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

Abstract

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. 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. 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). 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.