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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
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[17]
Kim Z, Kang SG, Roh JH, Park JH, Lee J, Kim S, Lim CW, Lee MH. Skin-
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