Page 22 - Read Online

produces a varied range in complication rates and types: occur, and misclassification of postoperative events. Once
simple mastectomy (4-5.72%), [4,5] skin-sparing mastectomy again, readers have to mindful of these significant limitations
(15.1-64.2%), [6,7] and nipple-sparing mastectomy (12.4-22%). [8,9] when drawing conclusions.
Each modality has benefits and short falls, and some of the
complications might be enhanced by a low BMI and poor As illustrated by the authors, the small sample size confirms
nutrition such as skin flap necrosis, with the rate reported that breast reconstruction in patients with low BMI is not
[6]
as 0-6.3% for skin-sparing mastectomy, and 5.2-9.5% for very common and an attempt to establish the etiology of
nipple-sparing mastectomy, [9,10] or nipple-necrosis with the being underweight unfortunately did not reach statistical
rate reported as 4.4-9.2% [8,9,11] in nipple-sparing mastectomy. significance. A patient with low BMI does not necessarily
Given the heterogeneity in complications rates, it would have entail malnourishment. In fact, an obese patient may well be
been interesting to see if the effect of the type of mastectomy malnourished despite the high BMI. Studies have shown that
was a confounding factor in the results. Furthermore, breast malnourished patients often require longer hospitalizations,
conservation therapy (BCT) accounts for the majority of have more postoperative complications, and have delayed
breast cancer treatment in the United States and the wound and fracture healing compared with well-nourished
[12]
readers have to be mindful that the conclusions drawn by patients. [19,20] For this reason, all patients regardless of their
this article do not apply to partial breast reconstruction. BMI should be evaluated for their nutritional status, and
Therefore, future research warrants inclusion and analysis of ensure adequate preoperative calorie, protein, vitamin,
each type of breast cancer therapy modality. and mineralintake. This helps optimization of the patient’s
nutritional status and minimization of postoperative
Secondly, the stratification of patients into prosthesis and complications.
autologous categories does not take into account the
heterogeneity of complications among the different types Low BMI is a poorly discussed topic and the limited number
of breast reconstruction procedures. It is known that the of eligible patients makes it challenging to obtain statistically
rates of complications differ among patients who undergo significant results. We commend the authors for this study
pedicled flaps (58.5-67.9%) and those who undergo free flaps and we believe it provides a great starting point for debate.
(17.7-26.9%). [13,14] Furthermore, it is known that patients’ BMI But because of the limitations (mostly dictated by the ACS-
can have an impact on the rates of complications like skin NSQIP data), we feel that definitive conclusions cannot be
flap necrosis, wound dehiscence, and graft and prosthesis drawn from this study, but look forward to future research
loss. [2,15] Even within each type of reconstruction, there is to evaluate the impact of low BMI in the varied spectrum of
a variation among the selected flap. For example, a meta- breast reconstruction.
analysis by Wang et al. revealed a lower rate of fat necrosis
[1]
(RR 0.502) and a higher rate of abdominal hernias (RR 2.354) Financial support and sponsorship
in muscle-sparing transverse rectus abdominismyocutaneous Nil.
(TRAM) flap than in deep inferior epigastric perforator flap.
Therefore, it is challenging to group pedicled flaps (e.g. Conficts of interest
latissimusdorsi, or TRAM) with free flaps (e.g. TRAM, muscle- There are no conflicts of interest.
sparing TRAM, DIEP), because variation in complication rates
exists among them, and each complication may be affected REFERENCES
differently by low BMI. Unfortunately, ACS-NSQIP does not
allow distinguish between specific free flap procedures, since 1. Wang XL, Liu LB, Song FM, Wang QY. Meta-analysis of the safety and
all free flap reconstructions are grouped under the same CPT factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps
code, making it impossible to perform subgroup analysis. for breast reconstruction. Aesthetic Plast Surg 2014;38:681-91.
These limitations restrict the authors’ ability to accurately 2. Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanchwala S. Impact
assess the impact of low BMI in breast reconstruction, since of obesity on outcomes in breast reconstruction: analysis of 15,937
patients from the ACS-NSQIP datasets. J Am CollSurg 2013;217:656-64.
too much variation exists between breast reconstruction 3. Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg
modalities. Therefore, future research warrants inclusion 2006;117: S42-58.
and analysis of each type of breast reconstruction modality. 4. El-Tamer MB, Ward BM, Schifftner T, Neumayer L, Khuri S, Henderson
Most importantly, the authors omitted in the analysis, W. Morbidity and mortality following breast cancer surgery in women:
certain key complications like hematoma, seroma, fat 5. national benchmarks for standards of care. Ann Surg 2007;245:665-71.
De Blacam C, Ogunleye AA, Momoh AO, Colakoglu S, Tobias AM, Sharma R,
necrosis, nipple necrosis, skin flap necrosis, and donor Houlihan MJ, Lee BT. High body mass index and smoking predict morbidity
site complications, which are known issues of breast in breast cancer surgery: a multivariate analysis of 26,988 patients from
reconstruction procedures [1,15,16] and whose incidence the national surgical quality improvement program database. Ann Surg
could be affected by the patient’s BMI. The ACS-NSQIP 6. 2012;255:551-5.
[17]
Kim Z, Kang SG, Roh JH, Park JH, Lee J, Kim S, Lim CW, Lee MH. Skin-
dataset tracks certain complications for only 30 days and sparing mastectomy and immediate latissimusdorsi flap reconstruction:
unfortunately does not include some very important and a retrospective analysis of the surgical and patient-reported outcomes.
most relevant complications. A lack of data may have World J Surg Oncol 2012;10:259.
resulted in an under-reporting of complications in this study. 7. Omranipour R, Bobin JY, Esouyeh M. Skin sparing mastectomy and
Also, Epelboym et al. [18] reported discordance in 27.3% of the immediate breast reconstruction (SSMIR) for early breast cancer: eight
years single institution experience. World J Surg Oncol 2008;6:43.
time in complication reporting by the ACS-NSQIP including: 8. Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. Breast
missed complications, reported complications that did not reconstruction following nipple sparing mastectomy: a systematic review
Plast Aesthet Res || Vol 3 || Issue 1 || Jan 15, 2016 15