Risks of free flap reconstruction amongst smoking patients: a NSQIP analysis of 4653 patients from 2010 to 2021.

BACKGROUND

Microvascular free flap reconstruction for complex soft tissue defects relies on vascular perfusion for overall flap survival. Smoking has been linked to complications in postoperative wound healing due to vasoconstriction and weakened immune status. We aim to investigate the impact of smoking on postoperative complications in patients undergoing free flap reconstructive surgery.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, adult patients (≥18 years old) undergoing microvascular free flap surgery (Current Procedural Terminology: 15 756-15 758) from 2010 to 2021 were included. Patients were excluded if they were <18 years old or if they lacked postoperative follow-up data or documented smoking status. Smokers were compared to non-smokers across demographics and postoperative complications.

RESULTS

Among 4653 free flap patients, 1202 (25.8%) were smokers. Smokers were more likely to be male, younger, non-diabetic, and have lower body mass index. After multivariable adjustment, smoking status was associated with higher odds of organ/space SSI (OR = 1.653, 95% CI: 1.068-2.558, P = 0.024) and wound disruption (OR = 1.597, 95% CI: 1.092-2.336, P = 0.016). There were no significant differences in rates of superficial or deep incisional SSIs, graft/flap failure, sepsis/septic shock, or venous thromboembolism.

CONCLUSION

Smoking was associated with increased rates of organ/space surgical site infections and wound dehiscence, but not with flap failure in patients undergoing microvascular free flap reconstruction. These findings support the role of preoperative smoking cessation counseling and more nuanced risk stratification focused on wound-related complications rather than flap survival.