Complications of Postmastectomy Breast Reconstructions in Smokers, Ex-smokers, and Nonsmokers

Abstract

Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex-smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10-year period. Ex-smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex-smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex-smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex-smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex-smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TR4AM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex-smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex-smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery.

Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis

“…1). There were seven prospective cohort studies, 12,[20][21][22][23][24][25] 16 retrospective cohort studies, [26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] and two RCTs (Table 1). 42,43 Both RCTs offered nicotine replacement therapy.…”

“…42,43 Both RCTs offered nicotine replacement therapy. 42,43 There were 14 studies from North America, 12,21,23,26,[30][31][32][33][34][35]37,[39][40][41] six from Europe, 22,27,28,38,42,43 four from Asia, 20,25,29,36 and one from Australia. 24 There were more male than female smokers, and smokers were younger than non-smokers or ex-smokers in many of the studies.…”

“…The follow-up periods were not specified in 13 studies (Table 1). 12,20,22,[27][28][29][30][33][34][35][36][37][38]40 The outcome assessor for postoperative complications was blinded to the smoking status of the patients in only five of the studies. 12,29,36,42,43 All five studies reporting the source of funding received public funding, 21,24,36,42,43 and the nicotine replacement products were provided by the manufacturers (Table 1).…”

“…22,24,27,28,[33][34][35][36][37][38][39][40][41][42][43] There was only one time point (i.e., less than or more than three to four weeks before surgery) with an adequate number of studies for meta-analysis. Thirteen studies involving 7,265 patients were included in the meta-analysis.…”

Systematic review of methodologies used to assess mastectomy flap viability

“…Other factors identified to pose a greater risk of mastectomy flap necrosis include patient‐related factors such as smoking8 9, diabetes mellitus10 11, high BMI10, 11, 12, high mastectomy specimen weight10 11, 13, and previous exposure to radiotherapy12 14. Intraoperative factors such as tumescent mastectomy technique9 15 and Wise‐pattern mastectomy incision13 16 have also been associated with a higher rate of mastectomy flap necrosis17.…”