Letter to Editor: The Impact of Body Mass Index on Breast Reduction Outcomes: A Multi-Institutional Data Analysis of 45,000 Cases over 15 Years.

We commend Knoedler et al. for their comprehensive study, "The impact of body mass index on breast reduction outcomes," which leverages a robust sample size and a reputable dataset to address an important topic in plastic surgery. While the study successfully highlights the relevance of BMI in breast reduction outcomes, we identify several methodological limitations that could affect the generalizability and depth of its findings. Crucially, the omission of confounding variables such as smoking, diabetes, immunologic and mental health status may limit the accuracy of the reported outcomes. Unlike previous work by the same authors on gynecomastia surgery, which incorporated more comprehensive factors, this study does not fully explore the relationship between BMI, reoperation, and complication rates. Moreover, the limited 30-day post-operative follow-up may overlook long-term complications such as fat necrosis and scarring, which are critical to patient satisfaction. The exclusion of male, non-binary patients, and those undergoing simultaneous procedures, while controlling variability, restricts the study's applicability to broader populations. Additionally, reliance on NSQIP, though valuable, omits nuances like surgical techniques and patient compliance. We suggest future studies incorporate a broader range of variables and follow-up periods to enhance the scope and precision of surgical outcome research.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .