ARE PATIENTS WITH LOW BODY MASS INDEX CANDIDATES FOR DEEP INFERIOR EPIGASTRIC PERFORATOR FLAPS FOR UNILATERAL BREAST RECONSTRUCTION? NEELESH A. KANTAK, M.D.,1 PIETER G.L. KOOLEN, M.D.,2 COLETTE MARTIN, B.S.,2 ADAM M. TOBIAS, M.D.,2 BERNARD T. LEE, M.D.,2 and SAMUEL J. LIN, M.D.2*

Thin women have not traditionally been considered ideal candidates for autologous breast reconstruction. The purpose of this study was to examine the use of deep inferior epigastric perforator (DIEP) flap reconstruction in thin women undergoing immediate unilateral breast reconstruction. A retrospective review of 1,040 consecutive patients was performed. In total, 381 patients met the inclusion criteria. To improve clinical interpretability, patients were divided into three groups based on body mass index: “thin” (BMI  22.99), “traditional” (>23 and 29.99), and “obese” (BMI >30) candidates. Flap characteristics were compared to mastectomy weights, and postoperative complications were analyzed. In all groups, flap size was generally more than sufficient to match the mastectomy specimen, as flap weight:mastectomy weight ratio ws greater than 1 in all groups with no significant difference between groups (1.1 in thin patients, 1.0 in traditional patients, and 1.0 in obese patients). Fat necrosis prevalence was lowest in the thin group (12.5%), compared to the traditional (15.9%, P 5 0.443) or obese (14.4%, P 5 0.698) groups. Prevalence of breast infection were lower in the thin patients (5.2%) versus the traditional (8.7%, P 5 0.287) or obese (14.4%, P 5 0.033). Abdominal wound healing complications and seroma were also lowest in thin patients. DIEP flap breast reconstruction may be an effective method for unilateral breast reconstruction in thin patients, with sufficient flap weights and lower incidence of complications than in heavier patients. As such, low BMI may not present a barrier in the reconstruction of a breast C 2015 Wiley Periodicals, Inc. Microsurgery 35:421–427, 2015. mound matching native breast size. V

Choosing a method of breast reconstruction in thin women presents a unique challenge. Traditionally, thin women have not been considered ideal candidates for autologous breast reconstruction given the lack of donor sites that can provide sufficient tissue.1 In particular, deep inferior epigastric perforator (DIEP) flap breast reconstruction, due to the lack of muscle harvest, rely on the presence of excess abdominal skin and fat to adequately reconstruct the breast mound. Thus, thin women are often offered implant-based reconstruction.2 However, implant-based reconstruction may present its own limitations in these patients. Patients with a thin body habitus and little subcutaneous fat are at greater risk for implant visibility and skin rippling.3 Additionally, in women who are undergoing unilateral mastectomy and reconstruction, contralateral mastopexy procedures are often required to achieve symmetry.4 Finally, in women with a history of breast radiotherapy or who are likely to require postoperative radiotherapy, implant-based reconstruction is associated with increased prevalence of wound dehiscence, capsular contracture, and implant extrusion.5–9 In these situations, autologous reconstruction is preferred as it brings vascular-

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Harvard Combined Plastic Surgery Program, Boston, MA Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Neelesh A. Kantak and Pieter G.L. Koolen contributed equally to this work. *Correspondence to: Samuel J. Lin, M.D., 110 Francis Street Suite 5A, Boston, MA 02115. E-mail: [email protected] Received 6 November 2014; Revision accepted 12 January 2015; Accepted 10 March 2015 Published online 28 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22407

ized, non-irradiated tissue into a radiated tissue bed. In a thin woman who meets any of these criteria, autologous reconstruction may be the preferred reconstructive choice. In recent years, DIEP flap breast reconstruction has become an increasingly popular choice for autologous breast reconstruction due to the preservation of the rectus abdominis muscle and fascia. The preservation of abdominal wall stability and strength relative to the transverse rectus abdominis flap (TRAM) flap has been documented.10 In contrast to the superior gluteal artery perforator flap (SGAP) flap, which has been frequently used in thin patients,11 DIEP flap breast reconstruction may achieve a more natural ptosis due to the nature of abdominal fat and its similarity to breast fat.12 The DIEP flap also provides the esthetic benefits of a donor site scar that can be concealed beneath the underwear line and achieves postoperative abdominal contouring. The aim of our study was to assess mastectomy and harvested flap volumes in order to obtain sufficient adipocutaneous tissue to achieve symmetry in candidates for breast reconstructive procedures presenting with scant abdominal tissue. In addition to evaluation of flap characteristics, analysis was performed across BMI groups to assess postoperative outcomes in patients with low BMI undergoing unilateral DIEP flap breast reconstruction.

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PATIENTS AND METHODS

A retrospective review of a prospectively maintained database of 1,040 consecutive patients who underwent unilateral or bilateral breast reconstruction between June 2004 and July 2013 at a single institution was performed. This study was approved by the

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Kantak et al. Table 1. Demographics/Co-morbidities Unilateral DIEP Reconstruction

Number of patients Age BMI Active smoker Diabetes Hypertension Chemotherapy Preoperative radiation Previous Abdominal surgery

BMI 30

P-values

96 51.3 6 8.7 21.5 6 1.1 9 (9.4%) 2 (2.1%) 4 (4.2%) 44 (45.8%) 43 (44.8%) 44 (45.8%)

195 50.5 6 8.4 26.0 6 1.8 24 (12.4%) 3 (1.5%) 29 (14.9%) 95 (48.7%) 78 (40.0%) 92 (47.7%)

90 52.2 6 7.8 34.0 6 3.8 12 (13.3%) 8 (8.9%) 24 (26.7%) 48 (53.3%) 34 (37.8%) 46 (51.1%)

0.274a 23 and 29.99), and “obese” (BMI >30). The BMI cutoff of 23 to designate “thin” patients was chosen as an arbitrary cutoff to allow a distinction between non-obese patients who were felt by the authors to represent a population that is typically offered abdominal flaps for autologous breast reconstruction from a population of truly thin patients. For each patient, data on demogaphics, comorbidities, mastectomy weight, flap characteristics (flap weight and number of perforators), and postoperative outcomes were obtained. Data extraction was performed by three authors involved in this study, independently from the surgical staff. To maximize accuracy all data were reviewed before being recorded in the database. Statistical analyses were performed using SPSS software version 21.0 (SPSS Inc., Chicago, IL). Pearson’s v2 tests and Fisher’s Exact tests were used to test for significant associations between categorical variables. ANOVA tests were used to assess distributions of continuous variables across multiple groups. Pearson’s correlation coefficients were obtained per subgroup in order to assess the extent to which harvested flaps could match the volume Microsurgery DOI 10.1002/micr

of an amputated breast. A two-tailed P values of

Are patients with low body mass index candidates for deep inferior epigastric perforator flaps for unilateral breast reconstruction?

Thin women have not traditionally been considered ideal candidates for autologous breast reconstruction. The purpose of this study was to examine the ...
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