Free Tissue Transfer in the Obese Patient: An Outcome and Cost Analysis in 1258 Consecutive Abdominally Based Reconstructions

Background: The authors' institution has seen an increase in obese and morbidly obese patients seeking autologous breast reconstruction. The authors provide a comprehensive outcome analysis of patients undergoing abdominally based autologous breast reconstruction. Methods: The authors identified obese patients receiving free tissue transfer for breast reconstruction. World Health Organization body mass index criteria were used: nonobese (body mass index, 20 to 29.9 kg/m(2)), class I (30 to 34.9 kg/m(2)), class II (35 to 39.9 kg/m(2)), and class III (> 40 kg/m(2)). Patient comorbidities, body mass index, complications (medical and surgical), and hospital resource use were examined. Results: Eight-hundred twelve patients undergoing 1258 free tissue transfers for breast reconstruction were included. Overall, 66.5 percent (n = 540) were considered nonobese, 22.9 percent (n = 186) had class I obesity, 5.0 percent (n = 41) had class II, and 5.7 percent (n = 45) had class III. Obesity was associated with a significant increase in minor (p = 0.001) and major (p = 0.013) complications. Morbidly obese patients had significantly higher rates of total flap loss (p = 0.006) and longer operative times (p = 0.0002). Complications translated into greater cost and resource consumption (p < 0.001). Muscle-sparing transverse rectus abdominis myocutaneous flap experienced a significantly higher rate of hernia compared with other flaps (p = 0.02), without a difference in flap loss rate (p = 0.61). Conclusions: Increasing obesity is associated with increased perioperative risk in free abdominally based autologous breast reconstruction, which translated into greater perioperative morbidity, higher hospital cost, and increased health care resource consumption. Higher body mass index is directly related to intraoperative technical difficulty, flap loss, donor-site morbidity, and cost use.