Women smokers face higher risks of complications from breast reconstruction surgery

  Many women may reduce their risk to that of non-smokers, according to the study

Women who quit smoking for at least three weeks prior to breast reconstruction surgery after a mastectomy may significantly reduce their risk of complications, according to a new report in the February issue of Plastic and Reconstructive Surgery (Vol. 107, No. 2 ). Many women may reduce their risk to that of non-smokers, according to the study.

During a 10-year period, the researchers evaluated more than 700 women who had undergone one of two types of breast reconstruction surgery: one in which the chest skin is expanded and an implant is inserted, and one in which tissue from the abdomen is transplanted to the chest, called a TRAM (transverse rectus abdominis musculocutaneous) flap.

Of the participants, 155 were current smokers at the time of the procedure, 76 were ex-smokers and 517 were non-smokers. Women who quit as recently as three weeks prior to undergoing either surgery were included in the ex-smokers category. The fact that the former smokers’’ overall complication risk was similar to that of non-smokers surprised even the researchers conducting the study.

"The literature is somewhat controversial on the long-term effects of cigarette smoking on wound healing, especially with flaps that have some compromise in their blood supply," says Randall Yetman, MD, a staff plastic surgeon at Cleveland Clinic and one of the co-authors of the study. "The three weeks is somewhat of a surprise."

More Complications In Smokers

They found that almost 40% of the smokers had complications, such as tissue death, tissue damage, and infection, compared to 25% of non- and ex-smokers.

Yetman says that he estimated it would take longer for the former smokers to be ready for surgery but that the study indicates that the nicotine is simply washing out of their system within three weeks.

During the surgery, there is a decreased supply of blood to the tissue at the reconstruction area, he says. Smoking causes an immediate constriction in blood vessels and produces an adverse effect on wound healing, oxygen delivery and blood flow in tissues, says Yetman. Therefore, women who smoke are even more vulnerable to tissue death, or necrosis, at the site of the reconstruction.

For example, wound dehiscence, meaning that the wound reopens instead of healing, was more than three times more common among smokers than among nonsmokers. Fat necrosis, which can cause pain, scar tissue formation, and lumpiness of the reconstructed breast was also three times more common in smokers.

"It’s clear that smoking has a detrimental effect on this operation," Yetman says. "But our study shows that if you stop smoking for three weeks, you fall into an acceptable range of complications that is almost as good as non-smokers. So, we have basically acted on that."

Debbie Saslow, PhD, director of breast and cervical cancer for the American Cancer Society says although results need to be confirmed in a larger study, they can provide valuable information for women considering this type of surgery. "We always push for informed consent," says Saslow. "Although there is a limited amount of data, women could be told that one study indicates that complications might be increased if they smoke but if they stop smoking for three weeks before the surgery, it could make a big difference in their results."

Women who smoke might consider delaying the surgery to allow themselves time to quit, and that, she adds, can be a significant side benefit. "There’s no downside for encouraging people to quit smoking, not just for the operation, but for their overall health," says Saslow.

Additional Information May Create Additional Anxiety

However, both Yetman and Saslow say there may be one downside to sharing this information with patients. "These women in this position are already having tremendous fear and stress, so we should make sure that warning them about potential complications is the right thing to do," says Saslow.

Yetman agrees. Providing this information to women could perhaps convince some women to choose an alternative operation altogether. But, he says the message from the study is clear and simple. "If you can stop smoking for three weeks, it’s safe to have a breast reconstruction. If you can’t, you shouldn’t have this procedure," he says.

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