Discussion: Metabolic Bridge Therapy before Microvascular Breast Reconstruction in Morbidly Obese Patients: A Proof-of-Concept Risk Analysis

The authors present a database-driven study to evaluate the concept of a metabolic bridge in effort to improve the risk profile for breast cancer patients undergoing autologous breast reconstruction.1 They queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program to identify the change in obesity-related comorbidities before and 1 year after bariatric surgery. They then paired this with Breast Reconstruction Risk Assessment scores to evaluate the risk modulation for possible autologous breast reconstruction. The authors should be commended for the effort to improve outcomes in autologous breast reconstruction in this challenging patient population. The incidence of obesity in the United States continues to rise, and as a result, nearly all breast reconstructive surgeons will encounter this patient population. As such, it is a noble effort to explore solutions that decrease the risk related to autologous tissue breast reconstruction in morbidly obese patients. The authors’ presented concept of using bariatric surgery as a metabolic bridge until a patient has a lower risk profile to undergo autologous breast reconstruction is one idea. There is no question that a high body mass index correlates with more complications following all forms of breast reconstruction, but that does necessarily mean that a metabolic bridge with bariatric surgery is appropriate. The implication in this hypothetical study is that postbariatric surgery patients behave the same as their matched patients who did not undergo massive weight loss surgery. Postbariatric body contouring is generally thought to be a high complication surgery despite the improvements in the patient risk profile. This is true for both restrictive and malabsorptive procedures,2 with reported complication rates of 34% to 56%.3 It is very likely that the tissues are changed with significant weight gain and that bariatric surgery does not completely reverse the surgical risk, and thus, the risk is not equivalent to a matched patient that never went through these significant body changes. The concept of a bridge therapy is interesting and, as referenced in the article, has been used in multiple previous situations. One cited example is the use of a left ventricular assist device while waiting for an available organ for heart transplant. This is an ideal use of a bridge therapy, as it is used to buy time to get to the more definitive treatment. This is very different from what the authors are alluding to in postoncologic reconstruction. Ideally, a bridge therapy has low morbidity and is used as a temporary measure. Not only does bariatric surgery require significant time for reversal of the patient’s comorbidities, it has its own complication rate of up to 20%.4 Potentially, there is a role for glucagon-like peptide-1 receptor agonists as an alternative. In addition, to optimize the aesthetic result, autologous breast reconstruction should be performed when a patient is at a stable weight; and as a result, a metabolic bridge with bariatric surgery likely requires more than 1 year delay from the oncologic procedure. Ultimately, it is unreasonable to delay oncologic treatment for any bridge therapy. These patients will still undergo mastectomy, but based on this concept, immediate reconstruction would no longer be offered. As a result, access to breast reconstruction would be decreased in an ever-increasing patient population. This approach is already very common, as many surgeons restrict autologous breast reconstruction based on body mass index cutoffs. Calling this delay a metabolic bridge therapy is interesting, and if the patient undergoes bariatric surgery and returns for reconstruction in the future, maybe there is a benefit. Ultimately, a controlled study is required to answer this question. As an alternative, surgeons could seek options to improve the process of autologous breast reconstruction in the obese patient population without forcing delayed reconstruction. In our experience, the most critical aspect of this is patient counseling. The typical complications, abdominal wounds, are relatively minor and easily managed. If the patient has an expectation for this, then they generally tolerate this very well. Technically, surgeons can use limited undermining and umbilical ablation to reduce risks as well.5 Postoperatively, extended anticoagulation is also often given. It is important that we continue to strive to improve access and outcomes in morbidly obese patients. At a minimum, the authors bring forth an option for discussion and should be commended for that effort. DISCLOSURE The author has no financial interest in any of the drugs, products, or devices mentioned in this Discussion or the associated article.