Article published online: 2024-02-23

Original Article

The Effects of Body Mass Index on Postoperative

Complications in Patients Undergoing
Autologous Free Flap Breast Reconstruction
Kassra Garoosi, BS1 YooJin Yoon, BS1 Julian Winocour, MD2 David W. Mathes, MD2
Christodoulos Kaoutzanis, MD2

1 School of Medicine, University of Colorado Anschutz Medical Address for correspondence Christodoulos Kaoutzanis, MD,
Campus, Aurora, Colorado Department of Surgery, Division of Plastics and Reconstructive
2 Division of Plastic and Reconstructive Surgery, University of Surgery, University of Colorado Anschutz Medical Campus, Aurora,
Colorado Anschutz Medical Campus, Aurora, Colorado CO 80045-2581 (e-mail: ckaoutzanis@gmail.com).

J Reconstr Microsurg

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Abstract Background The prevalence of obesity in the United States exceeds 40%, yet perioper-
ative effects of higher body mass index (BMI) in autologous breast reconstruction remain
poorly studied. The purpose of this study was to investigate BMI’s impact on postop
complications in abdominal and gluteal-based autologous breast reconstruction.
Methods We conducted a retrospective study using TriNetX, a health care database
containing de-identified data from more than 250 million patients. Patients undergo-
ing autologous breast reconstruction were identified by Current Procedural Terminol-
ogy codes. Four cohorts were established by BMI class: <24.99, 25 to 29.99, 30 to
34.99, and 35 to 39.99 kg/m2. Outcomes of interest were defined by International
Classification of Diseases,Tenth Revision (ICD-10) codes. A two-sample t-test was
performed to compare incidence of postoperative complications between cohorts
within 3 months of surgery. Patients with a BMI < 24.99 kg/m2 served as the control.
Cohorts were balanced on age, race, and ethnicity.
Results We identified 8,791 patients who underwent autologous breast reconstruction.
Of those, 1,143 had a BMI < 24.99 kg/m2, 1,867 had a BMI of 25 to 29.99 kg/m2, 1,396 had
a BMI of 30 to 34.99 kg/m2, and 559 had a BMI of 35 to 39.99 kg/m2. Patients with a BMI of
Keywords 25 to 29.99 kg/m2 had a significantly increased risk of cellulitis. Patients with a BMI of 30 to
► breast reconstruction 34.99 and 35 to 39.99 kg/m2 had a significantly increased risk of cellulitis, surgical site
► free flap infection, need for debridement, wound dehiscence, and flap failure.
reconstruction Conclusion Our study illustrates that there is an increased risk of postoperative
► postoperative complications associated with higher BMI classes. Understanding these data are
complications imperative for providers to adequately stratify patients and guide the procedural
► body mass index decision-making.

Obesity has reached epidemic proportions in the United ies documenting that the higher body mass index (BMI)
States, with a prevalence exceeding 40% in recent years.1–3 characteristic of obese individuals may exert detrimental
The impact of obesity on various aspects of health and effects on the surgical process, wound healing, and overall
medical procedures is well-documented with previous stud- patient recovery.4–6

received © 2024. Thieme. All rights reserved. DOI https://doi.org/

September 18, 2023 Thieme Medical Publishers, Inc., 10.1055/s-0044-1780518.
accepted after revision 333 Seventh Avenue, 18th Floor, ISSN 0743-684X.
January 21, 2024 New York, NY 10001, USA
Effects of BMI in Autologous Breast Reconstruction
Autologous free flap breast reconstruction, utilizing tissue
from the abdominal or gluteal regions, has emerged as a
prominent reconstructive option following mastectomy, of-
fering favorable aesthetic outcomes and improved quality of
life for breast cancer survivors.7 Several studies have inves-
tigated the effects of BMI class and postoperative outcomes
in free flap reconstruction, however, there have been
varied results, from demonstrating a neutral to negative
association.8–12 Additionally, many of the studies were
limited by their sample size which may have contributed
to the mixed results.8–11,13 Of the studies that had larger
sample sizes, the relationship between BMI and postoper-
ative outcomes in free flap reconstruction was not clearly
established due to the objective of the study (i.e., compar-
ing implant-based vs. autologous reconstruction)14,15 or
focusing primarily on transverse rectus abdominus mus-
culocutaneous flaps.9,16
Thus, with the increasing prevalence of autologous free
flap reconstruction and ongoing obesity epidemic, it is
imperative to understand the relationship between BMI
and postoperative outcomes. The purpose of this study
was to investigate the correlation between BMI class and
postoperative complications in patients undergoing abdom-
inal- and gluteal-based autologous free flap breast recon-
struction. By exploring this association through a
retrospective health care database, TriNetX, we aimed to
fill the existing knowledge gap in this field and provide
valuable insights into the impact of obesity on surgical
outcomes for this patient population.
Methods
Data Source
The TriNetX Research Network database (Cambridge, MA) is a
global health-collaborative clinical research platform col-
lecting real-time electronic medical data from more than 250
million patients, 120 health care organizations, and 19
countries.17 TriNetX is certified to the ISO 27001:2013
standard and maintains an Information Security Manage-
ment System to ensure the protection of the health care data
it has access to and to meet the requirements of the Health
Insurance Portability and Accountability Act (HIPAA) Securi-
ty Rule. Any data displayed on the TriNetX Platform in
aggregate form, or any patient level data provided in a
dataset generated by the TriNetX Platform only contain de-
identified data as per the de-identification standard defined
in Section §164.514(a) of the HIPAA Privacy Rule. Because
this database is free from all personal health information,
Institutional Review Board approval was not needed to
conduct this study.
Patient Selection/Design
This study was conducted as a retrospective cohort analysis of
the TriNetX database. We identified patients who underwent
abdominal- or gluteal-based free flap breast reconstruction
using Current Procedural Terminology (CPT) codes (CPT-
19364, CPT-19367, CPT-19368, CPT-19369) and Healthcare
Common Procedure Coding System (S) codes (S2066, S2067,
Journal of Reconstructive Microsurgery © 2024. Thieme. All rights reserved.
Garoosi et al.
S2068). Within the patient sample, four cohorts were then
established by BMI class: <24.99, 25 to 29.99, 30 to 34.99, and
35 to 39.99 kg/m2. Propensity score matching of cohorts was
performed by sex, age, and race/ethnicity.
Outcomes of interest were defined using ICD-10 codes,
which included seroma/hematoma/hemorrhage, cellulitis,
surgical site infection, abscess, need for incision/drainage,
need for debridement, wound dehiscence, incisional hernia,
flap failure, atelectasis, deep vein thrombosis, pulmonary
embolism, pneumonia, sepsis, and cardiac complications. A
two-sample t-test was performed to compare incidence of
postoperative complications between cohorts within
3 months of surgery. Odds ratios were calculated from
outcome incidence within each cohort. Patients with a
BMI < 24.99 kg/m2 served as the control. Statistical signifi-
cance was defined as a p-value less than 0.05 in all analyses.
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Results
Cohort Demographics
A total of 8,791 patients underwent autologous breast re-
construction. Of those, 1,143 had a BMI < 24.9 kg/m2, 1,867
had a BMI of 25 to 29.9 kg/m2, 1,396 had a BMI of 30 to
34.9 kg/m2, and 559 had a BMI of 35 to 39.9 kg/m2. For the
BMI 25 to 29.9 kg/m2 cohort, mean age was 52.9 years, the
predominant race/ethnicity was white, and the mean BMI
was 27.6
2.0 kg/m2. For the BMI 30 to 34.9 kg/m2 cohort,
mean age was 52.2 years, the predominant race/ethnicity
was white, and the mean BMI was 32.0
2.3 kg/m2. For the
BMI 35 to 39.9 kg/m2 cohort, mean age was 50.9 years, the
predominant race/ethnicity was white, and the mean BMI
was 36.6
2.1 kg/m2 (►Table 1).
Postoperative Outcomes
Patients with a BMI of 25 to 29.99 kg/m2 had a significantly
increased risk of cellulitis (odds ratio (OR) 1.504 [95% confi-
dence interval (CI) 1.008, 2.2.246]; ►Table 2). Patients with a
BMI of 30 to 34.99 kg/m2 had a significantly increased risk of
cellulitis (OR 1.681 [95% CI 1.128, 2.506]), surgical site infec-
tion (OR 1.928 [95% CI 1.349, 2.753]), need for debridement
(OR 2.104 [95% CI 1.460, 3.033]), wound dehiscence (OR 1.800
[95% CI 1.282, 2.527]), and flap failure (OR 1.986 [95% CI 1.314,
3.003]; ►Table 3). Patients with a BMI of 35 to 39.99 kg/m2 had
a significantly increased risk of cellulitis (OR 2.253 [95% CI
1.364, 3.722]), surgical site infection (OR 1.995 [95% CI 1.274,
3.123]), need for debridement (OR 3.513 [95% CI 1.943, 6.354]),
wound dehiscence (OR 1.785 [95% CI 1.139, 2.798]), and flap
failure (OR 1.838 [95% CI 1.073, 3.148]; ►Table 4).
Discussion
To the authors’ knowledge, this is the largest study investigating
the postoperative effects of BMI class in patients undergoing
abdominal- or gluteal-based free flap breast reconstruction.
This study revealed a clear trend of escalating risks of compli-
cations with higher BMI classes in patients undergoing abdomi-
nal- or gluteal-based free flap breast reconstruction, indicating
the need for heightened vigilance and personalized care for
 Effects of BMI in Autologous Breast Reconstruction Garoosi et al.

Table 1 TriNetX demographics by body mass index cohort

BMI (25–29.9 kg/m2) cohort

Before propensity score matching After propensity score matching
Characteristic BMI 25–29.9 kg/m2 Control p-Value BMI 25–29.9 kg/m2 Control p-Value
N ¼ 1,867 population N ¼ 1,110 population
N ¼ 1,143 N ¼ 1,110
Female, N (%) 1,851 (99.8) 1,31 (99.8) 0.924 1,107 (99.7) 1,108 (99.8) 0.924
Mean age (years) 51.9 53.0 0.006 52.9 52.9 0.899
Mean BMI (SD) 27.6
2.0 23.4
2.4 <0.001 27.6
2.0 23.4
2.4 <0.001
Race/ethnicity, N (%)
White 1,458 (78.6) 915 (80.8) 0.165 902 (81.3) 906 (81.6) 0.827
Black 155 (8.3) 46 (4.1) <0.001 50 (4.5) 46 (4.1) 0.676
Hispanic or Latino 224 (12.1) 87 (7.7) <0.001 82 (7.4) 86 (7.7) 0.748

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American Indian 10 (0.5) 10 (0.9) 0.264 10 (0.9) 10 (0.9) 1
Asian 44 (2.4) 52 (4.6) 0.001 42 (3.8) 39 (3.6) 0.734
Unknown/Other 190 (10.2) 117 (10.3) 0.945 113 (10.2) 116 (10.5) 0.834
BMI 30–34.9 kg/m2 cohort
Before propensity score matching After propensity score matching
Characteristic BMI 30–34.9 kg/m2 Control p-Value BMI 30–34.9 kg/m2 Control p-Value
N ¼ 1,396 population N ¼ 975 population
N ¼ 1,143 N ¼ 975
Female, N (%) 1,385 (99.9) 1,131 (99.8) 0.839 973 (99.8) 973 (99.8) 1
Mean age (years) 50.7 53.0 <0.001 52.2 52.2 0.971
Mean BMI (SD) 32.0
2.4 23.4
2.4 <0.001 32.0
2.3 23.5
2.5 <0.001
Race/ethnicity, N (%)
White 1,065 (76.8) 915 (80.8) 0.016 817 (83.8) 825 (84.6) 0.619
Black 181 (13.0) 46 (4.7) <0.001 55 (5.6) 46 (4.7) 0.358
Hispanic or Latino 187 (13.5) 87 (7.7) <0.001 71 (7.3) 86 (8.8) 0.212
American Indian 10 (0.7) 10 (0.9) 0.649 10 (1.0) 10 (1.0) 1
Asian 12 (0.9) 52 (4.6) <0.001 12 (1.2) 10 (1.0) 0.668
Unknown/Other 121 (8.7) 117 (10.3) 0.171 88 (9.0) 91 (9.3) 0.814
2
BMI 35–39.9 kg/m cohort
Before propensity score matching After propensity score matching
2
Characteristic BMI 35–39.9 kg/m Control p-Value BMI 35–39.9 kg/m2 Control p-Value
N ¼ 559 population N ¼ 499 population
N ¼ 1,143 N ¼ 499
Female, N (%) 558 (99.8) 1,131 (99.8) 0.991 498 (99.8) 498 (99.8) 1
Mean age (years) 50.5 53.0 <0.001 50.9 51.1 0.738
Mean BMI (SD) 36.7
2.2 23.6
2.7 <0.001 36.6
2.1 23.6
2.7 <0.001
Race/ethnicity, N (%)
White 396 (70.8) 915 (80.8) <0.001 395 (79.2) 406 (81.4) 0.382
Black 105 (18.8) 46 (4.1) <0.001 46 (9.2) 44 (8.8) 0.825
Hispanic or Latino 55 (9.8) 87 (7.7) 0.132 55 (11.0) 48 (9.6) 0.466
American Indian 10 (1.8) 10 (0.9) 0.105 10 (2.0) 10 (2.0) 1
Asian 10 (1.8) 52 (4.6) 0.004 10 (2.0) 10 (2.0) 1
Unknown/Other 51 (9.1) 117 (10.3) 0.436 51 (10.2) 43 (8.6) 0.386

Abbreviations: (%), frequency; BMI, body mass index; SD, standard deviation.

Journal of Reconstructive Microsurgery © 2024. Thieme. All rights reserved.

Effects of BMI in Autologous Breast Reconstruction Garoosi et al.

Table 2 A comparison of postoperative complications in patients with body mass index (25–29.9 kg/m2) following autologous
breast reconstructive surgery in TriNetXTM

Incidence (%) Odds ratio 95% CI p-Value

Seroma/Hematoma/Hemorrhage
BMI <24.9 kg/m2 64 (5.2) 0.901 (0.625, 1.299) 0.576
2
BMI 25–29.9 kg/m 58 (5.8)
Cellulitis
BMI <24.9 kg/m2 42 (3.8) 1.504a (1.008, 2.246) 0.045
2
BMI 25–29.9 kg/m 62 (5.6)
Surgical site infection
BMI <24.9 kg/m2 57 (5.1) 1.416 (0.996, 2.011) 0.052
2
BMI 25–29.9 kg/m 79 (7.1)

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Abscess
BMI <24.9 kg/m2 12 (1.1) 1.169 (0.538, 2.538) 0.693
BMI 25–29.9 kg/m2 14 (1.3)
Need for incision/drainage
BMI <24.9 kg/m2 19 (1.7) 1.595 (0.892, 2.851) 0.112
BMI 25–29.9 kg/m2 30 (2.7)
Need for debridement
BMI <24.9 kg/m2 59 (5.3) 1.384 (0.978, 1.958) 0.066
2
BMI 25–29.9 kg/m 80 (7.2)
Wound dehiscence
BMI <24.9 kg/m2 64 (5.8) 1.235 (0.878, 1.738) 0.225
2
BMI 25–29.9 kg/m 78 (7.0)
Incisional hernia
BMI <24.9 kg/m2 10 (0.9) 1.711 (0.780, 3.753) 0.175
2
BMI 25–29.9 kg/m 17 (1.5)
Flap failure
BMI <24.9 kg/m2 40 (3.6) 1.209 (0.788, 1.855) 0.384
2
BMI 25–29.9 kg/m 48 (4.3)
Atelectasis
BMI <24.9 kg/m2 68 (6.1) 1.079 (0.767, 1.518) 0.663
2
BMI 25–29.9 kg/m 73 (6.6)
Deep vein thrombosis
BMI <24.9 kg/m2 53 (4.8) 0.804 (0.533, 1.212) 0.297
2
BMI 25–29.9 kg/m 43 (3.9)
Pulmonary embolism
BMI <24.9 kg/m2 29 (2.6) 0.545 (0.294, 1.010) 0.050
2
BMI 25–29.9 kg/m 16 (1.4)
Pneumonia
BMI <24.9 kg/m2 10 (0.9) 1 (0.415, 2.412) 1
BMI 25–29.9 kg/m2 10 (0.9)
Sepsis
BMI <24.9 kg/m2 17 (1.5) 0.762 (0.368, 1.576) 0.462
BMI 25–29.9 kg/m2 13 (1.2)

Journal of Reconstructive Microsurgery © 2024. Thieme. All rights reserved.

 Effects of BMI in Autologous Breast Reconstruction Garoosi et al.

Table 2 (Continued)

Incidence (%) Odds ratio 95% CI p-Value

Urinary tract infection
BMI <24.9 kg/m2 10 (0.9) 1 (0.415, 2.412) 1
2
BMI 25–29.9 kg/m 10 (0.9)
Cardiac complication
BMI <24.9 kg/m2 53 (4.8) 1.080 (0.736, 1.584) 0.696
2
BMI 25–29.9 kg/m 57 (5.1)

Abbreviation: BMI, body mass index.

a
Indicates p < 0.05.

Table 3 A comparison of postoperative complications in patients body mass index (30–34.9 kg/m2) following autologous breast

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reconstructive surgery in TriNetXTM

Incidence (%) Odds ratio 95% CI p-Value

Seroma/Hematoma/Hemorrhage
BMI <24.9 kg/m2 59 (6.1) 0.910 (0.622, 1.331) 0.628
2
BMI 30–34.9 kg/m 54 (5.5)
Cellulitis
BMI <24.9 kg/m2 41 (4.2) 1.681a (1.128, 2.506) 0.010
2
BMI 30–34.9 kg/m 67 (6.9)
Surgical site infection
BMI <24.9 kg/m2 50 (5.1) 1.928a (1.349, 2.753) <0.001
2
BMI 30–34.9 kg/m 92 (9.4)
Abscess
BMI <24.9 kg/m2 11 (1.1) 1.277 (0.577, 2.826) 0.546
2
BMI 30–34.9 kg/m 14 (1.4)
Need for incision/drainage
BMI <24.9 kg/m2 17 (1.7) 0.881 (0.437, 1.773) 0.721
2
BMI 30–34.9 kg/m 15 (1.5)
Need for debridement
BMI <24.9 kg/m2 46 (4.7) 2.104a (1.460, 3.033) <0.001
2
BMI 30–34.9 kg/m 92 (9,4)
Wound dehiscence
BMI <24.9 kg/m2 57 (5.8) 1.800a (1.282, 2.527) 0.001
2
BMI 30–34.9 kg/m 98 (10.1)
Incisional hernia
BMI <24.9 kg/m2 10 (1.0) 1.101 (0.465, 2.605) 0.826
BMI 30–34.9 kg/m2 11 (1.1)
Flap failure
BMI <24.9 kg/m2 36 (3.7) 1.986a (1.314, 3.003) 0.001
2
BMI 30–34.9 kg/m 69 (7.1)
Atelectasis
BMI <24.9 kg/m2 61 (6.3) 1.177 (0.826, 1.677) 0.367
2
BMI 30–34.9 kg/m 71 (7.3)
(Continued)

Journal of Reconstructive Microsurgery © 2024. Thieme. All rights reserved.

Effects of BMI in Autologous Breast Reconstruction Garoosi et al.

Table 3 (Continued)

Incidence (%) Odds ratio 95% CI p-Value

Deep vein thrombosis
BMI <24.9 kg/m2 51 (5.2) 0.938 (0.626, 1.406) 0.757
2
BMI 30–34.9 kg/m 48 (4.9)
Pulmonary embolism
BMI <24.9 kg/m2 29 (3.0) 0.823 (0.476, 1.424) 0.486
2
BMI 30–34.9 kg/m 24 (2.5)
Pneumonia
BMI <24.9 kg/m2 10 (1.0) 1 (0.414, 2.413) 1
2
BMI 30–34.9 kg/m 10 (1.0)
Sepsis

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BMI <24.9 kg/m2 16 (1.6) 1.384 (0.722, 2.651) 0.326
BMI 25–29.9 kg/m2 22 (2.3)
Urinary tract infection
BMI <24.9 kg/m2 10 (1.0) 1 (0.414, 2.413) 1
BMI 30–34.9 kg/m2 10 (1.0)
Cardiac complication
BMI <24.9 kg/m2 43 (4.4) 1 (0.649, 1.541) 1
BMI 30–34.9 kg/m2 43 (4.4)

Abbreviation: BMI, body mass index.

a
Indicates p < 0.05.

Table 4 A comparison of postoperative complications in patients body mass index (35.0–39.9 kg/m2) following autologous breast
reconstructive surgery in TriNetXTM

Incidence (%) Odds ratio 95% CI p-Value

Seroma/Hematoma/Hemorrhage
BMI <24.9 kg/m2 36 (4.8) 0.650 (0.382, 1.106) 0.110
2
BMI 35.0–39.9 kg/m 24 (7.2)
Cellulitis
BMI <24.9 kg/m2 24 (4.8) 2.253a (1.364, 3.722) 0.001
2
BMI 35.0–39.9 kg/m 51 (10.2)
Surgical site infection
BMI <24.9 kg/m2 32 (6.4) 1.995a (1.274, 3.123) 0.002
2
BMI 35.0–39.9 kg/m 60 (12.0)
Abscess
BMI <24.9 kg/m2 10 (2.0) 1.412 (0.621, 3.209) 0.409
2
BMI 35.0–39.9 kg/m 14 (2.8)
Need for incision/drainage
BMI <24.9 kg/m2 10 (2.0) 1.412 (0.621, 3.209) 0.409
2
BMI 35.0–39.9 kg/m 14 (2.8)
Need for debridement
BMI <24.9 kg/m2 15 (3.0) 3.513a (1.943, 6.354) <0.001
2
BMI 35.0–39.9 kg/m 49 (9.8)

Journal of Reconstructive Microsurgery © 2024. Thieme. All rights reserved.

 Effects of BMI in Autologous Breast Reconstruction Garoosi et al.

Table 4 (Continued)

Incidence (%) Odds ratio 95% CI p-Value

Wound dehiscence
BMI <24.9 kg/m2 33 (6.6) 1.785a (1.139, 2.798) 0.011
2
BMI 35.0–39.9 kg/m 56 (11.2)
Incisional hernia
BMI <24.9 kg/m2 10 (2.0) 1 (0.413, 2.424) 1
2
BMI 35.0–39.9 kg/m 10 (2.0)
Flap failure
BMI <24.9 kg/m2 22 (4.4) 1.838a (1.073, 3.148) 0.025
2
BMI 35.0–39.9 kg/m 39 (7.8)
Atelectasis

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BMI <24.9 kg/m2 32 (6.4) 1.517 (0.413, 2.424) 1
BMI 35.0–39.9 kg/m2 47 (9.4)
Deep vein thrombosis
BMI <24.9 kg/m2 26 (5.2) 1.457 (0.868, 2.445) 0.152
BMI 35.0–39.9 kg/m2 37 (7.4)
Pulmonary embolism
BMI <24.9 kg/m2 13 (2.6) 1.480 (0.723, 3.030) 0.281
BMI 35.0–39.9 kg/m2 19 (3.8)
Pneumonia
BMI <24.9 kg/m2 10 (2.0) 1 (0.413, 2.424) 1
2
BMI 35.0–39.9 kg/m 10 (2.0)
Sepsis
BMI <24.9 kg/m2 10 (2.0) 1.308 (0.568, 3.012) 0.527
2
BMI 35.0–39.9 kg/m 13 (2.6)
Urinary tract infection
BMI <24.9 kg/m2 10 (2.0) N/A N/A N/A
2
BMI 35.0–39.9 kg/m 0 (0.0)
Cardiac complication
BMI <24.9 kg/m2 22 (4.4) 1.436 (0.819, 2.517) 0.204
2
BMI 35.0–39.9 kg/m 31 (6.2)

Abbreviations: BMI, body mass index; N/A, not available.

a
Indicates p < 0.05.

patients with obesity. These findings are especially crucial for
both providers and patients, as they highlight the potential
devastating effects of complications, such as flap failure, on
postoperative recovery. Additionally, by utilizing the extensive
and diverse patient population from the TriNetX database, our
study benefits from a large and varied sample, enhancing the
generalizability of our findings. Moreover, the ability to track
patient outcomes over time in the TriNetX database enables the
identification of long-term trends and treatment effectiveness,
supporting evidence-based decision-making in clinical practice.
The relationship between higher BMI class and postoper-
ative complications has been extensively studied in plastic
and reconstructive surgery. A meta-analysis of 727,935
patients by Bigarella et al focused on patients undergoing
plastic surgery procedures, including cosmetic procedures
and breast reconstruction, found that obese patients were at
the highest risk of developing a medical or surgical compli-
cations.18 Comparably, in a multicenter prospective study of
2,259 patients who underwent implant-based and autolo-
gous breast reconstruction, those with class II/III obesity
were noted to have higher rates of complications.7 Furthering
the relationship between obesity and increased postopera-
tive outcomes, Chen et al illustrated that obesity is associated
with a nearly 12-fold increased odds of postoperative com-
plications after elective breast procedures.19 While these
studies provide valuable information about the association
between BMI and postoperative complications in plastic
surgery procedures, the primary focus of these studies was

Journal of Reconstructive Microsurgery © 2024. Thieme. All rights reserved.

Effects of BMI in Autologous Breast Reconstruction
not autologous free flap breast reconstruction or their autol-
ogous reconstruction sample was limited in size.
The association between BMI and free flap reconstruction
outcomes remains a subject of interest and investigation,
with several studies exploring this relationship. The studies
examining the association between BMI and free flap recon-
struction have yielded diverse outcomes, which can be
attributed to the small sample sizes. For instance, both Chang
et al and Garvey et al concluded there was no significant
difference in outcomes between BMI classes in patients
undergoing autologous reconstruction, while Jandali et al
and Ozturk et al reported the inverse results in their inves-
tigations.8–11 Other investigators illustrated similar findings
in their studies as the ones reported in this study.20,21 While
single-institution studies may provide more granularity of
data, their small sample sizes and varying findings brings
into question the overall generalizability.
Expanding our evaluation beyond single-institution stud-
ies, the nuances of study focus and design emerge as crucial
elements complicating the determination of the relationship
between BMI and free flap reconstruction outcomes. For
example, prior studies by Spear et al and Mehrara et al
focused specifically on transverse rectus abdominus muscle
(TRAM) flaps, limiting their ability to elucidate the broader
relationship between BMI and free flap reconstruction.13,16
Likewise, the comparison of outcomes in obese patients
undergoing autologous versus implant-based reconstruction
in Garvey et al and Velazquez et al or the association between
timing of autologous breast reconstruction in Marquez et al
prevents the establishment of a clear relationship between
BMI and free flap reconstruction.15,22,23 Hanwright et al
attempted to explore the BMI impact on free flap reconstruc-
tion, however, their patient sample was only stratified into
two groups, BMI < 30 and >30 kg/m2, which limits our
understanding of individual BMI classes.14 In a recent study
by Sudduth et al, the investigators examined the effect of BMI
on free flap breast reconstruction outcomes, highlighting the
importance of considering BMI as a potential factor.24 How-
ever, it is noteworthy that this study, like others in the field,
primarily investigated overall complications rather than
delving into specific individual complications, thereby intro-
ducing a limitation to the comprehensive understanding of
the relationship between BMI and reconstruction outcomes.
Similarly, literature in other surgical specialties have
demonstrated mixed results, most notably the “obesity
paradox” seen in cardiovascular surgeries. The “obesity
paradox” is a phenomenon that suggests that overweight
and obese patients have better clinical outcomes following
cardiovascular surgery compared with normal weight
patients.25–27 For example, a systemic review by Galyfos
et al illustrated that obese patients were associated with
lower mortality, cardiac morbidity, and respiratory morbid-
ity after vascular surgery compared with normal weight
patients.26 The association between higher BMI class and
favorable operative outcomes has been even demonstrated
in other surgical procedures and specialties, such as colorec-
tal surgery,28,29 intra-abdominal cancer surgery,30 emergen-
cy abdominal operations,31 and general elective surgeries.32
Journal of Reconstructive Microsurgery © 2024. Thieme. All rights reserved.
Garoosi et al.
Interestingly, while there is significant amount of data
associating obesity with favorable postoperative outcomes,
the same can be noted about the inverse relationship in some
of the same surgical specialties.33,34
The stark difference in outcomes between surgical
specialties/procedures in patients with obesity, can be
explained by the varying molecular effects obesity has on
the cardiovascular system and wound healing. Investigation
of these underlying mechanisms provides valuable insight
into the increased complication rate seen in patients with
higher BMI in our study. Regarding the obesity paradox,
clinical observations and translational evidence suggest
that metabolically benign adipose tissue exists, and thus
adiposity is not necessarily unhealthy and dependent upon
various factors, such as regional fat distribution.35 While
Downloaded by: Universidad National Autonoma de Mexico (UNAM). Copyrighted material.
these features may have protective effect in cardiovascular
surgery, the same cannot be said about wound healing,
which is pertinent to free flap breast reconstruction recov-
ery. Of note, obesity has been shown to have a multifaceted
effect on wound healing, which includes the inherent ana-
tomic features of adipose tissue (avascularity), vascular
insufficiencies (impaired angiogenesis), cellular and compo-
sition modifications (chronic low-grade inflammation), oxi-
dative stress, alterations in immune mediators (higher levels
of proinflammatory markers), and nutritional deficiencies.4
In addition to the effects of higher BMI class on wound
healing, obesity is a risk factor for diabetes,36 cardiovascular
disease,37 and hypertension,38 all of which have deleterious
effects on wound healing.39–42 Given obesity’s effects on
many of the crucial aspects of wound healing and its associ-
ation with comorbid conditions, it comes with no surprise
the resulting increase of postoperative complications in
abdominal- or gluteal-based autologous flap reconstruction.
Despite the reports of obesity as a risk factor for postop-
erative complications in plastic and reconstructive surgery
literature, there is paucity of information regarding the
effects of obesity particularly in abdominal- and gluteal-
based autologous breast reconstruction. Additionally, given
the varying relationship between obesity and postoperative
outcomes in plastic surgery and other surgical specialties, it
is crucial to characterize the association in autologous flap
reconstruction. The clear relationship between higher BMI
classes and increased postoperative complications in free
flap reconstruction illustrated in our study addresses the
aforementioned knowledge gap. Furthermore, this study
provides clinicians with integral quantitative data, thus
facilitating an informed discussion with patients regarding
the risks associated with higher BMI when undergoing
autologous breast reconstruction.
Like any other database study, this study is not without
limitations. The TriNetX database is reliant upon accurate
coding which creates the potential for a reporting bias. The
quality of the study’s findings heavily depends on the
accuracy of the information recorded in the electronic health
records or claims data. Likewise, the data analysis was
dependent on the availability of variables, vigorousness of
variable definition, and accuracy of data coding and entry. Of
note, we were not able to run separate analysis for the
 Effects of BMI in Autologous Breast Reconstruction
various free flaps included in this study, particularly abdom-
inal- versus gluteal-based because of coding definition (i.e.,
CPT19364 and S2067 include both abdominal- and gluteal-
based free flaps). The large database does not account for
surgeon-specific factors such as surgical techniques that could
confound the results. Additionally, the database does not
differentiate between small complications that can be treated
with outpatient management versus clinically significant
complications requiring return to the operating room. We
did not look at complications past 90 days and may have
underreported complications. Lastly, due to sample size lim-
itations, we were not able to analyze the complications
associated with BMIs greater than 40 kg/m2. Because of this,
we intend to do a multi-institutional study of complications
associated with BMI classes in patients undergoing abdominal-
based free flap reconstruction to capture complication risk
associated with BMIs greater than 40 kg/m2, in addition to
further strengthening the findings of this study.
Conclusion
In conclusion, our study sheds light on the significant impact of
BMI on postoperative complications in patients undergoing
abdominal- or gluteal-based free flap breast reconstruction.
By contributing to a deeper understanding of the association
between BMI and complications in abdominal- or gluteal-
based free flap reconstruction, our study supports evidence-
based decision-making, ultimately leading to better patient
care and advancements in medical practice. Continued re-
search in this area will further enhance our understanding of
the complex relationship between obesity and postoperative
outcomes, paving the way for more effective strategies to
mitigate complications and improve the overall success of
autologous breast reconstruction procedures.
Funding
None.
Conflict of Interest
None declared.
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