Stacked DIEP Flaps for Unilateral Breast Reconstruction in Overweight and Obese Patients: Do the Benefits Outweigh the Risks?
Steven M. Sultan, M.D.1, Akhil K. Seth, MD2, David T. Greenspun, MD3, Heather A. Erhard, MD1.
1Montefiore Medical Center, Bronx, NY, USA, 2Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Greenwich Hospital, Greenwich, CT, USA.
Some surgeons have advocated the use of stacked deep inferior epigastric perforator (DIEP) flaps for unilateral autologous reconstruction in thin patients in whom a hemi-abdominal flap is insufficient to produce an adequate breast mound. There have been no studies, however, that have explored complication rates when using stacked DIEP flaps for unilateral reconstruction in overweight or obese patients.
Methods and Materials:
The authors performed a retrospective review of the two senior authors' patients over the past 49 months. In this time period, 57 patients underwent unilateral breast reconstruction with stacked DIEP flaps. The patients were divided into normal weight (BMI<25, n=25), and overweight/obese (BMI>25, n=32) groups. Demographics reviewed included age at reconstruction, mastectomy weight and flap weight. Comorbidities considered were hypertension, diabetes, chemotherapy, radiation, smoking within the past year and previous abdominal surgery.
Outcomes were reviewed for both major and minor complications. Major complications included reoperation for any reason during the initial hospitalization, partial or complete flap loss, pulmonary embolism and hernia formation. Minor complications included wound infection, seroma, abdominal bulge and fat necrosis.
The average BMI of the normal group was 23.0±1.3 kg/m2 while the average BMI of the overweight/obese group was 29.5±4.3 kg/m2 (p<0.01). There was no significant difference in age at reconstruction between the two groups (overweight/obese=54.5±8.7 years, normal BMI=53.8±7.9 years, p=0.38). Patients in the overweight/obese group had both significantly larger mastectomy specimens (overweight/obese=699.0±191.0 grams, normal BMI=489.4±185.6 grams, p<0.01) and flap weights (overweight/obese=851.7±235.5 grams, normal BMI=526.6±181.5 grams, p<0.01) than the normal group. There were no significant differences in comorbidities between the two groups. There was a trend towards a higher incidence of diabetes in the overweight/obese group, but this did not reach statistical significance (overweight/obese=9.7%, normal BMI=4.0%, p=0.21).
There was no statistically significant difference in the overall incidence of major complications between the two groups (overweight/obese=12.5%, normal BMI=8.0%, p=0.29). In addition there was no statistically significant difference in the incidence of any of the individual major complications reviewed. There was no significant difference in the overall incidence of minor complications between the two groups (overweight/obese=45.7%, normal BMI=40.0%, p=0.26). There was, however, a statistically significant increase in the incidence of fat necrosis in the flaps of the overweight/obese group when compared to the flaps of the normal BMI group (overweight/obese=21.9%, normal BMI=12.0%, p=0.05).
In many centers overweight or obese patients with unilateral breast cancers are consigned to implant-based reconstruction. Despite contralateral symmetry procedures, however, this approach often fails to yield a natural result. As the data presented here demonstrate, stacked DIEP flap reconstruction can be performed safely following unilateral mastectomy in overweight and obese patients with no increase in major complications. This technique likely trends towards a higher rate of minor complications in these patients, but it also provides better restoration of pre-mastectomy breast form and volume in this group. As the average BMI continues to increase nationally, it is imperative that plastic surgeons expand the indications for autologous reconstruction in order to parallel this demographic shift and better meet the needs of our patients.
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