I found the article regarding breast reduction in the morbidly obese (reference #1) to be quite interesting. It does seem to be an important question with the increasing obese population and with the "never events" list being expanded. They give their reason for looking at the topic:
Background: With an increasing obese population, plastic surgeons are consulted by women requesting larger breast reductions, with body mass indices in the obese to morbidly obese range (30 to ≥40 kg/m2) and breasts considered gigantomastic (>2000 g resected from each breast). There have been few descriptions of outcomes in the morbidly obese population. Previous literature reports high complication rates in obese women and large-volume breast reductions.
The article is a retrospective review of 179 consecutive patients who had surgery at the University of Texas Medical Branch at Galveston during the time frame of June 1996 to April 2006. I hope they will do another review in a prospective manner and see how it compares.
... We obtained data points including height, weight, preoperative symptoms, medical history, smoking history, breast size, physical examination, type of reduction, amount of resection, and postoperative course including complications. All complications were recorded, and included hematoma, seroma, asymmetry requiring further surgery, stitch abscess, open wounds, cellulitis, fat necrosis, flap loss, changes in nipple sensation, nipple loss, nipple graft loss, and hypertrophic scarring. All were recorded, with no gradation as to severity. These were recorded throughout the patient's follow-up course, ranging from 1 month to 1 year.
The most common pedicle type was the inferior pedicle or central mound used in 134 patients. Free nipple grafts were done in 37 patients. There were 29 patients who had surgery for gigantomastia (more than 2000 gm per side). Six of these women had inferior pedicle/central mound reductions. The other 23 had breast amputations with free nipple grafting.
There patient population characteristics:
Average reduction mass -- 1259 gm per breast (117 - 4875 gm)
Average age -- 35 yrs (15 - 68 yrs)
Average body mass index -- 34 (range, 20.7 - 54.4)
World Health Organization: 18 to 24.9 kg/m2 (normal weight), 25 to 29.9 kg/m2 (overweight), 30 to 39.9 kg/m2 (obese), and greater than 40 kg/m2 (morbidly obese)
- 93 women in the obese category
- 34 women in the morbidly obese category
There were a total of 90 patients (out of 179) with complications, or an overall complication rate of 50 percent. The most common complication was delayed healing which accounted for 65% of the complications
The complications were broken down as follows:
Delayed wound healing -- 65%
Cellulitis -- 17.6%
Hypertrophic scarring -- 8%
Hematoma -- 3%
Seroma -- 3%
Fat necrosis -- 3%
Nipple graft loss -- 1%
The overall complication rate was 50 percent.
There was no statistical difference in the incidence of complications attributable to size of reduction, age, or body mass index (p = 0.37, p = 0.13, and p = 0.38, respectively).
Also, smoking status, method used (p = 0.65 and p = 0.17, and p = 0.48 and p = 0.1, respectively) and
comorbidities had no effect on complication rates (reduction size, p = 0.054; age, p = 0.12; and body mass index, p = 0.072).
There was no significant increase in the rate of complications for each body mass index group based on the reduction mass (p = 0.75, p = 0.89, p = 0.23, and p = 0.07).
They conclude that reduction mammoplasty is "a safe operation for patients regardless of their age, size of reduction, or body mass index." I don't insist that patient's loss weight prior to a breast reduction, but I do (and will continue to do so) tell them that they are at more risk of wound/healing issues.
1. Breast Reduction: Safe in the Morbidly Obese?; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 370-378; Roehl, Kendall M.D.; Craig, E Stirling M.D.; Gómez, Victoria B.A.; Phillips, Linda G. M.D.
2. A Comparison of Complication Rates in Large and Small Inferior Pedicle Reduction Mammoplasty; Plast. Reconstr. Surg. 115: 736, 2005; O'Grady, K. F., Thoma, A., and Dal Cin, A.
3. Analysis of Breast Reduction Complications Derived from the BRAVO Study; Plast. Reconstr. Surg. 115: 1597, 2005; Cunningham, B. L., Gear, A. J., Kerrigan, C. L., et al.