1.   Because a major artery maintains the blood supply to the tram flap, smokers could find that artery soon clogged with plaque, compromising its function.

2.   But Leighton says tram flaps have advantages.

3.   Staerkel is also hesitant to recommend tram flaps, saying the operation is a long one and that patients who are obese or who smoke are not good candidates.

4.   Tram flaps are especially appropriate after radiation, when the skin has been rendered somewhat fibrous.