ORIGINAL PAPER Complications of abdominal-based free flaps for breast reconstruction in obese patients: a meta-analysis and case series Erik Matthew Wolfswinkel & William M. Weathers & Mohin A. Bhadkamkar & Jamal Bullocks & Shayan Izaddoost & Larry H. Hollier Jr. & Rodger H. Brown Received: 13 March 2013 / Accepted: 17 May 2013 / Published online: 18 July 2013 # Springer-Verlag Berlin Heidelberg 2013 Abstract Background Obese patients now constitute a larger proportion of women seeking postmastectomy reconstruction. Achieving optimal results with a low number of complications in the obese population is challenging. This meta-analysis compares the complication risks for obese and nonobese patients receiv- ing abdominal-based free flaps for breast reconstruction. Methods A retrospective case series of obese and nonobese patients undergoing abdominal-based free flaps for breast re- construction was performed and included in the meta-analysis. A literature search yielded 103 citations, and multilevel screen- ing identified 7 relevant studies. An eight study meta-analysis, using the DerSimonian and Laird random effects models, com- pared pooled relative risks for complications. Results There was a twofold risk of infection (relative risk (RR), 1.97; 95 % CI, 1.23, 3.14), two and one half times the risk of mastectomy flap necrosis (RR, 2.61; CI, 1.62, 4.20), and partial flap loss (RR, 2.62; CI, 1.23, 5.59) for obese patients compared to nonobese patients. Additionally, there was a fourfold increase in risk for total flap loss (RR, 4.12; CI, 1.01, 16.79) and donor-site seroma (RR, 4.03; CI, 2.46, 6.59). There was no significant difference in the risk for overall donor-site complications between the two populations (RR, 1.09; CI, 0.58, 2.05). Conclusions The findings reveal that obese patients have a higher risk of complications than nonobese patients receiving abdominal-based free flaps for breast reconstruction. As we move toward a pay-for-performance reimbursement system, appropriate risk adjustments will be a vital component, allowing provision of optimal treatment techniques for obese patients. Level of Evidence: Level IV, prognostic/risk study Keywords Obese . Breast . Reconstruction . Free TRAM . MS-TRAM . DIEP . Abdominal based . Microsurgery Introduction The number of mastectomies and breast reconstructions following a diagnosis of breast cancer has been increasing nationally [1–4]. Numerous studies have documented the positive benefits of breast reconstruction, including im- provements in self esteem, sexuality, and body image [2, 5–8]. As the US population becomes increasingly obese, patients with body mass indexes (BMI) ≥30 kg/m 2 will constitute a larger proportion of women seeking breast reconstruction [9, 10]. Achieving optimal results in this pop- ulation has presented a challenge for plastic surgeons [10–15]. With reported complications following abdominal-based breast reconstruction (ABBR) ranging from 31–56 % in the obese population, many surgeons have avoided using these techniques [10, 16–20]. Some surgeons have gone as far as to consider obesity a relative contraindication to traditional ABBR [10, 19, 21]. In spite of the high complication percentages reported with tradition ABBR techniques, obesity does not constitute a contraindication for breast reconstruction as previously assumed [10, 11, 18, 22]. Microsurgical reconstruction using free transverse rectus abdominis myocutaneous flaps (TRAM), free muscle-sparing TRAM flaps (MS-TRAM), and deep inferior epigastric perforator flaps (DIEP) repre- sents the bulk of ABBR and are reported to provide positive esthetic outcomes, high patient satisfaction, and lower complication percentages [18, 19, 23–25]. Surgeons now regularly offer these microsurgical reconstruction options to patients previously considered too high risk for traditional ABBR [17, 26]. The objectives of this study were to conduct a meta- analysis of the existing literature, with the addition of a E. M. Wolfswinkel : W. M. Weathers : M. A. Bhadkamkar : J. Bullocks : S. Izaddoost : L. H. Hollier Jr. : R. H. Brown (*) Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 6701 Fannin St. Suite 610, Houston, TX 77030, USA e-mail: Rb140110@bcm.edu Eur J Plast Surg (2013) 36:765–776 DOI 10.1007/s00238-013-0858-8