Smoking as a risk factor for wound dehiscence in nipple reconstruction: An analysis of 1683 cases

To the Editor: The goal of breast reconstruction is to create an aesthetically pleasing breast while conserving its natural structure. The nipple areolar complex (NAC) has been described as the defining element of the female breast, and successful recreation of a natural appearing NAC has been associated with increased patient satisfaction and selfesteem. Nipple areolar complex reconstruction was developed in the 1940s when Adams described the nipple areola-graft and labial graft. Methods include, local flaps, nipple sharing, cartilage, and tattooing; however, there is no universally accepted gold standard. All approaches share a common goal—to achieve symmetry in position, size, shape, texture, pigmentation, and projection. Lasting projection is difficult to achieve and techniques have emerged to overcome this issue. Studies on complications after nipple reconstruction are scarce—only one study has explicitly described risk factors for postoperative complications after NAC reconstruction. Momeni et al. focused on the following parameters: age, final implant volume, time from final implant placement to nipple reconstruction, and history of radiotherapy. Only radiotherapy was associated with a significant increase in complication rates. Of note, the authors found a complication rate of 13.2%, a quarter of which were problems with wound healing. The negative effects of smoking on wound healing have been well-described. Four toxic substances—nicotine, carbon monoxide, hydrocyanic acid, and nitrogen oxide—are the primary causative agents of tissue hypoxia, ischemia, and cellular dysfunction, which impair wound healing and tissue repair, and decreases scar quality. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program’s (NSQIP) database, identified 1752 nipple reconstruction patients between the years 2007-2014. Cases missing weight, height, age, gender, Wound Classification, or American Society of Anesthesiologists classification were excluded. Patients who had undergone surgery in the prior 30 days were also excluded. 1683 cases were eligible for analysis. Cohorts were delineated on the patient’s smoking status, with nonsmoker and smoker cohorts comprised of 1567 and 116 cases respectively. Bivariate analysis was performed on outcome variables for superficial incisional, deep incisional, organ/space surgical site infection, wound disruption, and graft/flap failure. Unadjusted univariate analysis identified differences between the cohorts in age (P<.001) and wound classification (P=.0082). Smokers had higher rates of wound disruption (0.3% vs 2.6%; P=.014). There was no significant difference between the cohorts in rate of superficial incisional infection (0.4% vs 0%; P=1). Following multivariate logistic regression, the rate of complications in smokers was significantly higher for wound disruption (OR 6.54; P=.017). Age and wound class were not independent predictors of wound disruption. Approximately 40% of breast cancer patients in the United States undergo radical or skin-sparing mastectomies with many electing immediate reconstruction. In over 80% of these cases, NAC reconstruction will follow surgery. Few studies have investigated risk factors for complications after this procedure, particularly the role of smoking. As a start, we leveraged the NSQIP dataset and analyzed 1683 nipple reconstruction patients across over 480 medical centers. We found smoking to be a significant risk factor for wound disturbance following NAC reconstruction (OR 6.54; P=.017). Smoking status has been well-documented in previous clinical studies to have adverse effects on breast reconstruction outcomes, and our results are in agreement with those. The development of an open wound overlying the implant, particularly in thin mastectomy flaps, may lead to inadvertent implant exposure and loss. A relatively small procedure to complete the breast may therefore risk the entire reconstruction. This emphasizes the importance of being selective when choosing patients to undergo NAC reconstruction. Our study is not without limitations. There are several methods for NAC reconstruction, including the use of nipple sharing, local flaps, or even labia minora or cartilage. All methods are coded under the same CPT code, and the NSQIP database does not track the particular operative technique. Further, by design, NSQIP limits patient follow-up to 30 days postoperatively. Thus, our findings may underestimate the incidence of complications. Finally, participating institutions were disproportionately hospital-based, which may bias against other practice settings. In conclusion, we found smoking to be a risk factor for wound disruption following NAC reconstruction. We hope this study provides further evidence for smoking cessation prior to beginning the reconstructive process.