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Objectives: To systematically review the current literature on the role of preoperative BMI and smoking status in predicting complications after breast reconstruction, and to assess whether any studies included active risk factor optimization Introduction: Postmastectomy breast reconstruction plays a pivotal role in the physical and emotional recovery of women with breast cancer. However, modificable risk factors such as elevated body mass index (BMI) and smoking have been associated with increased rates of postoperative complications. Optimizing these factors prior to surgery may improve outcomes, yet current evidence remains fragmented and has not been systematically compared. This review aims to evaluate whether preoperative intervention targeting these factors can reduce surgical complication rates. Materials / method: A systematic PubMed search was conducted (January 2008–March 2025) using MeSH terms “breast reconstruction,” “body mass index,” and “smoking.” Eligible studies included adult women undergoing immediate or delayed reconstruction and reporting outcomes associated with BMI or smoking. Extracted data included study design, reconstruction type, complications, and level of evidence. Risk of bias was assessed according to study design. Results: Ten studies were included, encompassing >4,000 reconstructions. All were observational (Level III evidence). Elevated BMI (≥25) was significantly associated with higher rates of wound dehiscence, infection, and seroma, particularly in autologous abdominal flaps. Morbid obesity (BMI ≥35) further increased reconstructive failure and hospital readmissions . Active smoking was consistently linked to skin flap necrosis, surgical site infection, and free flap loss, with the greatest risk observed in implant-based reconstructions. Notably, no randomized trials or structured preoperative optimization Conclusion: Preoperative obesity and smoking are strong predictors of adverse outcomes in breast reconstruction. While the association is consistently documented, a significant gap persists between risk identification and the application of targeted optimization strategies. Well-designed prospective trials are urgently needed to determine whether structured interventions, such as preoperative smoking cessation and weight reduction programs, can mitigate complications and improve reconstructive success