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Compound Effect Of Hypoalbuminemia And Obesity On Wound Healing After Autologous Breast Reconstruction
Sarah N. Chiang, B.S., Michael J. Finnan, MS, Gary B. Skolnick, BA, MBA, Amanda M. Westman, PhD, Justin M. Sacks, MD, MBA, Joani M. Christensen, MD.
Washington University in St. Louis, Saint Louis, MO, USA.

Purpose:
Obesity, smoking, and diabetes are commonly considered to impair wound healing postoperatively. Recently, malnutrition and sarcopenia have also been found to correlate with poor surgical outcomes; however, the role of malnutrition in obesity is understudied, particularly in breast reconstruction. We examine the ACS National Surgery Quality Improvement Program (NSQIP) database to determine the impact of obesity and hypoalbuminemia on complications after autologous breast reconstruction.
Methods:
Autologous breast reconstruction procedures (including pedicled and free flaps) were collected from the 2009-2019 NSQIP databases by CPT codes (n=23,690). Patients without height, weight, or preoperative serum albumin data were excluded (n=12,825). Demographics and postoperative outcomes were compared in patients with obesity (BMI >30) and malnutrition (albumin <3.5 g/dL). Classification tree analysis was performed to identify partitions most associated with wound complications.
Results:
A total of 10,865 procedures were included in analysis; 4,565 involved patients with obesity (42%). Obesity was associated with increased length of stay, reoperations, wound complications, and medical complications (all p<0.001). Among patients with obesity, 198 had malnutrition (4.3%). The combination of obesity and malnutrition was associated with a higher rate of wound complications (16%) over obesity alone (9.2%) or malnutrition alone (9.2%, both p<0.05). This relationship was established independently via classification tree analysis, which identified BMI ≥31 and albumin <3.8 as a partition associated with increased wound complications.
Conclusions:
Hypoalbuminemia, a marker of malnutrition, is common in obese patients and is associated with worse surgical outcomes after autologous breast reconstruction compared to obesity alone.


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