Complications of abdominal-based free flaps for breast
reconstruction in obese patients: a meta-analysis and case series
Erik Matthew Wolfswinkel
William M. Weathers
Mohin A. Bhadkamkar
Larry H. Hollier Jr.
Rodger H. Brown
Received: 13 March 2013 / Accepted: 17 May 2013 / Published online: 18 July 2013
Springer-Verlag Berlin Heidelberg 2013
Background Obese patients now constitute a larger proportion
of women seeking postmastectomy reconstruction. Achieving
optimal results with a low number of complications in the
obese population is challenging. This meta-analysis compares
the complication risks for obese and nonobese patients receiv-
ing abdominal-based free flaps for breast reconstruction.
Methods A retrospective case series of obese and nonobese
patients undergoing abdominal-based free flaps for breast re-
construction was performed and included in the meta-analysis.
A literature search yielded 103 citations, and multilevel screen-
ing identified 7 relevant studies. An eight study meta-analysis,
using the DerSimonian and Laird random effects models, com-
pared pooled relative risks for complications.
Results There was a twofold risk of infection (relative risk
(RR), 1.97; 95 % CI, 1.23, 3.14), two and one half times the
risk of mastectomy flap necrosis (RR, 2.61; CI, 1.62, 4.20),
and partial flap loss (RR, 2.62; CI, 1.23, 5.59) for obese
patients compared to nonobese patients. Additionally, there
was a fourfold increase in risk for total flap loss (RR, 4.12; CI,
1.01, 16.79) and donor-site seroma (RR, 4.03; CI, 2.46, 6.59).
There was no significant difference in the risk for overall
donor-site complications between the two populations (RR,
1.09; CI, 0.58, 2.05).
Conclusions The findings reveal that obese patients have a
higher risk of complications than nonobese patients receiving
abdominal-based free flaps for breast reconstruction. As we
move toward a pay-for-performance reimbursement system,
appropriate risk adjustments will be a vital component, allowing
provision of optimal treatment techniques for obese patients.
Level of Evidence: Level IV, prognostic/risk study
The number of mastectomies and breast reconstructions
following a diagnosis of breast cancer has been increasing
nationally [1–4]. Numerous studies have documented the
positive benefits of breast reconstruction, including im-
provements in self esteem, sexuality, and body image [2,
5–8]. As the US population becomes increasingly obese,
patients with body mass indexes (BMI) ≥30 kg/m
constitute a larger proportion of women seeking breast
reconstruction [9, 10]. Achieving optimal results in this pop-
ulation has presented a challenge for plastic surgeons [10–15].
With reported complications following abdominal-based
breast reconstruction (ABBR) ranging from 31–56 % in the
obese population, many surgeons have avoided using these
techniques [10, 16–20]. Some surgeons have gone as far as to
consider obesity a relative contraindication to traditional
ABBR [10, 19, 21].
In spite of the high complication percentages reported
with tradition ABBR techniques, obesity does not constitute
a contraindication for breast reconstruction as previously
assumed [10, 11, 18, 22]. Microsurgical reconstruction
using free transverse rectus abdominis myocutaneous flaps
(TRAM), free muscle-sparing TRAM flaps (MS-TRAM),
and deep inferior epigastric perforator flaps (DIEP) repre-
sents the bulk of ABBR and are reported to provide
positive esthetic outcomes, high patient satisfaction, and
lower complication percentages [18, 19, 23–25]. Surgeons
now regularly offer these microsurgical reconstruction options
to patients previously considered too high risk for traditional
ABBR [17, 26].
The objectives of this study were to conduct a meta-
analysis of the existing literature, with the addition of a
E. M. Wolfswinkel
W. M. Weathers
M. A. Bhadkamkar
L. H. Hollier Jr.
R. H. Brown (*)
Division of Plastic Surgery, Michael E. Debakey Department of
Surgery, Baylor College of Medicine, 6701 Fannin St. Suite 610,
Houston, TX 77030, USA
Eur J Plast Surg (2013) 36:765–776