Surgical Outcomes of Autologous Breast Reconstruction in Low Body Mass Index Patients: Beyond the Standard DIEP Flap

Abstract

Background:

Autologous breast reconstruction provides higher satisfaction than implant-based reconstruction in women with low body mass index (BMI). However, the accepted standard of microvascular breast reconstruction, the deep inferior epigastric perforator (DIEP) flap, can be challenging to achieve due to the paucity of adnominal bulk in these patients. This study compared operative outcomes in women with BMI less than 23.5 following reconstruction after one of three free flap methods: the DIEP flap, alternative flaps (ie, lumbar artery perforator flap or profounda artery perforator flap), and stacked flaps.

Methods:

A retrospective study was conducted on thin patients (BMI <23.5) who underwent autologous breast reconstruction between 2010 and 2021 by two senior authors (N.T.H. and S.S.T.) at a single institution. One hundred fifteen patients were divided into three reconstructive groups. Flap weights, complication rates, secondary revisions, and fat grafting in each group were then compared.

Results:

The success rate in all three groups was 100%, with only one partial flap loss in the stacked group. There was a significant difference in overall minor complications and donor complications among the three groups, with alternative flaps experiencing the most. All three groups had similar incidences of recipient breast complications, medical complications, need for secondary revisions, and amount of fat grafted.

Conclusions:

Autologous breast reconstruction in low BMI patients yields successful and durable results. This study shows that predictable results in the thin patient population can be obtained via alternate autologous methods beyond the standard DIEP flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.

Breast reconstruction is a critical aspect of comprehensive cancer care. In modern times, there are multiple options that even allow autologous reconstruction in extremes of body mass index (BMI). Although autologous breast reconstruction provides higher satisfaction in women with low BMI,¹ many surgeons favor implants secondary to concern over donor sites. The deep inferior epigastric perforator (DIEP) flap, the typical first choice,² can be challenging to use in these patients due to the paucity of abdominal bulk. In such cases, consideration of alternative microsurgical reconstructive methods is necessary.^2–4 Historically, common alternative options include the gluteal flaps,^5,6 thigh flaps,^3,7–10 and back flaps.^11–13 Alternative flap selection often depends on surgeon experience and the patient’s anatomy. In thin patients, it can be difficult to locate a single suitable donor site, and thus, in some situations, multiple flaps are required for a single breast.^14–17

Although it seems evident that high BMI patients would have more complications, this is only because there is a surplus of data on this topic.^18–20 What is not known is the impact of low BMI on outcomes. It is conceivable that a low BMI would force surgeons to be more aggressive with an individual donor site to achieve body-proportionate breast reconstruction, thus leaving the patient with an increased risk of donor-site complications. This study examined the impact of low BMI on outcomes using current commonly used autologous tissue options.

PATIENTS AND METHODS

After approval was obtained from our institutional review board, a retrospective chart review was conducted on thin patients (BMI <23.5) treated with autologous breast reconstruction between 2010 and 2021. All patients were treated by the two senior authors (N.T.H. and S.S.T.) at a single institution. One hundred thirteen patients were analyzed and divided into three reconstructive groups: 36 patients underwent reconstruction with DIEP flaps, 34 with alternative flaps [profunda artery perforator flaps (PAP) and lumbar artery perforator flaps (LAP)], and 43 with stacked flaps.

Data collected for each patient included demographics (age, race, BMI), laterality of reconstruction, timing of reconstruction, comorbidities (hypertension, diabetes, autoimmune conditions, smoking status), oncologic treatments (mastectomy type, radiation, chemotherapy), surgical history (prior reconstructive and cosmetic breast surgery), duration of follow-up, flap data (weight, procedure time, hospital length of stay), intraoperative and postoperative complications (flap loss, infection, hematomas, seromas, fat necrosis, deep vein thrombosis, and pulmonary embolism), number of secondary revisions, and amount of fat grafting. Complications were further broken down into major and minor categories, as well as by location (donor site and recipient breast). Major complications were defined as any complication that required unexpected surgical intervention or a hospital admission. Minor complications included those that were treated outpatient or did not require any medical intervention.

Baseline characteristics of patients, flap data, and complication rates were compared among the three reconstructive groups. Continuous variables (such as age, BMI, procedure time, and flap weight) were compared using analysis of variance tests. Categorical variables were evaluated using Fisher exact test for sample sizes less than five, and Pearson chi-square for larger samples. Before analysis with analysis of variance tests, continuous variables were tested for normal distribution using the Shapiro test for normality. Variables that were not normally distributed (BMI and length of stay) were analyzed using the Kruskal-Wallis test. An alpha value of less than 0.05 was used to define statistical significance for all tests. Statistical analysis was performed using SPSS version 24.0 software (IBM, Armonk, NY).

RESULTS

One hundred thirteen patients were divided into three autologous reconstructive groups: 36 in the DIEP group, 34 in the alternative group, and 43 in the stacked group. In the alternative group, 27 patients (79.4%) underwent reconstruction with PAP flaps and seven patients (20.6%) with LAP flaps (Fig. 1). In the stacked group, 20 patients (48.8%) had double-pedicle DIEP flaps, 10 patients (20.9%) had four flaps with DIEPs and PAPs, one patient (2.3%) had four flaps with DIEPs and LAPs, four patients (9.3%) had four flaps with PAPs and LAPs, and eight (20.9%) had double-stacked PAP flaps (Fig. 2).

Fig. 1.

A pie graph that shows the distribution of PAP and LAP flaps in the alternative flaps group.

Fig. 2.

A pie graph that shows the distribution of types of flaps in the stacked flaps group.

Demographics among the three reconstructive groups were compared (Table 1). Age, BMI, race, smoking status, and incidence of chronic conditions were similar across the three groups, with no statistical difference among them. History of breast surgery included prior placement of cosmetic implants and reconstructive breast surgery with tissue expanders, implants, or autologous flaps. Of note, the DIEP flap group had the fewest number of patients who underwent past reconstructions, with four patients (11.1%) compared with the alternative group with 10 patients (29.4%) and the stacked group with 14 patients (32.6%), although this did not reach a significant difference.

Table 1.

Baseline Demographics, Oncological Treatment, and Procedure Characteristics of Patients in Each Group^a

Characteristics	DIEP	Alternative	Stacked	P
Patients	36	34	43	N/A
Breasts	71	64	58	N/A
Age (SD)	50.97 (11.03)	49.76 (9.28)	50.98 (8.32)	0.826
BMI (SD)	22.15 (1.18)	21.86 (1.37)	22.05 (1.19)	0.735
Race				0.331
White	23 (63.9)	29 (85.3)	33 (76.7)
Black	3 (8.3)	2 (5.9)	2 (4.7)
Asian	8 (22.2)	1 (2.9)	5 (11.6)
Hispanic	1 (2.8)	2 (5.9)	2 (4.7)
Other	1 (2.8)	0 (0)	1 (2.3)
Smoking				0.981
Never	30 (83.3)	29 (85.3)	34 (79.1)
Former	6 (16.7)	5 (14.7)	8 (18.6)
Current	0 (0)	0 (0)	1 (2.3)
PMHx
HTN	4 (11.1)	6 (17.6)	5 (11.6)	0.733
DM	2 (5.6)	0 (0)	1 (2.3)	0.505
Autoimmune	3 (8.3)	1 (2.9)	2 (4.7)	0.67
Surgical Hx
Cosmetic	2 (5.6)	3 (8.8)	2 (4.7)	0.793
Reconstruction	4 (11.1)	10 (29.4)	14 (32.6)	0.067
Mastectomy type				0.035
Radical	1 (2.8)	0 (0)	0 (0)
Total	10 (27.8)	11 (32.4)	14 (32.6)
Skin sparing	20 (55.6)	9 (26.5)	13 (30.2)
Nipple sparing	4 (11.1)	14 (41.2)	11 (25.6)
Partial	0 (0)	0 (0)	1 (2.3)
Mixed	0 (0)	0 (0)	2 (4.7)
Radiation	13 (36.1)	16 (47.1)	27 (62.8)	0.058
Chemotherapy
Adjuvant	8 (22.2)	5 (14.7)	9 (20.9)	0.696
Neoadjuvant	9 (25.0)	6 (17.6)	14 (32.6)	0.329
Laterality				<0.001
Unilateral	1 (2.8)	4 (11.8)	28 (65.1)
Bilateral	35 (97.2)	30 (88.2)	15 (34.9)
Follow-up days (SD)
Since reconstruction	487.31 (542.311)	497.29 (392.612)	481 (470.234)	0.989
Since last revision	309.28 (460.203)	286.59 (410.684)	240.46 (372.125)	0.786
Timing				0.767
Immediate	7 (19.4)	4 (11.8)	3 (7.0)
Delayed-immediate	22 (61.1)	23 (67.7)	32 (74.4)
Delayed	6 (16.7)	6 (17.6)	6 (14.0)
Mixed	1 (2.8)	1 (2.9)	2 (4.7)
Procedure time (SD)	378.61 (146.97)	346.94(113.68)	436.00 (141.18)	0.016
Length of stay (SD)	3.39 (1.42)	3.09 (1.11)	3.16 (1.13)	0.66

^aValues are expressed as no. (%), except for age, BMI, procedure time, and length of stay, which are expressed as mean (SD).

Oncological treatment was also compared (Table 1). Among the three groups, the proportion of patients in each mastectomy type category (radical, total, skin sparing, nipple sparing, and partial, mixed) statistically differed. The majority of DIEP patients (55.6%) underwent skin-sparing mastectomies, whereas the most prevalent mastectomy types in the alternative and stacked groups where nipple-sparing (41.2%) and total mastectomies (32.6%), respectively. In addition, 27 patients (62.8%) in the stacked flap group underwent radiation therapy, which was higher than in the other groups [DIEP flaps (36.1%) and alternative flaps (47.1%)], and approached statistical significance (P = 0.058). In terms of the surgery under study, the laterality of reconstruction statistically differed (P < 0.001). In the stacked group, the majority of patients (65.1% unilateral) underwent unilateral reconstructions, whereas in the DIEP group (97.2% bilateral) and alternative group (88.2% bilateral), the majority of patients underwent bilateral reconstructions. The average duration of follow-up from the date of the reconstruction and from the last breast revision were both insignificant across the three groups (P = 0.989 and P = 0.786, respectively). For the cohort as a whole, mean number of days of follow-up from the date of reconstruction was 488.53 days and 278.68 days from the last breast revision surgery.

Procedure time also significantly differed (P = 0.016), with the stacked group having the longest operation time at an average of 436.0 minutes compared with 378.6 minutes in the DIEP group and 346.9 minutes in the alternative group.

When comparing harvested flap weights from each donor site and weight of the final reconstructed breasts between appropriate groups, significant differences were noted (Table 2) Average weights of DIEP flaps harvested in the standard group were heavier than those of abdominal flaps harvested in the stacked group bilaterally (P < 0.001), despite comparable BMIs in these two groups. LAP flaps statistically weighed less when harvested from stacked group patients when compared with alternative group patients bilaterally (P < 0.001), unlike PAP flaps that did not differ between the two groups. In addition, final breast weight significantly differed with the heaviest final breast weight in the stacked group (P < 0.001).

Table 2.

Weights of Harvested Flaps and Final Recipient Breast Weights^a

	DIEP	Alternative	Stacked	P
Left donor site
Abdomen
Flaps harvested	36	N/A	31
Mean weight (SD)	431.36 (143.45)	N/A	316.21 (75.14)	<0.001
Back
Flaps harvested	N/A	7	5
Mean weight (SD)	N/A	518.57 (159.63)	388.00 (180.33)	0.214
Thighs
Flaps harvested	N/A	25	22
Mean weight (SD)	N/A	320.24 (87.32)	217.73 (63.64)	<0.001
Right donor site
Abdomen
Flaps harvested	35	N/A	31
Mean weight (SD)	431.200 (149.56)	N/A	318.76 (75.72)	<0.001
Back
Flaps harvested	N/A	7	4
Mean weight (SD)	N/A	523.71 (138.17)	380.00 (170.29)	0.16
Thighs
Flaps harvested	N/A	25	22
Mean weight (SD)	N/A	306.12 (87.320)	214.45 (52.593)	<0.001
Recipient
Right breast
Breasts reconstructed	35	32	26
Mean weight (SD)	431.20 (149.56)	353.72 (133.98)	573.23 (169.77)	<0.001
Left breast
Breasts reconstructed	36	32	32
Mean weight (SD)	431.36 (143.45)	363.63 (133.32)	562.44 (148.62)	<0.001

^aValues are expressed as mean (SD), except for number of flaps and breasts, which is expressed as a whole digit nunber.

The flap success rate in the DIEP and alternative groups was 100%, with one and three patients experiencing a flap compromise, respectively (Table 3). Salvage of these flaps was successful, and none resulted in partial or total loss. Two patients in the stacked group had vascular compromises, and both were PAP and DIEP four-flap procedures. All flaps were salvaged, with only one partial flap loss, a PAP flap in a four-flap procedure, resulting in a success rate of 100% as well (Table 3).

Table 3.

Success Rates, Flap Compromises, and Flap Losses for Each Group^a

	DIEP	Alternative	Stacked
Flap compromises	1 (2.8)	3 (8.8)	2 (4.7)
Flap(s) affected	1 DIEP	2 PAPs, 1 LAP	2 stacked DIEP & PAP
Partial flap losses	0	0	1 (2.3)
Flap affected			PAP
Total flap losses	0	0	0
Success rate	100%	100%	100%

^aValues are expressed as no. (%), except for success rate, which is expressed as a percentage per patient.

The overall major complication rate was 11.1% in the DIEP flaps, 10 (29.4%) in the alternative flaps, and 11.6% in the stacked flaps (Table 4). Overall major complications were defined as any postoperative complication, donor or breast, which required unexpected surgical intervention. Overall major complications were comparable across all three reconstructive groups (P = 0.063). Overall minor complications that were treated in the outpatient setting or did not require any intervention were statistically different as well (P = 0.022), with the alternative flap group experiencing the highest incidence of overall minor complications at 47.1%, and the standard DIEP group experiencing the lowest at 19.4%. Medical complications did not differ significantly among the groups.

Table 4.

Number of Patients Who Experienced a Minor or Major Complication^a

Complication	DIEP	Alternative	Stacked	P
Overall
Any major complicationb	4 (11.1)	10 (29.4)	5 (11.6)	0.063
Any minor complicationb	7 (19.4)	16 (47.1)	10 (23.3)	0.022
Medical
Any medical complication	0 (0)	2 (5.9)	0 (0)	0.089
Deep vein thrombosis	0 (0)	1 (2.9)	0 (0)	0.301
Pulmonary embolism	0 (0)	1 (2.9)	0 (0)	0.301

^aValues are expressed as no. (%) of patients who experienced a certain complication.

^bOverall major and minor complications are not additive because a single patient could experience both types of complications simultaneously. All rows are expressed per single patient.

Complications were further broken down by location (recipient and donor sites) and subtype of complication (wound, infection, hematoma, seroma, and fat necrosis; Table 5). Patients in all three groups had a comparable incidence of any major recipient breast complication (including compromises and partial and total flap losses). In terms of major donor complications, the alternative group had a higher occurrence of major donor hematomas and any major donor complication, with a statistically significant difference in incidence rate among the three groups (P = 0.002 and P = 0.016, respectively). Moreover, there was a significant difference in minor donor wound complications among the three groups (P = 0.015), with the alternative group having the highest incidence of wounds on the thighs. Finally, the three groups did not have a comparable rate of any minor donor complications (P = 0.008).

Table 5.

Complications Categorized by Location and Subtype^a

Complication	DIEP	Alternative	Stacked	P
Recipient site
Any major breast complicationb	3 (8.3)	3 (8.8)	3 (7.0)	N/A
Subtypes
Wound	1 (2.8)	0 (0)	0 (0)	0.619
Infection	1 (2.8)	0 (0)	0 (0)	0.524
Hematoma	1 (2.8)	1 (2.9)	0 (0)	0.524
Seroma	0 (0)	0 (0)	1 (2.3)	N/A
Fat Necrosis	0 (0)	0 (0)	1 (2.3)	N/A
Any minor breast complicationc	5 (13.9)	5 (14.7)	6 (14.0)	N/A
Subtypes
Wound	1 (2.8)	1 (2.9)	3 (7.0)	0.624
Infection	0 (0)	0 (0)	0 (0)	N/A
Hematoma	3 (8.3)	0 (0)	0 (0)	0.56
Seroma	0 (0)	0 (0)	2 (4.7)	0.331
Fat necrosis	1 (2.8)	4 (11.8)	1 (2.3)	0.186
Donor site
Any major donor complicationc	1 (2.8)	8 (23.5)	3 (7.0)	0.016
Subtypes:
Wound	0 (0)	3 (8.8)	3 (7.0)	0.215
Infection	1 (2.8)	1 (2.9)	1 (2.3)	N/A
Hematoma	0 (0)	5 (14.7)	0 (0)	0.002
Seroma	0 (0)	0 (0)	0 (0)	N/A
Fat necrosis	0 (0)	0 (0)	1 (2.3)	N/A
Any minor donor complicationc	3 (8.3)	12 (35.3)	6 (14.0)	0.008
Subtypes:
Wound	1 (2.8)	9 (26.5)	6 (14.0)	0.015
Infection	1 (2.8)	5 (14.7)	1 (2.3)	0.073
Hematoma	1 (2.8)	0 (0)	0 (0)	0.619
Seroma	0 (0)	1 (2.9)	0 (0)	0.301
Fat necrosis	0 (0)	0 (0)	0 (0)	N/A

^aAll rows are expressed per single patient. Values are expressed as no. (%).

^bMajor breast complications also included flap compromise, partial losses, and total losses.

^cComplications are not additive since a single patient could experience one or more subtype.

The number of revisionary operations after initial reconstruction were quantified and compared (Table 6). Revisions included procedures such as fat grafting, recipient, and donor site skin revisions, breast reductions, and flap repositioning. The proportion of patients who underwent zero, one, two, three, or four revision sessions was similar across all groups (P = 0.498). When specifically analyzing fat grafting, no significance was noted in either the number of sessions (P = 0.205) or the amount of total fat injected (P = 0.133) for each patient group. When excluding all patients who received no fat grafting, average total fat grafted was still not significantly different among the three groups (P = 0.866).

Table 6.

Mean Amount of Fat Grafted, Number of Revisionary Operations, and Fat Grafting Sessions^a

	DIEP	Alternative	Stacked	P
All revisions
No. of revisions				0.498
0	7 (19.4)	5 (14.7)	5 (11.6)
1	20 (55.6)	15 (44.1)	23 (53.5)
2	5 (13.9)	12 (35.3)	10 (23.2)
3	3 (8.3)	2 (5.9)	5 (11.6)
4	1 (2.8)	0 (0)	0 (0)
Fat grafting
No. fat grafting sessions				0.205
0	12 (33.3)	8 (23.5)	18 (41.9)
1	17 (47.2)	21(61.8)	18 (41.9)
2	3 (8.3)	5 (14.7)	6 (14.0)
3	4 (11.1)	0 (0)	1 (2.3)
Mean total mL of fat injectedb
All patients (SD)	174.69 (234.34)	161.74 (151.11)	103.00 (107.97)	0.133
Grafting patients only (SD)	262.04 (244.29)	211.50 (138.54)	177.16 (81.94)	0.866

^aValues are expressed as no. (%), except for mL of fat injected and number of revisions, which are expressed as mean (SD).

^bMean mL of fat injected accounts for the total fat injected after all sessions, not per session.

DISCUSSION

BMI has been repeatedly linked to outcomes in the plastic surgery literature. Typically, this is in the obese patient population, and has led many surgeons to have strict cut-offs when offering more complex procedures, such as autologous breast reconstruction. In contrast, some surgeons will proceed with high BMI patients when the individual has a clear understanding of the related risks.

A low BMI presents a different situation in that surgeons will often avoid autologous options purely based on lack of available tissue in traditional locations. As the surgeon’s armamentarium increases, there are alternative approaches available to still provide total autologous breast reconstruction for these patients,^2,14–16 but what is not fully elucidated is the morbidity profile of low BMI patients treated with autologous tissue breast reconstruction.

It is typically assumed that people in the normal BMI range of 18.5 to 24.9 are healthy and should be ideal candidates for surgery. In autologous tissue breast reconstruction, these patients present a different set of challenges with the main concern being obtaining enough tissue for total reconstruction. In higher BMI patients, a surgeon does not have to be overly aggressive in an individual donor site to obtain adequate volume, but in smaller patients, this becomes a real concern and could potentially lead to more tension on closure and, thus, ultimately result in increased donor-site complications.

Previous reports show that DIEP flap breast reconstruction can be accomplished with a favorable outcome in low BMI,^21,22 but at extremes, the DIEP flap is not always available.²³ In this study, we compared surgical outcomes in patients with a BMI of 23.5 or less following reconstruction after one of the three free flap methods: the accepted standard DIEP flap (Fig. 3), our typical alternative flaps (PAP flaps and LAP flaps),² and stacked flaps. The overall goal was to evaluate the safety and outcomes in low BMI patients treated with a standardized algorithm offering multiple autologous options for breast reconstruction.

Fig. 3.

A 42-year-old woman (BMI 21) treated with bilateral skin-sparing mastectomy and immediate breast reconstruction with DIEP flaps. She underwent one breast revision and nipple reconstruction with tattoo.

Comparison of surgical outcome revealed a 100% flap success rate for all three groups with similar rates of overall major complications and recipient breast complications. Microsurgery in thin patients is often easier than in obese patients, given the flaps are thinner, allowing for easier positioning of hands. Presumably, thinner patients are healthier and, thus, could have healthier vessels to work with. In addition, this 100% success could simply be from a generally high success rate all together and a relatively small sample size.

Significant differences in surgical outcomes among the groups were primarily due to donor-site complications, most of which occurred in the alternative group. In this series, the alternative group (PAP flaps and LAP flaps) had similar rates of donor-site complications compared with each other. However, when analyzing donor sites (the abdomen, back, or thighs) independently from their reconstructive group, which included stacked flaps, thighs were found to experience the most donor-site complications. Wounds were the most common issue encountered in this comparison.

In low BMI patients, the PAP flap is a safe and reliable breast reconstruction method, but patients should be counseled regarding the relatively high rate of donor-site complications (Fig. 4). [See Figure, Supplemental Digital Content 1, which shows a 28-year-old woman (BMI 19) treated with prophylactic bilateral nipple-sparing mastectomy and immediate breast reconstruction with PAP flaps. No revisions performed. Posterior donor-site view is shown, http://links.lww.com/PRS/G123.] Other studies have also shown promising results supporting the use of thigh-based flaps for autologous breast reconstruction, but special attention to the donor-site complications is important.²⁴ Previously, a series of 265 PAP flaps, in all BMI groups, showed adequate flap volume for aesthetically pleasing breasts and donor complications comparable to other free tissue options. Moreover, patients reported minimal long-term functional impact on their thighs and overall great satisfaction with their results.^3,25 In this series, donor-site wounds were also a common complication (20.9% for all major and minor donor wounds), but interestingly, donor complication rates were higher in the low BMI study. The discrepancy in donor-site complication rates could be secondary to decreased laxity and the required relatively aggressive flap harvest in low BMI patients.

Fig. 4.

Anterior views of 28-year-old woman (BMI 19) treated with prophylactic bilateral nipple-sparing mastectomy and immediate breast reconstruction with PAP flaps. No revisions were performed. Posterior views are shown in Figure, Supplemental Digital Content 1, http://links.lww.com/PRS/G123.

LAP flaps also yield excellent results and should be considered when exploring alternative donor sites (Fig. 5). [See Figure, Supplemental Digital Content 2, which shows a 39-year-old woman (BMI 21) treated with delayed-immediate LAP flaps following nipple-sparing mastectomy. The patient underwent one subsequent revision for removal of monitoring skin paddles. Posterior donor-site view is shown, http://links.lww.com/PRS/G124.] In a previous series of 30 bilateral LAP flaps, we showed that these flaps can safely be harvested simultaneously for bilateral breast reconstruction, achieving high success rates and high patient satisfaction.⁴ In this series, seromas were the most common complication (13%); however, two of those cases resulted from premature inadvertent drain removal by the patient. In addition, with experience, it is thought that modifications of donor-site closure could result in decreased seroma rates. In this low BMI cohort, LAP flap patients had one incidence of donor-site hematoma, and one incidence of a donor-site seroma. Wounds are less common in this area, likely relating to the thick dermal tissue available for closure in the lower back.

Fig. 5.

Anterior views of a 39-year-old woman (BMI 21) treated with delayed-immediate LAP flaps after nipple-sparing mastectomy. She underwent one subsequent revision operation for removal of monitoring skin paddles. Posterior views are shown in Figure, Supplemental Digital Content 2, http://links.lww.com/PRS/G124.

In the case that single donor sites do not provide adequate tissue for total reconstruction, stacked flaps can be used (Figs. 6 through 10). [See Figure, Supplemental Digital Content 3, which shows a 58-year-old woman (BMI 21.9) with a history of implant-based reconstruction converted to autologous tissue with stacked DIEP and PAP flaps. The patient underwent three revision operations. Posterior donor-site view is shown, http://links.lww.com/PRS/G125. See Figure, Supplemental Digital Content 4, which shows a 46-year-old woman (BMI 23) treated with bilateral skin-sparing mastectomy and tissue expanders followed by right breast radiation. She subsequently underwent delayed-immediate bilateral stacked DIEP and LAP flaps. The patient underwent three revision operations. Posterior donor-site view is shown, http://links.lww.com/PRS/G126. See Figure, Supplemental Digital Content 5, which shows a 65-year-old female (BMI 18.5) treated with delayed-immediate stacked PAP and LAP flaps after skin-sparing mastectomy. The patient underwent a single revision operation with nipple reconstruction. Posterior donor-site view is shown, http://links.lww.com/PRS/G127.] Stacked flaps are used for increased skin, increased tissue to span the entire appropriate base of the breast, and for increased projection. Similar to our previous work with stacked flaps, in the low BMI group, there are relatively similar complication rates despite significantly longer procedure times.¹⁴

Fig. 6.

A 47 -year-old woman (BMI 21) self-referred after right mastectomy and failed right implant-based reconstruction after radiation. She was treated with a conjoined bilateral DIEP flap. One revision operation was performed.

Fig. 10.

A 57-year-old woman (BMI 20) self-referred after bilateral immediate DIEP flaps and nipple-sparing mastectomy and after failed right DIEP flap at an outside facility. Her breast was reconstructed with stacked PAP flaps to the serratus and thoracodorsal vessels. No revision operations were performed.

Fig. 7.

A 58-year-old woman (BMI 21.9) with a history of implant-based reconstruction was converted to autologous tissue with stacked DIEP and PAP flaps. She underwent three revision operations. Anterior views are shown.

Fig. 8.

A 46 -year-old woman (BMI 23) was treated with bilateral skin-sparing mastectomy and tissue expanders followed by right breast radiation. She subsequently underwent delayed-immediate bilateral stacked DIEP and LAP flaps. The patient underwent three revision operations. Anterior views are shown.

Fig. 9.

A 65-year-old woman (BMI 18.5) was treated with delayed-immediate stacked PAP and LAP flaps after skin-sparing mastectomy. She underwent a single revision operation with nipple reconstruction. Anterior views are shown.

The number of surgical revisions performed after the index reconstruction and the total fat grafted did not differ depending on the type of flap received. This suggest that all three autologous reconstruction methods provide a similar need for additional secondary operations. Theoretically, this supports the use of alternative options and tailoring of the flap donor location, or even the number of flaps, to the patient’s reconstructive needs. In modern times, the goal is to provide a reconstructive approach that is appropriate for the individual’s body in a comparative nature.

Study limitations include the moderately low average BMI and limited number of patients with a BMI less than 20. A larger sample size with these specific characteristics would provide greater insight into the morbidity profile of the lower extreme of BMI patients treated with autologous tissue breast reconstruction. Likewise, it is common knowledge that BMI is not the most accurate measurement for assessing percent body fat or fat distribution. These are major factors that are considered when choosing the best reconstruction method for individual patients and should consequently be included in approaching patients and future studies.

CONCLUSIONS

Autologous breast reconstruction in low BMI patients yields successful and durable results. In low BMI patients, surgeons should consider all reconstructive options starting with DIEP flaps and ranging to alternatives, such as PAP flaps and LAP flaps, or stacked flaps. This study shows that predictable results can be achieved in the thin patient population.

DISCLOSURE

The authors have no financial interests to declare in relation to the content of this article.