Obesity No Barrier to Breast Reconstruction

October 7, 2010 (Toronto, Canada) — Obese cancer patients, although more difficult to treat, are being referred for breast reconstruction at the same rate as normal or overweight patients, according to the results of a population-based study presented here at Plastic Surgery 2010: Joint Annual Scientific Meeting of the American Society of Plastic Surgery and the Canadian Society of Aesthetic Plastic Surgery.

Moreover, obese patients are as satisfied with the results of their reconstruction as normal weight patients, Anita Kulkarni, MD, from the University of Michigan in Ann Arbor, said.

"According to the [Centers for Disease Control and Prevention], the prevalence of obesity in America has increased from 40% to 70% in the past 20 years. We noticed that more and more breast cancer patients coming into clinic were overweight and obese," Dr. Kulkarni told Medscape Medical News.

She and her team were interested in evaluating the experience of these women with breast reconstruction, but when they searched the literature, the only studies they could find focused on complication risks and rates in this population.

"We wanted more information to guide this increasingly relevant patient population, so we decided to study their experience using the large database we already had access to through the SEER [Surveillance, Epidemiology, and End Results] cancer registries," she said.

The investigators performed a 5-year follow-up survey of 384 patients with breast cancer who underwent mastectomy. Patients were from the Los Angeles, California, and Detroit SEER cancer registries. Dr. Kulkarni and colleagues compared breast reconstruction referral patterns, satisfaction, motivating factors for the surgery, and type of reconstruction across weight categories.

One third of the women were normal weight (body mass index [BMI], <25 kg/m2) one third were overweight (BMI, 25 to 30 kg/m2), and one third were obese (BMI, >30 kg/m2).

The researchers found that about half of the women in each weight category received reconstruction, and that obesity did not limit access to either immediate or delayed breast reconstruction.

Overweight and obese women were slightly more likely to receive a transverse rectus abdominus myocutaneous flap reconstruction (42% vs 39%) than normal weight women (24%).

Motivating factors for reconstruction were similar for all women, with 43% of normal weight, 47% of overweight, and 43% of obese women reporting that they wanted to feel whole again. Almost half of the women in each of the 3 groups said they wanted to avoid a prosthesis.

Other motivating factors for reconstruction were to feel less self-conscious during sex (32% of normal weight, 40% of overweight, and 35% of obese women) and to overcome the constant reminder of cancer (32% of normal weight, 33% of overweight, and 31% of obese women).

Satisfaction with the reconstruction was similar across all 3 groups. However, obese women were more satisfied with the way their clothing fit after the surgery. Compared with 28% of overweight and 15% of normal weight women, 33% of obese women said they were satisfied with clothing fit afterward (P <.01). Obese women were also more likely to feel sexually attractive than overweight and normal weight women (30% vs 21% and 15%; P =.01).

Dr. Kulkarni said she was expecting to find that obese patients did not receive reconstruction at high rates because surgeons might be fearful of complications and poor results; the available literature describes high complication rates in these patients. "We were surprised to find that they are receiving reconstruction at high rates and that they are not having difficulty obtaining referrals to plastic surgeons," she said after her talk.

"We were also pleasantly surprised to find them receiving autologous reconstruction at high rates. We know that autologous reconstruction produces better results in obese patients because of the usually large, pendulous contralateral breast, but we didn't expect surgeons to so readily provide complex reconstruction to this sometimes difficult population," she added.

Another surprise was that obese patients were no more concerned about complication rates than were normal weight patients. However, when they were asked if they felt that they had been adequately informed about what to expect after reconstruction, obese patients reported that they felt less informed, Dr. Kulkarni said.

"This suggests that the informed consent process may need to be strengthened for this population. Perhaps surgeons need to spend additional time in the preoperative period reviewing complications and risks specific to obese patients so they feel more informed going into breast reconstruction," she said.

Karol Gutowski, MD, from the University of Chicago in Illinois, agreed that surgeons should inform their obese patients about what they can expect from reconstruction surgery.

"The concern with obese patients is that it is harder to get a good reconstruction because, a lot of times, the implants aren't big enough or in the right shape," he told Medscape Medical News. "Obesity also has a certain number of risk factors associated with surgery and reconstruction, so obese patients may need to have a slightly different set of expectations, but it doesn't mean they can't have it done."

Surgeons should educate these patients beforehand, he said. "We can show them pictures of what is possible. A woman who might be 250 pounds and have triple-D breasts is very much harder to reconstruct, but if she understands that the surgeon might need to do something with the other side, to lift the breast, or to reduce it, and so on, she will have better tolerance. Discuss the expectations beforehand, because people with different body types and breast types can get totally different results. It's based on what God gave you."

Dr. Kulkarni and Dr. Gutowski have disclosed no relevant financial relationships.

Plastic Surgery 2010: Joint Annual Scientific Meeting of the American Society of Plastic Surgery (ASPS) and the Canadian Society of Aesthetic Plastic Surgery (CSAPS). Presented October 4, 2010.

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Authors and Disclosures
Journalist
Fran Lowry
is a freelance writer for Medscape.