Thin women have not traditionally been considered ideal candidates for autologous breast reconstruction. The purpose of this study was to examine the use of deep inferior epigastric perforator (DIEP) flap reconstruction in thin women undergoing immediate unilateral breast reconstruction. A retrospective review of 1,040 consecutive patients was performed. In total, 381 patients met the inclusion criteria. To improve clinical interpretability, patients were divided into three groups based on body mass index: "thin" (BMI ≤ 22.99), "traditional" (>23 and ≤29.99), and "obese" (BMI >30) candidates. Flap characteristics were compared to mastectomy weights, and postoperative complications were analyzed. In all groups, flap size was generally more than sufficient to match the mastectomy specimen, as flap weight:mastectomy weight ratio ws greater than 1 in all groups with no significant difference between groups (1.1 in thin patients, 1.0 in traditional patients, and 1.0 in obese patients). Fat necrosis prevalence was lowest in the thin group (12.5%), compared to the traditional (15.9%, P = 0.443) or obese (14.4%, P = 0.698) groups. Prevalence of breast infection were lower in the thin patients (5.2%) versus the traditional (8.7%, P = 0.287) or obese (14.4%, P = 0.033). Abdominal wound healing complications and seroma were also lowest in thin patients. DIEP flap breast reconstruction may be an effective method for unilateral breast reconstruction in thin patients, with sufficient flap weights and lower incidence of complications than in heavier patients. As such, low BMI may not present a barrier in the reconstruction of a breast mound matching native breast size.

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