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Impact of Smoking on Aesthetic Reconstruction: An Analysis of 927 Face Flaps

Salomon Puyana, MD MS1, Carolina Puyana, MD MPH2, Hooman Hajebian, MD3, Natalia Mejia4, David Jansen, MD1 and Abigail Chaffin1, (1)Tulane University School of Medicine, New Orleans, LA, (2)University of Illinois at Chicago, Chicago, IL, (3)Ochsner Medical Center, New Orleans, LA, (4)CES University School of Medicine, Medellin, Colombia
Goals/Purpose: The use of myocutaneous or fasciocutaneous pedicled flaps in surgical reconstruction is a valuable tool for the correction of large and complex defects. Smoking is the greatest risk factor for the development of facial, head, and neck cancers, which represents a large proportion of patients undergoing facial, head, and neck flap procedures.1 Smoking induces poor tissue oxygenation, weakens immune function, impairs wound healing, and patients who smoke are considered to be worse surgical candidates than nonsmokers.2 In prior analyses, perioperative smoking was not associated with a significant increase in risk for wound complication following free flap reconstruction, although no large population data yet exists on pedicled flap reconstruction of the face, head, and neck.3 When treating patients who are smokers, we are faced with the dilemma of providing coverage vs an aesthetic reconstruction. Flaps provide a more robust and aesthetically pleasing reconstruction, yet complications in wound healing pertaining to areas such as the face and neck, could result in cosmetically unfavorable outcomes. In our study we aim to examine smoking as a preoperative risk factor for wound complications following pedicled face flaps.

Methods/Technique: A retrospective cohort study was conducted utilizing data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), collected from 2005 to 2017. A search for current procedural terminology (CPT) code 15732 identified face flap cases. Patients with other surgical procedures performed in the prior 30 days, preoperative wound infection, sepsis, or missing information for age, sex, wound classification, or American Society of Anesthesiology (ASA) physical status classification were excluded. Multivariate logistic regression models were fitted to evaluate the association between smoking and development of wound complications as seen in table 1.

Results/Complications: A total of 927 pedicled face flaps (CPT 15732) cases were analyzed and separated into two cohorts based on current smoking status: 743 (80.2%) non-smokers vs. 184 (19.8%) smokers. There was no statistical difference in the patients’ gender (p=0.9337), race (p=0.3520), or rate of diabetes (p=0.2193). Patients in the non-smoker cohort were significantly older in years (62.6, SD 17.5) vs. (53.9, SD 13.6), (p<0.0001), and had a significantly higher mean BMI (28.4, SD 7.6) vs. (27.05, SD 7.2), (p=0.0242) compared to smokers. Cases performed by plastic surgeons had significantly higher rates of non-smoker vs smoker patients (p=0.0171). There were no significant differences among the rates of wound complication development for smokers vs. non-smokers as follows: superficial incisional surgical site infection (1.9% vs 4.3%; p=0.059) and wound dehiscence (0.5% vs. 0.5%; p=1). Multivariate logistic regression models resulted in no significant differences in wound complication development for smoker vs non-smokers (adjusted OR, 1.059 (95% CI: 0.483–2.322); p=0.8857), (Table 1).

Smoking is a well-recognized risk factor for delayed wound healing. It causes vasoconstriction, tissue hypoxia, and inhibits enzymatic systems involved in wound repair.4 Previous retrospective studies in flap surgery have mixed results in identifying an increase in risk of wound complications associated with preoperative cigarette smoking.3 In our study, smokers did not have significantly higher likelihood of developing postoperative wound complications compared to non-smokers 30 days after undergoing face flap procedures. Studies in plastic surgery have been performed to identify associations between preoperative smoking cessation and risk reduction in flap procedures, although no proven study yet exists outside of retrospective reviews.5,6 For selected facial defects face flaps have the advantage of providing a more aesthetically appealing outcome when compared to more conservative approaches such as primary repair, delayed closure, skin grafts and local tissue rearrangements. This study supports the use of face flaps even in patients who are smokers.

Limitations, The ACS NSQIP database contains only 30-day postoperative data and lacks nicotine biomarkers; Failing to capture long term outcomes and potentially underestimating smoker or smoking cessation rates in this period.

Conclusion: Our study showed smokers did not have significantly worse outcomes compared to nonsmokers who had pedicle face flaps. Although smoking cessation is recommended given multiple health benefits, our study does not support excluding patients who smoke from receiving face flaps based on the risk of wound complications.

References

1. Hashibe, M., Brennan, P., Chuang, S. et al. (2009). Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer epidemiology, biomarkers & prevention,18(2),541–550.
2. Kaufman, T., Eichenlaub, E.H., Levin, et al. (1984). Tobacco smoking: impairment of experimental flap survival. Annals of plastic surgery,13(6),468–472.
3. Crippen MM, Patel N, Filimonov A, et al. Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery. JAMA Facial PlastSurg. 2019;21(1):20-26.
4. Silverstein P. (1992). Smoking and wound healing. The American journal of medicine, 93(1A),22S–24S.
5. Kaufman, T., Eichenlaub, E.H., Levin, et al. (1984). Tobacco smoking: impairment of experimental flap survival. Annals of plastic surgery,13(6),468–472.
6. Hwang, K., Son, J.S., Ryu, W.K. (2018). Smoking and Flap Survival. Plastic surgery, 26(4),280–285.
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