Impact of Obesity on Outcomes in Breast Reconstruction: Analysis of 15,937 Patients from the ACS-NSQIP Datasets

BACKGROUND: Obesity is a growing epidemic in the United States (US) affecting more than 33% of adults. We aimed to use the World Health Organization (WHO) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP database from 2005 to 2010. STUDY DESIGN: We reviewed the 2005 to 2010 ACS-NSQIP databases identifying encounters for Current Procedural Terminology (CPT) codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominis myocutaneous pTRAM, free TRAM, and latissimus dorsi flap with or without implant). Patients were classified and compared based on WHO obesity criteria: nonobese (body mass index BMI = 20 to 29.9 kg/m(2)), class I (BMI = 30 to 34.9 kg/m(2)), class II (BMI = 35 to 39.9 kg/m(2)), and class III (BMI > 40 kg/m(2)). RESULTS: During the study period 15,937 breast reconstructions were performed. The majority of reconstructions were immediate reconstructions (85.0%) and implant-based (79.1%). The incidence of obesity was 27.1%, with 16.3% defined as class I obese, 6.9% defined as class II obese, and 4.0% defined as class III obese. The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions, higher American Society of Anesthesiologists (ASA) physical status (p < 0.001), longer operative times (p = 0.0001), and greater lengths of hospital stay (p = 0.0001). Progressively higher BMIs were associated with higher rates of complications, including wound (p < 0.001), medical (p < 0.001), infections (p < 0.001), major surgical (p < 0.001), graft and prosthesis loss (p < 0.001), and return to the operating room (p < 0.001). CONCLUSIONS: This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large, prospective multicenter dataset. Increasing obesity is associated with increased perioperative morbidity. Data derived from this cohort study can be used to risk-stratify patients, enhance risk counseling, and advocate for institutional reimbursement in obese patients undergoing breast reconstruction.