The effects of body mass index on operative time and outcomes in nipple-sparing mastectomy

https://doi.org/10.1016/j.amjsurg.2019.12.011Get rights and content

Highlights

  • •

    BMI and operative time have a positive correlation for nipple-sparing mastectomy.

  • •

    Higher BMI marginally increased risk of nipple-areola ischemic complications.

  • •

    Longer operative time did not impact morbidity.

  • •

    Other patient factors did not impact ischemic complications.

Abstract

Background

Nipple-sparing mastectomy (NSM) use is increasing. We investigated the relationships between body mass index (BMI), operative time (OT), and ischemic complications.

Methods

A single center, retrospective review was performed of NSMs from 2006 to 2018. Analysis included descriptive statistics, Wilcoxon rank-sum test and logistic regression.

Results

Among 294 patients, 510 breast reconstructions were performed (216 bilateral). Median OTs in the prosthetic-based (266 patients, 90.5%) and autologous tissue groups (28 patients, 9.5%) were 266 and 529 min, respectively. Median OTs ranged from 236 to 358 min for those with BMI <20 and ≥ 40, respectively. Increasing BMI correlated with OT (r = 0.33, p < 0.001) and was associated with slightly higher odds of major NAC ischemic complications (OR = 1.09, p = 0.02).

Conclusion

Higher BMI is associated with up to 50% longer OT, but is not a contraindication to NSM with reconstruction. Surgeons should recognize increased time and resource utilization.

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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