Download PDF
J Reconstr Microsurg 2020; 36(09): 694-702
DOI: 10.1055/s-0040-1714426
Original Article

Impact of Smoking Status in Free Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: A Multicenter Study

Lukas Prantl‡   *
1   Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
,
Nicholas Moellhoff‡   *
2   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
,
Uwe V. Fritschen
3   Department of Plastic and Esthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, Berlin, Germany
,
Guenter Germann
4   Department of Plastic, Reconstructive, Esthetic and Handsurgery, ETHIANUM Klinik Heidelberg, Heidelberg, Germany
,
Riccardo E. Giunta
2   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
,
Florian Zeman
5   Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
,
Andreas Kehrer 
1   Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
,
Daniel Lonic
1   Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
,
P. Niclas Broer
6   Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
,
Denis Ehrl
2   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
,
Paul I. Heidekrueger
1   Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Background Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. Using the largest database available in Europe, the presented study investigated the impact of cigarette smoking on deep inferior epigastric artery perforator (DIEP) free-flap breast reconstructions.

Methods In total, 3,926 female patients underwent 4,577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups: nonsmokers (NS) and smokers (S). Impact of smoking on surgical complications, controlled for covariates, and cluster effects within the cancer centers were analyzed by using generalized linear mixed models.

Results Overall, there was no significant difference between the groups of patients regarding the rate of total flap loss. However, the rate of partial flap loss (0.9 vs. 3.2%, p < 0.001) and wound-healing disturbances requiring revision surgery (donor site: 1.5 vs. 4.0; recipient site: 1.3 vs. 3.6%, both p < 0.001) was significantly higher in smokers. Multivariable analysis identified smoking to be an independent risk factor for revision surgery (p = 0.001) and partial flap loss (p < 0.0001).

Conclusion Our findings suggest that successful free tissue transfer can be achieved in smokers despite higher rates of partial flap losses and wound-healing disturbances. However, patients with a history of smoking requiring DIEP flap reconstruction should be critically evaluated preoperatively, informed in detail about the higher risk of complications and encouraged to quit smoking prior to surgery.

Keywords

DIEP flap - smoking status - breast reconstruction

* These authors have contributed equally to the preparation of the manuscript.




Publication History

Received: 30 March 2020

Accepted: 16 June 2020

Article published online:
29 July 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Samet JM. Tobacco smoking: the leading cause of preventable disease worldwide. Thorac Surg Clin 2013; 23 (02) 103-112
    CrossrefPubMedGoogle Scholar
  • 2 Goodchild M, Nargis N, Tursan d'Espaignet E. Global economic cost of smoking-attributable diseases. Tob Control 2018; 27 (01) 58-64
    CrossrefPubMedGoogle Scholar
  • 3 Whiteford L. Nicotine, CO and HCN: the detrimental effects of smoking on wound healing. Br J Community Nurs 2003; 8 (12) S22-S26
    CrossrefPubMedGoogle Scholar
  • 4 Burns DM. Tobacco-related diseases. Semin Oncol Nurs 2003; 19 (04) 244-249
    CrossrefPubMedGoogle Scholar
  • 5 West R. Tobacco smoking: Health impact, prevalence, correlates and interventions. Psychol Health 2017; 32 (08) 1018-1036
    CrossrefPubMedGoogle Scholar
  • 6 Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011; 124 (02) 144-154.e8
    CrossrefPubMedGoogle Scholar
  • 7 Sørensen LT, Jørgensen S, Petersen LJ. , et al. Acute effects of nicotine and smoking on blood flow, tissue oxygen, and aerobe metabolism of the skin and subcutis. J Surg Res 2009; 152 (02) 224-230
    CrossrefPubMedGoogle Scholar
  • 8 Ehrl D, Heidekrueger PI, Haas EM. , et al. Does cigarette smoking harm microsurgical free flap reconstruction?. J Reconstr Microsurg 2018; 34 (07) 492-498
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Chang DW, Reece GP, Wang B. , et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg 2000; 105 (07) 2374-2380
    CrossrefPubMedGoogle Scholar
  • 10 Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg 2005; 116 (07) 1873-1880
    CrossrefPubMedGoogle Scholar
  • 11 van Adrichem LN, Hoegen R, Hovius SE. , et al. The effect of cigarette smoking on the survival of free vascularized and pedicled epigastric flaps in the rat. Plast Reconstr Surg 1996; 97 (01) 86-96
    CrossrefPubMedGoogle Scholar
  • 12 Zimmerman DD, Delemarre JB, Gosselink MP, Hop WC, Briel JW, Schouten WR. Smoking affects the outcome of transanal mucosal advancement flap repair of trans-sphincteric fistulas. Br J Surg 2003; 90 (03) 351-354
    CrossrefPubMedGoogle Scholar
  • 13 Healy C, Allen Sr RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg 2014; 30 (02) 121-125
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Chang DW. Breast Reconstruction with Microvascular MS-TRAM and DIEP Flaps. Arch Plast Surg 2012; 39 (01) 3-10
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Fritschen UV, Grill B, Wagner J. , et al. [Quality assurance in breast reconstruction - Establishment of a prospective national online registry for microsurgical breast reconstructions]. Handchir Mikrochir Plast Chir 2019; 52 (02) 58-66
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Collaborators GBDT. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017; 389 (10082): 1885-1906
    CrossrefPubMedGoogle Scholar
  • 17 Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg 1984; 73 (06) 911-915
    CrossrefPubMedGoogle Scholar
  • 18 Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr Surg 2003; 111 (06) 2082-2087 , discussion 2088–2089
    CrossrefPubMedGoogle Scholar
  • 19 Hillam JS, Borsting EA, Chim JH, Thaller SR. Smoking as a risk factor for breast reduction: an analysis of 13,503 cases. J Plast Reconstr Aesthet Surg 2017; 70 (06) 734-740
    CrossrefPubMedGoogle Scholar
  • 20 Messa CA, Messa CA. One-stage augmentation mastopexy: a retrospective ten-year review of 2183 consecutive procedures. Aesthet Surg J 2019; 39 (12) 1352-1367
    CrossrefPubMedGoogle Scholar
  • 21 Krupski WC. The peripheral vascular consequences of smoking. Ann Vasc Surg 1991; 5 (03) 291-304
    CrossrefPubMedGoogle Scholar
  • 22 Tosun Z, Karabekmez FE, Duymaz A, Ozkan A, Keskin M, Avunduk MC. Preventing negative effects of smoking on microarterial anastomosis. Ann Plast Surg 2010; 65 (01) 91-95
    CrossrefPubMedGoogle Scholar
  • 23 Rinker B. The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Ann Plast Surg 2013; 70 (05) 599-605
    CrossrefPubMedGoogle Scholar
  • 24 Theocharidis V, Economopoulos KP. Smoking cessation prior to elective plastic surgery: why, when and how?. Tob Induc Dis 2014 12. (01)
    Google Scholar
  • 25 Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002; 359 (9301): 114-117
    CrossrefPubMedGoogle Scholar
  • 26 Kuri M, Nakagawa M, Tanaka H, Hasuo S, Kishi Y. Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery. Anesthesiology 2005; 102 (05) 892-896
    CrossrefPubMedGoogle Scholar
  • 27 Michael Pittilo R. Cigarette smoking, endothelial injury and cardiovascular disease. Int J Exp Pathol 2000; 81 (04) 219-230
    CrossrefPubMedGoogle Scholar
  • 28 Pittilo RM. Cigarette smoking and endothelial injury: a review. Adv Exp Med Biol 1990; 273: 61-78
    CrossrefPubMedGoogle Scholar
  • 29 Rao VK, Morrison WA, O'Brien BM. Effect of nicotine on blood flow and patency of experimental microvascular anastomosis. Ann Plast Surg 1983; 11 (03) 206-209
    CrossrefPubMedGoogle Scholar
  • 30 Davis JW, Davis RF. Acute effect of tobacco cigarette smoking on the platelet aggregate ratio. Am J Med Sci 1979; 278 (02) 139-143
    CrossrefPubMedGoogle Scholar
  • 31 Hawkins RI. Smoking, platelets and thrombosis. Nature 1972; 236 (5348): 450-452
    CrossrefPubMedGoogle Scholar
  • 32 Khouri RK, Cooley BC, Kunselman AR. , et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
    CrossrefPubMedGoogle Scholar
  • 33 Chen KT, Mardini S, Chuang DC. , et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
    CrossrefPubMedGoogle Scholar
  • 34 Bozikov K, Arnez ZM. Factors predicting free flap complications in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2006; 59 (07) 737-742
    CrossrefPubMedGoogle Scholar
  • 35 Miller RB, Reece G, Kroll SS. , et al. Microvascular breast reconstruction in the diabetic patient. Plast Reconstr Surg 2007; 119 (01) 38-45 , discussion 46–48
    CrossrefPubMedGoogle Scholar
  • 36 Valentini V, Cassoni A, Marianetti TM. , et al. Diabetes as main risk factor in head and neck reconstructive surgery with free flaps. J Craniofac Surg 2008; 19 (04) 1080-1084
    CrossrefPubMedGoogle Scholar
  • 37 Serletti JM, Higgins JP, Moran S, Orlando GS. Factors affecting outcome in free-tissue transfer in the elderly. Plast Reconstr Surg 2000; 106 (01) 66-70
    CrossrefPubMedGoogle Scholar
  • 38 Panayi AC, Agha RA, Sieber BA, Orgill DP. Impact of obesity on outcomes in breast reconstruction: a systematic review and meta-analysis. J Reconstr Microsurg 2018; 34 (05) 363-375
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanchwala S. Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets. J Am Coll Surg 2013; 217 (04) 656-664
    CrossrefPubMedGoogle Scholar
  • 40 Chang LD, Buncke G, Slezak S, Buncke HJ. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg 1996; 12 (07) 467-474
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Wong AK, Joanna Nguyen T, Peric M. , et al. Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery 2015; 35 (01) 6-12
    CrossrefPubMedGoogle Scholar
  • 42 Reus III WF, Colen LB, Straker DJ. Tobacco smoking and complications in elective microsurgery. Plast Reconstr Surg 1992; 89 (03) 490-494
    CrossrefPubMedGoogle Scholar
  • 43 Goldminz D, Bennett RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol 1991; 127 (07) 1012-1015
    CrossrefPubMedGoogle Scholar
  • 44 Mosely LH, Finseth F, Goody M. Nicotine and its effect on wound healing. Plast Reconstr Surg 1978; 61 (04) 570-575
    CrossrefPubMedGoogle Scholar
  • 45 Xanthoulea S, Deliaert A, Romano A, Rensen SS, Buurman WA, van der Hulst RR. Nicotine effect on inflammatory and growth factor responses in murine cutaneous wound healing. Int Immunopharmacol 2013; 17 (04) 1155-1164
    CrossrefPubMedGoogle Scholar
  • 46 Abedi N, Ho AL, Knox A. , et al. Predictors of mastectomy flap necrosis in patients undergoing immediate breast reconstruction: a review of 718 patients. Ann Plast Surg 2016; 76 (06) 629-634
    CrossrefPubMedGoogle Scholar
  • 47 McCarthy CM, Mehrara BJ, Riedel E. , et al. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg 2008; 121 (06) 1886-1892
    CrossrefPubMedGoogle Scholar
  • 48 Wang TY, Serletti JM, Cuker A. , et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg 2012; 129 (02) 443-453
    CrossrefPubMedGoogle Scholar
  • 49 Beugels J, Meijvogel JLW, Tuinder SMH. , et al. The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat 2019; 176 (02) 367-375
    CrossrefPubMedGoogle Scholar
  • 50 Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications after microvascular breast reconstruction: experience with 1195 flaps. Plast Reconstr Surg 2006; 118 (05) 1100-1109 , discussion 1110–1111
    CrossrefPubMedGoogle Scholar
  • 51 Schaverien MV, Munnoch DA. Effect of neoadjuvant chemotherapy on outcomes of immediate free autologous breast reconstruction. Eur J Surg Oncol 2013; 39 (05) 430-436
    CrossrefPubMedGoogle Scholar
  • 52 Fracol ME, Basta MN, Nelson JA. , et al. Bilateral free flap breast reconstruction after unilateral radiation: comparing intraoperative vascular complications and postoperative outcomes in radiated versus nonradiated breasts. Ann Plast Surg 2016; 76 (03) 311-314
    CrossrefPubMedGoogle Scholar
  • 53 Fosnot J, Fischer JP, Smartt Jr JM. , et al. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction?. Plast Reconstr Surg 2011; 127 (02) 496-504
    CrossrefPubMedGoogle Scholar
  • 54 Borghini A, Gianicolo EA, Picano E, Andreassi MG. Ionizing radiation and atherosclerosis: current knowledge and future challenges. Atherosclerosis 2013; 230 (01) 40-47
    CrossrefPubMedGoogle Scholar