Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction

Free pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast r econstruction is often advocated as the procedure of choice for autogenous tissue breast reconstruction in high-risk patients, such as smokers. Howeve r. whether use of the free TRAM flap is a desirable option for breast recon struction in smokers is still unclear. All patients undergoing breast recon struction with free TRAM flaps at our institution between February of 1989 and May of 1998 were reviewed. Patients were classified as smokers, former smokers (patients who had stopped smoking at least 4 weeks before surgery), and nonsmokers. Flap and donor-site complications in the three groups were compared. Information on demographic characteristics, body mass index, and comorbid medical conditions was used to perform multivariate statistical a nalysis. A total of 936 breast reconstructions with free TRAM flaps were performed i n 718 patients (80.9 percent immediate; 23.3 percent bilateral). There were 478 non smokers, 150 former smokers, and 90 smokers. Flap complications oc curred in 222 (23.7 percent) of 996 flaps. Smokers had a higher incidence o f mastectomy flap necrosis than nonsmokers (18.9 percent versus 9.0 percent ; p = 0.005). Smokers who under-went immediate reconstruction had a signifi cantly higher incidence of mastectomy skin flap necrosis than did smokers w ho underwent delayed reconstruction (21.7 percent versus 0 percent; p = 0.0 39). Donor-site complications occurred in 106 (14.8 percent) of 718 patient s. Donor-site complications were more common in smokers than in former smok ers (25.6 percent versus 10.0 percent; p = 0.001) or nonsmokers (25.6 perce nt versus 14.2 percent; p = 0.007). Compared with nonsmokers, smokers had s ignificantly higher rates of abdominal flap necrosis (4.4 percent versus 0. 8 percent; P = 0.025) and hernia (6.7 percent versus 2.1 percent; p = 0.016 ). No significant difference in complication rates was noted between former smokers and nonsmokers. Among smokers, patients with a smoking history of greater than 10 pack-years had a significantly higher overall complication rate compared with patients with a smoking history of 10 or fewer park-veer s (55.8 percent versus 23.8 percent; p = 0.049). In summary, free TRAM flap breast reconstruction in smokers was not associa ted with a significant increase in the rates of vessel thrombosis, flap los s, or fat necrosis compared with rates in nonsmokers. vowel er, smokers wer e at significantly higher risk fur mastectomy skin flap necrosis, abdominal flap necrosis, and hernia compared with nonsmokers. Patients with a smokin g history of greater than 10 pack-years were at especially high risk for pe rioperative complications, suggesting that this should be considered a rela tive contraindication for free TRAM flap breast reconstruction. Smoking-rel ated complications were significantly reduced when the reconstruction was d elayed or when the patient stopped smoking at least 4 weeks before surgery.