The effects of body mass index on operative time and outcomes in nipple-sparing mastectomy
Introduction
Nipple-sparing mastectomy (NSM) is a safe and effective procedure in selected patients, both prophylactically and oncologically.1, 2, 3, 4 Preservation of the nipple-areolar complex (NAC) affords better aesthetic outcomes and patient satisfaction5 and has led to significant increases in the rates of patients undergoing NSM.1
Body mass index (BMI) has been associated with a number of surgical outcomes. In some surgical procedures increasing BMI has been shown to be associated with increased operative time (OT).6, 7, 8, 9, 10 Increased OT has also been associated with increased morbidity in some studies.11, 12, 13 The role that BMI plays in OT and whether it impacts postoperative morbidity has not been evaluated for patients undergoing NSM. Consistent factors associated with postoperative morbidity in NSM include perioperative tobacco use and previous breast/chest wall irradiation.14, 15, 16, 17, 18, 19 However, not all data support an association of increased BMI with a higher risk of complications.19, 20, 21, 22, 23 One would expect BMI to also be related to longer OTs for NSM as higher BMI tends to be associated with larger breast size and greater surface area of dissection, but to date this has not been shown. The aim of this study is to assess the association between BMI and OT for NSM, and the clinical implications of these two factors.
Section snippets
Data source and patient selection
We performed a retrospective review of a prospectively maintained breast surgery database of operations performed from June 2006 to June 2018. Patients that underwent attempted NSM with immediate autologous or prosthetic-based reconstructions were included in analysis. Pre-operative imaging and clinical assessments were used to determine candidacy for NSM. Frozen pathology of the nipple margin was obtained during the operation and a positive margin or surgeon discretion resulted in conversion
Patient demographics
A total of 510 mastectomies were performed in 294 patients. Patient demographics and disease specific details can be found in Table 1. Median BMI for all patients was 23.4 (range 15.8–48.1). The majority of women were white (83%) with a mean age of 50 years (±10.2). Approximately 25% of women had previous major breast surgery (n = 72), which we defined as breast augmentation, reduction mammoplasty, mastopexy, or lumpectomy with radiation. The most common specimen histology were invasive ductal
Discussion
Over the past decade there has been a substantial increase in patients undergoing NSM for both prophylactic and cancer operations without deleterious oncologic effect.24, 25, 26 Some studies have shown improved patient satisfaction with NSM versus traditional mastectomies.5,27,28 NSM is not without risk however, as there is substantial devascularization of the NAC predisposing to infection, poor wound healing, and necrosis. Within our cohort, a positive linear relationship existed between
Conclusions
Increasing BMI is associated with longer operative times for NSM and is modestly associated with NAC ischemia requiring intervention. BMI is not associated with ischemia of mastectomy skin flaps. Surgeons should appropriately counsel patients with higher BMIs considering NSM of their increased NAC ischemic risks and should allocate more operative time for such patients.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors have no conflicts of interest to disclose.
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