Smoking is universally considered to be a risk factor for surgical complications. The incidence of complications following tissue expander/implant breast reconstruction in patients who smoke has not been previously evaluated.A review of complications following tissue expander/implant reconstruction in 515 patients was performed. Patients who had 2-stage, tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between May 2002 and December 2003 were included. Complications in smokers (n=132) and nonsmokers (n=383) were compared. The rate of overall complications, reconstructive failure, mastectomy flap necrosis, and infectious complications was significantly higher in smokers compared with nonsmokers. The rate of complications in ex-smokers was also higher than in nonsmokers. Using multivariate statistical analysis to adjust for confounding variables, smoking was identified as independent predictor of postoperative complications.A significant association between smoking status and postoperative complications exists. Thus, smokers who undergo postmastectomy expander/implant reconstruction should be informed of the increased risk of surgical complications and should be counseled on smoking cessation.