Comparing autologous breast reconstruction in high vs. low body mass index patients
Original Article

Comparing autologous breast reconstruction in high vs. low body mass index patients

Colin G. White-Dzuro ORCID logo, Nicholas T. Haddock ORCID logo

Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA

Contributions: (I) Conception and design: Both authors; (II) Administrative support: Both authors; (III) Provision of study materials or patients: Both authors; (IV) Collection and assembly of data: Both authors; (V) Data analysis and interpretation: Both authors; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors.

Correspondence to: Nicholas T. Haddock, MD. Department of Plastic Surgery, The University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8593, USA. Email: Nicholas.Haddock@utsouthwestern.edu.

Background: Breast reconstruction has been shown to significantly improve quality of life (QoL) for women who must undergo mastectomy. Between the implant-based and autologous-based reconstruction, autologous-based reconstruction has demonstrated better outcomes in both QoL and overall satisfaction as reported by the BREAST-Q. For patients desiring autologous reconstruction, a woman’s weight and body habitus can affect not only the pre-operative planning, but also outcomes in terms of both complications as well as overall satisfaction. Here, we present our cohort that has been stratified by body mass index (BMI) and compare how BMI can influence flap selection as well as complications.

Methods: After institutional review board approval, a retrospective review in a REDCap database-guided analysis was conducted of patients who underwent autologous reconstruction with longitudinal follow-up at a single academic institution from 2013 to 2024. Patients were then stratified into BMI categories as outlined by the Centers for Disease Control (CDC) including healthy (18.5≤ BMI <25 kg/m2), overweight (25≤ BMI <30 kg/m2), and obese (BMI ≥30 kg/m2). Data were then obtained and the subgroups were compared. Statistical significance was set at a P value less than 0.05 for all tests. Pearson Chi-squared tests were used to compare flap types, categorical comorbidities, and complications across the groups, and one-way analysis of variance (ANOVA) was used to compare average length of surgery.

Results: A total of 957 patients were identified who fit the inclusion criteria, with 239 patients sorted into the healthy (18.5≤ BMI <25 kg/m2) subgroup, 348 patients into the overweight (25≤ BMI <30 kg/m2) subgroup, and 370 patients into the obese (BMI ≥30 kg/m2) subgroup. There were significant differences in comorbid conditions between the groups including diabetes and hypertension (P<0.05), with the incidence of these comorbidities increasing from healthy to overweight to obese subgroups. The rate of multi-flap procedures was significantly higher in the Healthy subgroup (33.9%) as compared to the overweight (23.3%) and obese (11.6%) subgroups (P<0.05). There was a significant difference in the type of flaps used between the subgroups (P<0.05), as well as in the incidence of deep inferior epigastric perforators (DIEPs), profunda artery perforators, and lumbar artery perforators between the subgroups (P<0.05). There was a significant difference found for incidence of flap site infection (P<0.05), seroma (P<0.05), and wound (P<0.05), as well as in overall donor site complications (P<0.05) between the subgroups, with a greater incidence occurring within the obese subgroup as compared to the overweight or healthy subgroups.

Conclusions: In this retrospective cohort study, we found that patients with healthy BMI are more likely to undergo multi-flap or non-abdominally based flap reconstruction and less frequently rely on DIEP flaps than women of overweight or obese BMI. Furthermore, patients with obese BMI are more likely to have post-operative complications at either the breast or donor site. A deeper look into perioperative data and complications will help understand other differences between the subgroups in terms of surgical efficacy and safety.

Keywords: Breast reconstruction; autologous; body mass index (BMI)

Submitted Jul 30, 2025. Accepted for publication Sep 28, 2025. Published online Dec 23, 2025.

doi: 10.21037/gs-2025-337

Highlight box

Key findings

• Patients with low body mass index (BMI) are more likely to undergo multi-flap or non-abdominally based flap reconstruction and less frequently rely on deep inferior epigastric perforator flaps than women of high BMI. Furthermore, patients with high BMI are more likely to have post-operative complications at either breast or donor site.

What is known and what is new?

• Previous literature has reported links between BMI and complications in autologous reconstruction.

• This manuscript utilizes a larger cohort than most studies and expands on the types of complications, as well as documents the variety of autologous tissue options depending on patient BMI.

What is the implication, and what should change now?

• This correlates BMI with complications after reconstruction and can guide surgeons into patient-specific post-operative care plans depending on BMI.

Introduction

Breast reconstruction has been shown to significantly improve quality of life (QoL) for women who must undergo mastectomy (1). Women who desire reconstruction can choose from two different methods: implant-based and autologous-based. Between the two, autologous-based reconstruction has demonstrated better outcomes in both QoL and overall satisfaction as reported by the BREAST-Q, a validated patient reported outcome measure (PROM) (2-4).

For patients desiring autologous reconstruction, the reconstructive surgeon must have a variety of options in their armamentarium to best fit the patient based on their characteristics. This ranges from pedicle-based flaps like the latissimus dorsi (LD), the transverse rectus abdominus myocutaneous (TRAM), or the thoracodorsal artery perforator (TDAP) flap, to perforator-based free flaps like deep inferior epigastric perforator (DIEP), profunda artery perforator (PAP), and lumbar artery perforator (LAP) flap (5). Despite being a more tedious dissection and often increasing operative times, perforator-based flaps offer significantly decreased donor site morbidity when compared to muscle flaps without compromising the outcome (6).

Perforator flap selection depends largely on patient-specific factors as well as surgeon comfort and preference, and can vary by location of the donor site as well as the number of flaps recruited (7). Specifically, a woman’s weight and body habitus can affect not only the pre-operative planning, but also outcomes in terms of both complications as well as overall satisfaction (8). Here, we present our cohort that has been stratified by body mass index (BMI) and compare how BMI can influence flap selection as well as post-operative complications. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-337/rc).

Methods

Data collection

After institutional review board approval, a retrospective review in a REDCap database-guided analysis was conducted of patients who underwent autologous reconstruction with longitudinal follow-up at a single academic institution from 2013 to 2024 (9,10). All data in the REDCap database were originally obtained from the electronic medical record. Patients were then stratified into BMI categories as outlined by the Centers for Disease Control (CDC) including healthy (18.5≤ BMI <25 kg/m2), overweight (25≤ BMI <30 kg/m2), and obese (BMI ≥30 kg/m2). Data were then obtained including type of flap utilized, perioperative data (length of procedure in minutes), and complications from both flap and donor site, and the subgroups were compared. Flap complications include occurrence of infection, hematoma, seroma, presence of post-operative wound, pneumothorax, or flap loss, and donor site complications include infection and presence of post-operative wound. Any patients with missing data were excluded from the analysis.

Statistical analysis

Statistical significance was set at a P value less than 0.05 for all tests. All statistics were performed using Microsoft Excel and IBM SPSS Statistics for Macintosh, version 29.0 (11). Pearson Chi-squared tests were used to compare flap types, categorical comorbidities, and complications across the groups. One-way analysis of variance (ANOVA) was used to compare average length of surgery. Post-hoc analysis using Bonferroni correction was then performed to determine which subgroups demonstrated statistically significant differences.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of The University of Texas Southwestern Medical Center (No. STU052015-021) and individual consent for this retrospective analysis was waived.

Results

Demographics and flap selection

Our retrospective review yielded a total of 957 patients who met the inclusion criteria, having undergone autologous-based breast reconstruction and continued with longitudinal follow-up. After stratification of the patients by their BMI, we sorted 239 patients into the healthy (18.5≤ BMI <25 kg/m2) subgroup, 348 patients into the overweight (25≤ BMI <30 kg/m2) subgroup, and 370 patients into the obese (BMI ≥30 kg/m2) subgroup. All results and statistical analysis are shown in Table 1. The average ages of the healthy, overweight, and obese subgroups were 52±10.3, 53±9.8, and 53±9.8 years, respectively. There were significant differences in certain comorbid conditions between the groups including diabetes, hypertension, and history of deep vein thrombosis (DVT) (P<0.05), with the incidence of these comorbidities increasing from healthy to overweight to obese subgroups. There was no statistically significant difference in incidence of either autoimmune disease or history of smoking between the subgroups (P=0.65, P=0.10, respectively).

Table 1

Patients are stratified here by BMI into three subgroups: healthy (18.5≤ BMI <25 kg/m2), overweight (25≤ BMI <30 kg/m2) and obese (BMI ≥30 kg/m2). Patients are then compared between the subgroups based on comorbid conditions, type of autologous reconstruction, and complications

Items 18.5≤ BMI <25 kg/m2 (n=239) 25≤ BMI <30 kg/m2 (n=348) BMI ≥30 kg/m2 (n=370) P
Comorbidities
   Hypertension 44 (18.4)† 99 (28.4) 153 (41.3)† <0.05*
   Diabetes 7 (2.9)† 29 (8.3) 56 (15.1)† <0.05*
   Autoimmune 15 (6.3) 29 (8.3) 28 (7.6) 0.65
   History of DVT 4 (1.5) 8 (2.3) 21 (5.7)† <0.05*
   History of smoking 41 (17.1) 85 (24.4) 84 (22.7) 0.10
Laterality –
   Unilateral 69 (28.9) 66 (19.0) 59 (15.9)
   Bilateral 170 (71.1) 282 (81.0) 311 (84.1)
Multi-flap 81 (33.9)† 81 (23.3) 43 (11.6)† <0.05*
Total number of flaps 502 726 729 <0.05*
   DIEP 287 (57.1)† 534 (73.6) 642 (88.1)† <0.05*
   LAP 71 (14.2)† 66 (9.0) 26 (3.6)† <0.05*
   PAP 132 (26.3)† 102 (14.1) 36 (4.9)† <0.05*
   Other 12 (2.4) 24 (3.3) 25 (3.4) 0.55
Average length of surgery (minutes) 402 429 437 0.09
Flap complications 70 (13.9) 103 (14.2) 117 (16.0) 0.49
   Infection 4 (0.8)† 17 (2.3) 28 (3.8)† <0.05*
   Hematoma 15 (3.0) 19 (2.6) 14 (1.9) 0.46
   Seroma 4 (0.8) 6 (0.8) 19 (2.6)† <0.05*
   Wound 26 (5.2)† 56 (7.7) 93 (12.8)† <0.05*
   Pneumothorax 4 (0.8) 1 (0.003) 7 (0.02) 0.11
   Flap loss 14 (2.8) 14 (1.9) 15 (2.1) 0.57
Donor site complications 58 (11.6) 95 (13.1) 126 (17.3)† <0.05*
   Infection 13 (2.6) 11 (1.5) 32 (4.4)† <0.05*
   Wound 46 (9.2) 70 (9.6) 93 (12.8)† <0.05*

Data are presented as number (%). Statistical significance is reported in the rightmost column as P value. *, denotes statistical significance; †, denotes statistical significance following post-hoc analysis with Bonferroni correction. BMI, body mass index; DIEP, deep inferior epigastric artery perforator; DVT, deep vein thrombosis; LAP, lumbar artery perforator; PAP, profunda artery perforator.

The rate of multi-flap procedures was significantly higher in the healthy subgroup (33.9%) as compared to the overweight (23.3%) and obese (11.6%) subgroups (P<0.05). The total number of flaps performed was 502 for the healthy subgroup, 726 for the overweight subgroup, and 729 for the obese subgroup. Overall, there was a significant difference in the type of flaps used between the subgroups (P<0.05), as well as in the incidence of DIEPs, PAPs, and LAPs between the subgroups (P<0.05); DIEPs were more likely to be the flap of choice in obese patients (88.1%) rather than overweight (73.6%) or healthy (57.1%) patients, whereas PAPs (26.3%) and LAPs (14.2%) were more likely to be chosen for Healthy patients than overweight (14.1% and 9.1%, respectively) or obese (4.9% and 3.6%, respectively) patients.

Flap and donor site complications

Overall, there was no significant difference found between the three subgroups for overall flap complications (P=0.49). However, when broken down by type of complication, there was a significant difference found for incidence of infection (P<0.05), seroma (P<0.05), and wound (P<0.05), with a greater incidence occurring within the obese subgroup as compared to the overweight or healthy subgroups.

When comparing donor site complications, there was a significant difference in overall incidence of donor site complications (P<0.05) between the subgroups, with the highest incidence rate in the obese subgroup (17.3%) compared to the overweight (13.1%) or the healthy (11.6%) subgroups. This significant difference was also observed as the donor site complications were analyzed individually, with the obese subgroup showing a higher incidence of both donor site infection (4.4%) and donor site wound (12.8%) than the overweight (1.5% and 9.6%, respectively) and healthy subgroups (2.6% and 9.2%, respectively) (P<0.05).

Discussion

The results above demonstrate that as BMI increases, so does the incidence of both flap and donor site complications in autologous breast reconstruction. This work expands on published literature by the senior author indicating the correlation between BMI and poorer outcomes after surgery. One such publication shows that for PAP flaps, patients with a higher BMI were at greater risk for donor site wound complications (12). In another study, this group showed a correlation between patients who developed abdominal wall weakness or hernia after DIEP flap and higher BMI (13). Furthermore, this study agrees with prior studies indicating the risks associated with higher BMI in autologous breast reconstruction; Barnes et al. published a retrospective case series of 365 patients who underwent autologous breast reconstruction and found that the rates of both breast and donor site complications increased with BMI, and the optimal BMI cutoff to minimize breast and donor site complications were 32.7 and 30.0 kg/m2, respectively (14). Similarly, Garoosi et al. showed that patients with BMI ≥30 kg/m2 had increased risk of complications, including infection, wound breakdown, and flap failure (15). Much of the published literature on this topic involves DIEP flaps; this study offers a broader perspective since many other institutions do not perform multi-flap surgery, nor do they offer such a large volume of various reconstructive options.

Outside of breast reconstruction, higher BMI is a known predictor of poorer surgical outcomes and complications (16-18). On a cellular level, the pathophysiology of healing is multifactorial and includes impaired vascularity, diminished collagen synthesis, and chronic inflammation (19). Furthermore, patients with greater levels of adiposity often translates to greater mechanical stress on the incision line, which can lead to incisional breakdown and wound infection (20). We have shown here in this study that our BMI ≥30 kg/m2 cohort had a significantly higher incidence of diabetes than the lower BMI cohort, which can also negatively affect wound healing as well as increase the risk of infection. Although not seen here in this study, obesity has also been linked to longer operative times compared to healthy BMI matched cohorts, which in turn can increase risk of intra- and post-operative complications (21). All these factors must be considered when considering breast reconstruction on a patient with high BMI, and future work can investigate wound healing adjuncts that may help offset or mitigate these risks.

In terms of flap selection, this study demonstrated that women in the obese BMI subgroup (BMI ≥30 kg/m2) were significantly more likely to undergo DIEP flap than women in the overweight (25≤ BMI <30 kg/m2) or healthy (18.5≤ BMI <25 kg/m2) subgroups. The reason for this is likely two-fold: firstly, studies about fat deposition patterns in women demonstrate that obese women tend to carry a significant amount of subcutaneous adipose tissue around their abdomen (22,23), therefore, the most logical place to act as a donor site would be the abdomen, and the amount of adiposity in this area is sufficient to reconstruct breasts that match that patients frame; secondly, women with a lower BMI lack the abdominal tissue to sufficiently reconstruct breasts and so are more likely to either choose LAP flaps, PAP flaps, or multi-flap reconstruction with DIEPs as well as PAPs or LAPs. Furthermore, studies have shown that larger breast sizes are perceived to be more attractive in underweight women (24), so multi-flap reconstruction is necessary to achieve an aesthetic outcome rather than single flap alone. This work validates the hypothesis; women of lower BMI are significantly more likely to undergo multi-flap reconstruction or non-abdominally based options (P<0.01).

The data presented here gives a broad look at how BMI can influence flap selection and complications following autologous reconstruction, and can be further parsed in future studies for a more in-depth look at tailoring patient care. For instance, we may be able to identify specific BMI cut-offs at which risk of infection significantly increases and discharge those patients with prophylactic antibiotics. In a similar vein, prior work from the senior author found a correlation between higher BMI and umbilical complications following DIEP flaps, and that umbilectomy during DIEP reconstruction reduced the risk of wound complications in select patients (25,26). Developing specific peri- and post-operative care plans for patients with higher BMI may help mitigate these complications and provide better outcomes.

The major limitations of this study are similar to those inherent in all retrospective review studies. A number of patients were excluded from this study for missing necessary data for a full statistical analysis, and so the entire surgical cohort could not be analyzed. Furthermore, although we are confident that every patient included received longitudinal follow-up, our dataset did not include a quantified length of follow-up time for each patient and thus may slightly vary from patient to patient. Additionally, this study introduces a correlation between BMI and increased rate of post-operative complications. Although this is supported by a body of literature on the subject, we cannot claim a causative relationship.

Conclusions

Patients with healthy BMI are more likely to undergo multi-flap or non-abdominally based flap reconstruction and less frequently rely on DIEP flaps than women of overweight or obese BMI. Furthermore, patients with obese BMI are more likely to have post-operative complications at either the breast or donor site. Recognizing these differences will help tailor future care for better outcomes regardless of BMI.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Sarah N. Bishop) for the series “Aesthetic Breast Reconstruction” published in Gland Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-337/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-337/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-337/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-337/coif). The series “Aesthetic Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of The University of Texas Southwestern Medical Center (No. STU052015-021) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: White-Dzuro CG, Haddock NT. Comparing autologous breast reconstruction in high vs. low body mass index patients. Gland Surg 2025;14(12):2433-2439. doi: 10.21037/gs-2025-337

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