We hypothesized that for obese patients, abdominal-based free flap, rather than implant-based, and delayed, rather than immediate, breast reconstruction would result in fewer overall complications and reconstruction losses.
We retrospectively analyzed consecutive implant- and abdominal-based free-flap breast reconstructions performed in obese patients between 2005 and 2010 utilizing the World Health Organization obesity classifications: class I (30.0–34.9 kg/m2), class II (35.0–39.9 kg/m2), and class III (≥40 kg/m2). Primary outcome measures included flap failures and overall complications. Logistic regression analysis identified associations between patient, defect, and reconstructive characteristics and surgical outcomes.
The analysis included 990 breast reconstructions (548 flaps vs. 442 implants) in 700 patients. Mean follow-up was 17 months. Age (p<0.01), smoking (p=0.02), medical illness (p=0.01), and BMI>37 (p=0.01) predicted overall complications on regression analysis. Implants demonstrated a higher failure rate (15.8%) than flaps (1.5%; p<0.001). While failure rates were similar for immediate and delayed flap reconstructions overall (1.3% vs. 1.9%; p=0.7) and among obesity classifications, there was a trend toward more implant failures in immediate rather than delayed reconstructions (16.8% vs. 5.3%; p=0.06). Differences between immediate implant versus flap reconstruction failure rates were highest among more obese patients (class II [24.7% vs. 1.3%, respectively; p<0.01] and class III [25.4% vs. 0%, respectively; p<0.01] compared to class I [11.7% vs. 1.4%, respectively; p<0.01]).
Obese patients, particularly patients with class II and III obesity, experience higher failure rates with implant-based breast reconstruction, particularly immediate reconstruction. Free flap techniques or delayed implant reconstruction may be warranted in this population.