Compound Effect of Hypoalbuminemia and Obesity on Complications after Autologous Breast Reconstruction

Background: Obesity is among the risk factors identified that impair postoperative wound healing. Recently, malnutrition and sarcopenia have also been found to correlate with poor surgical outcomes; however, the effect of malnutrition in the setting of obesity is understudied, particularly in reconstructive surgery. The authors examine the American College of Surgeons National Surgery Quality Improvement Program database to determine the impact of obesity plus hypoalbuminemia on complications after autologous breast reconstruction. Methods: Autologous breast reconstruction procedures (pedicled and free flaps) were collected from the 2009 to 2019 National Surgery Quality Improvement Program databases by CPT codes (n = 23,690). Patients without height, weight, or preoperative serum albumin data (n = 12,825) were excluded. Demographics and postoperative outcomes were compared in patients with obesity (body mass index >30 kg/m2) and malnutrition (albumin <3.5 g/dL). Propensity score-matched cohorts with and without malnutrition were also compared. Results: A total of 10,865 procedures were included in analysis; 4565 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 difference is recapitulated in propensity score-matched analysis. Conclusion: Hypoalbuminemia, a marker of malnutrition, is underappreciated in obese patients and is associated with worse surgical outcomes after autologous breast reconstruction compared with obesity alone.