Obesity and Breast Reconstruction

Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study

Dhivya R. Srinivasa, M.D.; Mark W. Clemens, M.D.; Ji Qi, M.S.; Jennifer B. Hamill, M.P.H.; Hyungjin M. Kim, Sc.D.; Andrea L. Pusic, M.D., M.H.S.; Edwin G. Wilkins, M.D., M.S.; Charles E. Butler, M.D.; Patrick B. Garvey, M.D.


Plast Reconstr Surg. 2020;145(3):481e-490e. 

In This Article

Abstract and Introduction


Background: The authors' purpose was to evaluate the effects of body mass index, as defined by World Health Organization criteria, on complications and patient-reported outcomes in implant-based and autologous breast reconstruction.

Methods: Complications and BREAST-Q patient-reported outcomes were analyzed 2 years after breast reconstruction for women from 11 participating sites. Separate mixed-effects regressions were performed to assess body mass index effects on outcomes.

Results: A total of 2259 patients (1625 implant-based and 634 autologous) were included. Women with class II/III obesity had higher risks of any complication in both the implant (OR, 1.66; p = 0.03) and autologous (OR, 3.35; p < 0.001) groups, and higher risks of major complications in both the implant (OR, 1.71, p = 0.04) and autologous (OR, 2.72; p = 0.001) groups, compared with underweight/normal weight patients. Both class I (OR, 1.97; p = 0.03) and class II/III (OR, 3.30; p = 0.001) obesity patients experienced higher reconstructive failures in the implant cohort. Class I obesity implant patients reported significantly lower Satisfaction with Breasts scores (mean difference, −5.37; p = 0.007). Body mass index did not significantly affect patient-reported outcomes for autologous reconstruction patients.

Conclusions:Obesity was associated with higher risks for complications in both implant-based and autologous breast reconstruction; however, it only significantly affected reconstruction failure and patient-reported outcomes in the implant reconstruction patients. Quality-of-life benefits and surgical risk should be presented to each patient as they relate to her body mass index, to optimize shared decision-making for breast reconstruction.

Clinical Question/Level of Evidence: Risk, I.


The obesity epidemic has evolved into a major health crisis in the United States, with increasing numbers of patients now labeled as "obese" or "super obese."[1–3] Currently, over 40 percent of the U.S. population is obese, with body mass indices of 30 kg/m2 or higher.[4] Obesity has been linked to a multitude of health conditions, including breast cancer, where previous reports have noted significant effects of body mass index on both the risk and age at onset of the disease. With rising numbers of patients choosing mastectomy and reconstruction for breast cancer treatment or prophylaxis,[5,6] more overweight and obese women are seeking breast reconstruction. Given the multitude of implant- and autologous tissue–based options available, plastic surgeons are commonly faced with the challenge of choosing the "right" operation for patients with a high body mass index.

Although obesity has been previously evaluated as a risk factor for surgical complications in breast reconstruction, the results of these studies have been mixed, with investigators reporting varying effects of body mass index on complication rates.[7–17] Most of these studies have been limited by their single-center and/or single-surgeon designs and variable lengths of follow-up. In many cases, previous analyses have failed to control for important demographic and clinical covariates, which may confound the effects of body mass index on outcomes. Furthermore, few studies have evaluated the impact of body mass index on patient-reported outcomes,[18–24] key measures of the benefits of reconstruction. To promote evidence-based decision-making in breast reconstruction for overweight and obese patients, additional research is needed to comprehensively evaluate the effects of body mass index on complications and patient-reported outcomes. Because obesity may present significant clinical challenges for both patients and surgeons, high-quality data on the risks and benefits of reconstructive procedures in this population are essential to choosing the operation that best fits each woman and to achieving optimal outcomes. To achieve these objectives, we sought to evaluate the effects of body mass index on complications and patient-reported outcomes in a multicenter, prospective cohort study of implant-based and autologous breast reconstruction.