INTRODUCTION: Smoking is associated with increased complications after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The deep inferior epigastric perforator (DIEP) flap spares the abdominal wall musculature, and thus results in less abdominal wall morbidity with excellent aesthetic results. Few studies have investigated the effect of smoking on DIEP flap complication rates.

METHODS: We retrospectively reviewed the charts of 60 consecutive DIEP flap reconstructions over a one-year period. One surgeon completed all flaps utilizing the same technique. Two surgical oncologists performed the skin-sparing mastectomies. Patients were assigned to two groups for comparison: smoking history or non-smokers. Any flap or donor-site complications were recorded.

RESULTS: Forty-three patients, mean age of 52.0 years, comprised the non-smoking group. Seventeen patients with a smoking history, mean age of 60.8 years, and a mean pack-year smoking history of 28.1 years. Total flap complications for the non-smokers and smokers were 23% and 41% respectively. The only flap failure occurred in the smoking history group. Minor fat necrosis, defined as any palpable firmness >2 cm within the flap not requiring an operation, was seen in 4.7% of non-smokers vs. 5.9% of the smokers. Major fat necrosis, defined as firmness requiring a second surgery for pain, cosmesis or to rule out cancer, was seen in 2.3% of the non-smokers vs. 5.9% of the smokers. Mastectomy skin flap necrosis was seen in 14.0% of the non-smokers vs. 23.5% of the smokers. Total donor complications for the non-smokers and smokers were 38.5% and 60.0% respectively. The only abdominal hernia occurred in the smoking group. Abdominal diastasis was seen in 5.1% non-smokers vs. 20.0% of smokers. Skin separation occurred in 13.2% of non-smokers vs. 35.7% of smokers

CONCLUSIONS: Consistent with other methods of autologous breast reconstruction, DIEP flap reconstruction carries potential complications related to the flap itself, the mastectomy skin flap and the abdominal donor-site. Our data suggests that a history of smoking increases the rate of complications in each of these sites. While the DIEP flap itself incurs more fat necrosis, the most significant complication occurs on the mastectomy skin flaps. Smoking's deleterious effects are seen on these random pattern flaps, specifically in the peri-aereolar area. Most abdominal wall complications are minor and resolve non-surgically. The DIEP flap shows an association between increasing postoperative complications and smoking history as do all autologous reconstructions. Nevertheless, lower abdominal wall complications give this flap an advantage over other autologous tissue reconstructions.