Breast reduction pros and cons for patients with a high BMI and higher rate of surgical complications

INTERNATIONAL REPORT Breast reduction may be advantageous for those who need the procedure, but some recent research reveals that its drawbacks for patients with a higher body mass index (BMI) include a higher rate of wound complications, as well as rebound weight gain following the procedure.

"In my experience, the incidence of wound complications increases as the BMI of the patient increases," says Alastair J. Platt, M.D., Department of Plastic Surgery, Castle Hill Hospital, Cottingham, East Yorkshire, U.K.

"Larger ladies tend to have larger breasts with relatively more fat within them. It is easier to rush this, the wounds may be tighter in an effort to try to get the shape better in the larger-framed lady and this will all lead to increasing amounts of fat necrosis and subsequent loss of areas of overlying skin and T-junction breakdown," he explains.

Dr. Platt conducted a prospective, randomized study in 30 patients undergoing bilateral breast reduction by inferior pedicle technique to determine the effect and outcome of unilateral saline wound irrigation and BMI. Wound dehiscence, infection, fat necrosis and breast comfort were assessed at one, four and eight weeks after surgery. Patients included in the study had a mean weight of 67.7 kg and a mean BMI of 26.3. The mean weight of breast tissue excised per patient was 1,270 g.

Results showed that 13 of the 60 breasts had minor wound breakdown, all of which healed by the final follow-up at eight weeks post-op. Those patients with a BMI greater than 26.3 had a wound breakdown rate of 33 percent, and those with a BMI less than 26.3 percent had a wound breakdown rate of 10 percent — clearly indicating that BMI was significantly associated with wound breakdown.

According to Dr. Platt, other similar studies with breast reduction patients have shown an almost 100 percent wound complication rate as the BMI approaches 40.

"The upper limit of a normal BMI is around 26. In overweight patients, a BMI of 30 would be a number to shoot for before a breast reduction surgery is done. I think it is acceptable to do a breast reduction surgery in patients with a BMI of 32 or 33 if they have enormous breasts. Ultimately, the patients will benefit from the surgery and in most cases, it is worth it to take that extra risk," Dr. Platt tells Cosmetic Surgery Times .

However, Dr. Platt cautions that those patients who have enormous breasts and are still overweight should consult their surgeon to assess if the increased risk of wound healing is an acceptable one. Dr. Platt says that serious consideration must be given to a patient with a high BMI before the surgery is undertaken. If the patient is overweight and the breasts are in proportion to that patient, then perhaps they should be encouraged to lose weight before surgery.

In the literature, there are over 200 techniques described for performing a breast reduction surgery and it is therefore very difficult to obtain hard statistics on the techniques of breast reduction surgeries and their associated risks and outcomes. Patients will always have a kaleidoscope of different characteristics such as age, weight, size of breasts, positive innate healing potential, as well as all of the different techniques themselves. And yet, an elevated BMI regularly emerges in studies as an associated risk factor.

"Staying consistent with the literature, I think there have been some factors that have been shown to be detrimental to a fully successful breast reduction surgery, and one clear factor is a high BMI," Dr. Platt says.

COMPLICATIONS ABOUND Dr. Platt contends that the heavier the patient, the more complications they will run into in the operating room. This does not necessarily mean that overweight patients shouldn't have the operation, but it certainly means that these complications should be taken into consideration before the procedure is performed.

"Breast reduction surgery can be justified if the breasts are absolutely enormous and very burdensome to the patient. It is not necessarily a rule of thumb, but in overweight patients, the surgeon should expect complications such as wound dehiscence, areas of fat necrosis, painful induration as well as infections and discharge, all of which can be very serious

complications. The worst of these complications can be the loss of the nipple-areola complex," Dr. Platt says.