Regular Article| Volume 28, ISSUE 8, P815-820, December 2002

Smoking as a risk factor for wound healing and infection in breast cancer surgery

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      Aim: Clinical studies suggest that smoking is associated with wound necrosis after breast cancer surgery. However, the significance of smoking as a risk factor for wound infection, skin flap necrosis, and epidermolysis when adjusting for other potential risk factors remains to be studied.
      Methods: From June 1994 through August 1996, 425 patients underwent breast cancer surgery as simple mastectomy, modified radical mastectomy, or breast conserving surgery. The patients were evaluated postoperatively for wound infection, skin flap necrosis, and epidermolysis. Association between these complications and 17 patient, operative, and postoperative variables were analysed by three separate multiple logistic regression analyses.
      Results: When compared to non-smoking, smoking was significantly associated with wound infection after all types of surgery (light smoking (1–14 grams per day): [odds ratio (OR)=2.95, 95% confidence interval (95% CI)=1.07–8.16], and heavy smoking (≥15 grams per day): OR=3.46 (1.52–7.85). A similar significant association was found as regards skin flap necrosis and epidermolysis after simple mastectomy and modified radical mastectomy: both light and heavy smoking were predictive for skin flap necrosis: light smoking: OR=6.85 (1.96–23.90), heavy smoking: OR=9.22 (2.91–29.25) and for epidermolysis: light smoking: OR=3.98 (1.52–10.43) and heavy smoking: OR=4.28 (1.81–10.13). No significant dose-response relation was disclosed. Other risk factors and confounders associated with complicated wound healing were adjusted for in the analysis: diabetes, obesity, alcohol, NSAIDs, duration of surgery, and surgical experience.
      Conclusion: Independent of other risk factors, smoking is predictive for post-mastectomy wound infection, skin flap necrosis, and epidermolysis.


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        • Feigenberg Z
        • Zer M
        • Dintsman M
        Comparison of postoperative complications following radical and modified mastectomy.
        World J Surg. 1977; 1: 207-211
        • Budd DC
        • Cochran RC
        • Sturtz DL
        • Fouty Jr, WJ
        Surgical morbidity after mastectomy operations.
        Am J Surg. 1978; 135: 218-220
        • Bertin ML
        • Crowe J
        • Gordon SM
        Determinants of surgical site infection after breast surgery.
        Am J Infect Control. 1998; 26: 61-65
        • Hayes JA
        • Bryan RM
        Wound healing following mastectomy.
        Aust NZ J Surg. 1984; 54: 25-27
        • Hunt TK
        • Hopf HW
        Wound healing and wound infection. What surgeons and anaesthesiologists can do.
        Surg Clin North Am. 1997; 77: 587-606
        • Aitken DR
        • Minton JP
        Complications associated with mastectomy.
        Surg Clin North Am. 1983; 63: 1331-1352
        • Chang DW
        • Reece GP
        • Wang B
        • Robb GL
        • Miller MJ
        • Evans GRD
        Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction.
        Plast Reconstr Surg. 2000; 105: 2374-2380
        • Zimmermann NE
        • Dahl MB
        • Graversen HP
        Effects of tobacco smoking on the incidence of flap necrosis after mastectomy.
        Ugeskr Laeger. 1997; 159: 4974-4976
        • Vinton AL
        • Traverso LW
        • Jolly PC
        Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection.
        Am J Surg. 1991; 161: 584-588
        • Jensen JA
        • Goodson WH
        • Williams H
        • Hunt TK
        Cigarette smoking decreases tissue oxygen.
        Arch Surg. 1991; 126: 1131-1134
        • Nolan J
        • Jenkins RA
        • Kurihara K
        • Schultz RC
        The acute effects of cigarette smoke exposure on experimental skin flaps.
        Plast Reconstr Surg. 1985; 75: 544-551
        • Horby J
        • Pilsgaard B
        • Jorgensen T
        Compressive bandage and postoperative complications to breast cancer surgery. A randomised trial.
        Eur J Cancer. 1996; 32A: 17
        • Garner JS
        • Jarvis WR
        • Emori TG
        • Horan TC
        • Hughes JM
        CDC definitions for nosocomial infections, 1988.
        Am J Infect Control. 1988; 16: 128-140
        • Chen J
        • Gutkin Z
        • Bawnik J
        Postoperative infections in breast surgery.
        J Hosp Infect. 1991; 17: 61-65
        • Morecraft R
        • Blair WF
        • Brown TD
        • Gable RH
        Acute effects of smoking on digital artery blood flow in humans.
        J Hand Surg. 1994; 19: 1-7
        • Enderle MD
        • Pfohl M
        • Kellermann N
        • Haering HU
        • Hoffmeister HM
        Endothelial function, variables of fibrinolysis and coagulation in smokers and healthy controls.
        Haemostasis. 2000; 30: 149-158
        • Holt PG
        Immune and inflammatory function in cigarette smokers.
        Thorax. 1987; 42: 241-249
        • Hopf HW
        • Hunt TK
        • West JM
        • Blomquist P
        • Goodson WH
        • Jensen A
        Wound tissue oxygen tension predicts the risk of wound infection in surgical patients.
        Arch Surg. 1997; 132: 997-1004
        • Allen DB
        • Maguire JJ
        • Mahdavian M
        • Wicke C
        • Marocci L
        • Scheuenstuhl H
        Wound hypoxia and acidosis limit neutrophil bacterial killing mechanisms.
        Arch Surg. 1997; 132: 991-996
        • Babior BM
        Oxygen-dependent microbial killing by phagocytes.
        N Engl J Med. 1978; 298: 659-668
        • Greif R
        • Akca O
        • Horn EP
        • Kurz A
        • Sessler DI
        Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection.
        N Engl J Med. 2000; 342: 161-167
        • Dowd GS
        Predicting stump healing following amputation for peripheral vascular disease using transcutaneous oxygen monitor.
        Ann R Coll Surg. 1986; 68: 31-35
        • Lind J
        • Kramhoft M
        • Bodtker S
        The influence of smoking on complications after primary amputations of the lower extremity.
        Clin Orthop. 1991; 267: 211-217
        • Niinikoski J
        • Jussila P
        • Vihersaari T
        Radical mastectomy wound as a model for studies of human wound metabolism.
        Am J Surg. 1973; 126: 53-58
        • Cruse PJ
        • Foord R
        The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds.
        Surg Clin North Am. 1980; 60: 27-40
        • Pearl SH
        • Kanat IO
        Diabetes and healing: a review of the literature.
        J Foot Surg. 1988; 27: 268-270
        • McMurry Jr, JF
        Wound healing with diabetes mellitus. Better glucose control for better wound healing in diabetes.
        Surg Clin North Am. 1984; 64: 769-778
        • Tan JS
        • Anderson JL
        • Watanakunakorn C
        • Phair JP
        Neutrophil dysfunction in diabetes mellitus.
        J Lab Clin Med. 1975; 85: 26-33
        • Felding C
        • Jensen LM
        • Tonnesen H
        Influence of alcohol intake on postoperative morbidity after hysterectomy.
        Am J Obstet Gynecol. 1992; 166: 667-670
        • Gronbaek MN
        • Iversen L
        • Olsen J
        • Becker PU
        • Hardt F
        • Sorensen TIA
        Sensible drinking limits.
        Ugeskr Laeger. 1997; 159: 5939-5945
        • Rotstein C
        • Ferguson R
        • Cummings KM
        • Piedmonte MR
        • Lucey J
        • Banish A
        Determinants of clean surgical wound infections for breast procedures at an oncology centre.
        Infect Control Hosp Epidemiol. 1992; 13: 207-214
        • Hoefer Jr, RA
        • DuBois JJ
        • Ostrow LB
        • Silver LF
        Wound complications following modified radical mastectomy: an analysis of perioperative factors.
        J Am Osteopath Assoc. 1990; 90: 47-53
        • Funnell IC
        • Crowe PJ
        • Dent DM
        Does surgical experience influence mastectomy complications?.
        Ann R Coll Surg Engl. 1992; 74: 178-180
        • Say CC
        • Donegan W
        A biostatistical evaluation of complications from mastectomy.
        Surg Gynecol Obstet. 1974; 138: 370-376
        • Beatty JD
        • Robinson GV
        • Zaia JA
        • Benfield JR
        • Kemeny MM
        • Meguid MM
        A prospective analysis of nosocomial wound infection after mastectomy.
        Arch Surg. 1983; 118: 1421-1424
        • Fang C
        • Alexander JW
        • MacMillan BG
        • Austin LS
        Failure of topical prostaglandin inhibitors to improve wound healing following deep partial-thickness burns.
        J Trauma. 1983; 23: 300-304