.00001) were more likely to develop surgical complications than Class I (RR 1.32, 95% CI 1.15–1.50; p < 0.0001) or III patients (RR 1.66, 95% CI 1.36–2.03; p < 0.00001) undergoing reconstruction ([Table 9]). Class III patients were more likely to develop complications than Class I patients. Three of the four studies included in this subgroup analysis showed these results.[27] [28] [32]
Abbreviations: CI, confidence interval; RR, risk ratio.
Subgroup analysis for medical complications was not possible as the majority of papers gave the overall number of medical complications, without distinguishing the specific complication.[18] [24] [25] [31] As only two papers provided numbers for specific medical complications the data were deemed inadequate for subgroup analysis.[16] [23]
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Sensitivity Analysis
When performing the meta-analysis with just the comparative studies, again the group of obese women was more likely to experience surgical complications (RR 2.36, 95% CI 2.22–2.52; p < 0.00001) and the RR was comparable to the analysis with all studies ([Table 10]). A summary of the RRs of all outcomes is presented in [Table 11].
Abbreviations: CI, confidence interval; RR, risk ratio.
Heterogeneity Chi[2] =569.76, df = 12 (p < 0.00001); I 2 = 98%.
Test for overall effect: Z = 26.63 (p < 0.00001).
Abbreviations: CI, confidence interval; RR, risk ratio.
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Discussion
Main Findings
Surgical Complications
Consistent with this meta-analysis, there is a well-documented correlation between obesity and the development of both surgical and medical complications in the perioperative period. Obesity increases the risk for complications by influencing the normal physiology through various mechanisms. For example, animal studies have shown that the skin of obese mice is mechanically weaker and unable to generate as much hydrothermal isometric force as the skin of lean mice, believed to be due to a mismatch between the increase in skin surface area and collagen deposition.[57] In addition, decreased collagen deposition results in impaired wound healing in obese mice.[58] Overall, obese animal models display impaired myofibroblast activity and collagen maturation, processes which are both necessary for proper healing of surgical wounds.[59]
In addition, obesity is associated with a chronic, low-grade systemic inflammation referred to as metainflammation. This type of inflammation displays minimal increase in circulating proinflammatory factors and lacks the typical clinical signs of inflammation and may play a part in decreased flap survival.[60] Furthermore, the high mass of adipose tissue surrounding the perforating vessels in certain types of autologous reconstructions may compromise the patency of their lumen, consequently resulting in a decreased blood supply to the flap.[61] In addition, flap loss may be related to the increase in arterial thrombosis and secondarily to increased pedicle tension.[23] Overall, tissue flaps in obese patients are heavier and larger, and a limited vascular supply is may not able to adequately perfuse the greater volume of tissue.[15]
The increased occurrence of infection and necrosis is believed to be due to poor perfusion of the edges of the reconstruction furthest from the vascular inflow leading to relative hypoxia of these tissues.[62] Seroma formation is believed to be due to dead space formation in poorly perfused adipose tissue.[63] Furthermore, given that obesity is associated with increased intraabdominal pressure, it is believed this is what weakens the abdominal wall contributing to the increased risk of hernia occurrence.[64] Furthermore, hypoxia impairs collagen synthesis resulting in deficient healing. Research has also suggested that obesity may cause hernia occurrence by increasing the likelihood of wound infection.[65] A deficiency of macronutrients and micronutrients has also been suggested as a possible cause of inadequate wound healing in obese individuals.[62]
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Medical Complications
The higher occurrence of medical complications seen in this meta-analysis is not surprising, as obese patients often have multiple medical comorbidities, which increase the risk for postoperative medical complications such as DVT and PE. Despite a higher occurrence of DVT and PE being mentioned in the reviewed articles, numerical data were not sufficient to be used in the meta-analysis. It is recommended that obese patients with multiple comorbid conditions should be monitored closely for postoperative medical complications and should receive appropriate mechanical and pharmacological venous thromboembolic prophylaxis with weight-adjusted dosages calculated for the latter.[45] One study found that medical complications were more likely to occur in patients undergoing pedicled TRAM reconstruction than latissimus and free flap reconstruction, suggesting that this increased risk may be due to either a selection bias, as patients prone to thrombotic events were more likely to undergo pedicled flap reconstruction, or due to the fact that perioperative anticoagulants are more routinely used in patients undergoing free tissue transfer.[16]
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Length of Postoperative Hospital Stay
Despite the increase in postoperative complications, the mean length of postoperative hospital stay for obese women was comparable with studies of nonobese patients. The length of stay in the obese population varied from 4.2[23] to 7 days,[43] lengths of stay which are comparable with studies in nonobese populations.[35] [40]
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Reoperation
Overall, the rate of reoperation was higher in the obese population. This is not surprising given the increased occurrence of surgical complications in obese patients. One study differentiated between reconstruction types, reporting that free flap patients had the highest rate of reoperation, followed by TRAM flaps, tissue expander and, last latissimus flaps.[16]
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Patient Satisfaction
Despite a higher occurrence of complications, obese women achieved equivalent postoperative satisfaction scores to the comparison group,[18] and reported similar satisfaction levels in terms of decision-making prior to surgery and also surgical outcome.[44] A significant decrease in aesthetic satisfaction was seen in obese women undergoing expander and implant reconstructions, reported to be due to the challenge in achieving symmetry to a native large volume contralateral breasts.[38]
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Implications for Clinical Practice
To minimize the occurrence of the complications mentioned in this meta-analysis and provide better care for obese women, we recommend that clinicians counsel patients with a BMI > 30 regarding the high risk of complications and to consider weight loss with delayed reconstruction as an option. The literature regarding breast reconstruction following weight loss is not robust, requiring surgeons to utilize good clinical judgment in making individual patient recommendations in the setting of oncologic considerations. It should be emphasized that obesity should not be considered a contraindication for reconstructive breast surgery. Previous research suggests that the preoperative weight loss not only facilitates reconstruction and enhances outcomes[26] but also improves postreconstructive satisfaction in obese women.[66] Research has shown that the dilated perforators seen in obesity exist even after weight reduction and can consequently be harvested during surgery to supply a less bulky and robust flap.[67] [68] It has also been suggested that the decreased fat in the flap leads to lower risk of fat necrosis[69] and the decreased density of the flaps seen in weight loss patients allows for easier perforator dissection and flap mobilization.[26]
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Strengths and Limitations
The strengths of this systematic review and meta-analysis are that it is noncommercial, with strict inclusion and exclusion criteria; it assessed the methodological quality of the studies using the GRADE criteria, and performed a sensitivity analysis to provide more robust conclusions. A study protocol was published a priori following peer-review and we have reported in line with the PRISMA criteria.[9] [70] At the time of writing, this review was the largest and most comprehensive review of the effect of obesity on breast reconstruction, analyzing the most recent studies including two from 2016.
There are several limitations to our work. Most importantly, only nonrandomized studies, which carry inherent biases such as selection bias, met the inclusion criteria. All studies were case series with an LoE of 4 and approximately half of the studies were of low or very low quality. This may weaken the strength of this review. It should be noted that the majority of discussions around case series revolve around their relevance to a potential cause–effect relationship.[71] By respecting the limitations of these studies and accepting them for what they are, we can learn a great deal from such evidence.[72] Our search criteria excluded unpublished data and abstracts and this could add to publication bias.
Unfortunately, only eight papers offered data on implant reconstruction, but these did not, however, distinguish between the different kind of implants. This would be a great future research question. This review did not provide a distinction between immediate and delayed reconstruction as the included papers either analyzed immediate and delayed reconstruction as a single group or did not clearly state whether reconstruction was immediate or delayed. Finally, autologous reconstruction, which includes TRAM, LDM, DIEP, and SIEA flaps, was analyzed as a single group as data for each flap individually were limited. These techniques have varying characteristics and consequently there is heterogeneity in the effect of obesity on each type, resulting in biased observations.
Assessing if different implants have a different relationship to obesity would be a useful research question to address. The impact of breast size would also be interesting to assess. Obesity has known hormonal and nutritional dimensions and given the strength of the effect shown in our meta-analysis, obesity is likely an independent risk factor. However, despite studies not controlling for breast size, breast size itself may be a confounder in this analysis and certainly could be another independent risk factor. Future studies could provide an answer for this question.
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Implications for Future Research
This review and meta-analysis highlight the need for carefully assessing obese patients prior to reconstructive breast surgery but also highlight the need for further research. The majority of papers in this review investigated the group of obese women as a whole. The subgroup analysis of the different classes of obesity found that the Class II patients had higher surgical complication rates than the Class III patients. Current research on the reasons behind this is lacking and future research would ideally classify obesity into the different WHO classes, providing more specific information on the 30 to 35, 35 to 40, and > 40 BMI groups, helping to clarify the reasons and allowing for more tailored risk profiling. BMI was categorized into distinct group ranges but it is likely to be a continuous variable as far as risk is concerned. Ultimately identification of a “threshold” level of obesity would be ideal and this could be the subject of future research.
Furthermore, this review found that obese women were more likely to experience surgical complications during both implant and autologous reconstruction in comparison to nonobese women. Direct comparison of the two types of procedures was not possible in this review as the numerical data was limited. Future studies specifically aimed at comparing implant and autologous reconstruction are necessary to provide a more accurate comparison of the two procedures.
As previously mentioned, all the studies in this review were case series, which are known to suffer from methodological and reporting issues.[73] Issues with the reporting of surgical case series were highlighted in a systematic review of autologous fat grafting for breast reconstruction where the majority of studies failed to provide information about patient demographics and prior treatment.[74]
In the drive to improve the quality of research in clinical practice, various reporting guidelines for different study types have been developed, such as for case reports[75] and systematic reviews.[70] Examples include the CONSORT statement[76] [77] and the STROBE guidelines.[78] Case series should be reported in line with recently published expert consensus guidelines such as the PROCESS guidelines.[79] There are a variety of outcome measures reported in case series and an agreement on a core set of outcome measures to report would help future researchers aggregate studies.
The lack of high-quality research underscores the need for authors to adhere to stringent reporting guidelines. All research should be registered before recruiting patients.[80] With the launch of the Research Registry, surgeons are encouraged to prospectively register their research and to submit a protocol, which will undergo peer review allowing them to enhance their work.[74]
#
#
Conclusion
According to this meta-analysis, obese women were more likely to experience surgical and medical complications and had a higher chance of returning to the operating room. Given the high rates of complications in patients undergoing breast reconstruction with a BMI over 30, careful counseling about the risks and possible delay in reconstruction until weight loss has occurred should be considered.
#
#
Conflict of Interest
None of the authors have any conflicts of interest, relevant to this article, to declare.
-
References
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Address for correspondence
-
References
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- 18 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
- 19 Alipour S, Omranipour R, Akrami R. Obesity should not prevent from TRAM flap breast reconstruction in developing countries. Indian J Surg 2015; 77 (Suppl. 02) 341-344
- 20 Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ, Rosa JH, Taub PJ. Flap failure and wound complications in autologous breast reconstruction: a national perspective. Aesthetic Plast Surg 2015; 39 (06) 902-909
- 21 Mennie JC, Mohanna PN, O'Donoghue JM, Rainsbury R, Cromwell DA. Donor-site hernia repair in abdominal flap breast reconstruction: a population-based cohort study of 7929 patients. Plast Reconstr Surg 2015; 136 (01) 1-9
- 22 Selber JC, Wren JH, Garvey PB. , et al. Critical evaluation of risk factors and early complications in 564 consecutive two-stage implant-based breast reconstructions using acellular dermal matrix at a single center. Plast Reconstr Surg 2015; 136 (01) 10-20
- 23 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
- 24 Fischer JP, Nelson JA, Au A, Tuggle III CT, Serletti JM, Wu LC. Complications and morbidity following breast reconstruction—a review of 16,063 cases from the 2005-2010 NSQIP datasets. J Plast Surg Hand Surg 2014; 48 (02) 104-114
- 25 Nelson JA, Fischer JP, Yan C. , et al. The impact of obesity on abdominal wall function after free autologous breast reconstruction. Microsurgery 2014; 34 (05) 352-360
- 26 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
- 27 Wink JD, Fischer JP, Nelson JA, Serletti JM, Wu LC. Direct-to-implant breast reconstruction: an analysis of 1612 cases from the ACS-NSQIP surgical outcomes database. J Plast Surg Hand Surg 2014; 48 (06) 375-381
- 28 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
- 29 Ireton JE, Kluft JA, Ascherman JA. Unilateral and bilateral breast reconstruction with pedicled TRAM flaps: an outcomes analysis of 188 consecutive patients. Plast Reconstr Surg Glob Open 2013; 1 (02) 1-7
- 30 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
- 31 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
- 32 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
- 33 Yezhelyev M, Duggal CS, Carlson GW, Losken A. Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients. Ann Plast Surg 2013; 70 (05) 557-562
- 34 Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg 2011; 127 (03) 1086-1092
- 35 Appleton SE, Ngan A, Kent B, Morris SF. Risk factors influencing transfusion rates in DIEP flap breast reconstruction. Plast Reconstr Surg 2011; 127 (05) 1773-1782
- 36 Rossetto LA, Abla LEF, Vidal R. , et al. Factors associated with hernia and bulge formation at the donor site of the pedicled TRAM flap. Eur J Plast Surg 2010; 33 (04) 203-208
- 37 Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 2010; 126 (02) 367-374
- 38 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
- 39 Greco III JA, Castaldo ET, Nanney LB. , et al. Autologous breast reconstruction: the Vanderbilt experience (1998 to 2005) of independent predictors of displeasing outcomes. J Am Coll Surg 2008; 207 (01) 49-56
- 40 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 , discussion 1110–1111
- 41 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 (05) 492-497
- 42 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
- 43 Moran SL, Serletti JM. Outcome comparison between free and pedicled TRAM flap breast reconstruction in the obese patient. Plast Reconstr Surg 2001; 108 (07) 1954-1960 , discussion 1961–1962
- 44 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
- 45 Fischer JP, Sieber B, Nelson JA. , et al. Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: an experience with 1303 flaps. Plast Reconstr Surg 2013; 131 (02) 195-203
- 46 Ducic I, Spear SL, Cuoco F, Hannan C. Safety and risk factors for breast reconstruction with pedicled transverse rectus abdominis musculocutaneous flaps: a 10-year analysis. Ann Plast Surg 2005; 55 (06) 559-564
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