NEW ORLEANSSmokers can reduce smoking-related complications of
breast reconstruction by quitting smoking several weeks before
surgery. For heavy smokers, delaying reconstruction may result in
fewer complications, according to a study presented at the 68th
Annual Scientific Meeting of the American Society of Plastic and
Reconstructive Surgeons (now known as the American Society of Plastic Surgeons).
The purpose of our study was to determine whether free TRAM
[pedicled transverse rectus abdominis myocu-taneous] flap is a
desirable option for breast reconstruction in patients who
smoke, said David W. Chang, MD, assistant professor of plastic
surgery, M.D. Anderson Cancer Center. Specifically, we wanted
to assess the risk associated with free TRAM in smokers during breast
reconstruction and to develop some guidelines for free TRAM for
breast reconstruction in smokers.
The study found that smokers with a history of more than 10
pack-years of smoking had more breast reconstruction complications
than did nonsmokers. Former smokers (defined as smokers who had quit
smoking at least 4 weeks before reconstructive surgery) achieved
roughly the same complication profile as nonsmokers.
The researchers reviewed 936 free TRAM breast reconstruction
procedures in 718 patientsincluding 478 nonsmokers, 150 former
smokers, and 90 active smokers. All patients underwent the
reconstructive procedure at M.D. Anderson Cancer Center between
February 1, 1989 and May 31, 1998.
Flap complications occurred in 222 procedures (23.7%). The most
common flap complication was mastectomy skin flap necrosis (10.3%).
Smokers had a higher incidence of mastectomy flap necrosis than
nonsmokers (18.9% vs 9%, P = .005).
Donor site complications occurred in 14.8% of the 718 patients and
were more common in active smokers than in former smokers (25.6% vs
10%, P = .001) and nonsmokers (25.6% vs 14.2%, P = .007).
Immediate vs Delayed
Smokers who underwent immediate reconstruction (97 procedures) had
significantly more flap complicationsdefined as partial or
total flap loss, vessel thrombosis, hematoma, infection, seroma, fat
necrosis, and mastectomy skin flap necrosisthan did the smokers
who had delayed reconstruction (16 procedures) (31% vs 25%).
Notably, mastectomy flap necrosis was present in 21.7% of the
immediate-reconstruction patients who smoked, but in none of the
delayed-reconstruction patients who smoked.
Although the investigators concluded that free TRAM can be performed
without a significant increase in the rates of vessel thrombosis,
flap loss, or fat necrosis, they did observe a higher risk for
mastectomy skin flap necrosis, abdominal flap necrosis, and hernia in
smokers and a much higher risk of perioperative complications in
smokers with a 10 pack-year history.
Dr. Chang concluded, While smoking may increase complications,
they can be reduced by delaying reconstruction or stopping smoking at
least 4 weeks before reconstruction.