Smokers Can Benefit From Free TRAM Breast Reconstruction

NEW ORLEANS—Smokers 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 68^th 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.”

More Complications

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 patients—including 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 complications—defined as partial or total flap loss, vessel thrombosis, hematoma, infection, seroma, fat necrosis, and mastectomy skin flap necrosis—than 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.”