The Association Between Smoking and Plastic Surgery Outcomes in 40,465 Patients: An Analysis of the ACS-NSQIP Datasets

Purpose: In plastic surgery, studies in smokers showing impaired post-operative wound healing and increased infection rates focus predominantly on breast procedures.^1-4 However, smoking may affect post-surgical outcomes differently depending on anatomic location and tissue type. Using the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) datasets, this study examined associations between smoking and post-operative complications after a wide range of plastic surgery procedures.

Materials and Methods: ACS-NSQIP datasets were reviewed for all plastic surgery procedures performed between 2007 and 2012. Complications were categorized into four major dependent variables: major surgical or major medical complications, wound complications, and wound infections. Smoking status was the independent variable. Results were adjusted for sex, race, age, year, and CPT code and analyzed using chi-squared tests and multivariable logistic regression models. Confidence intervals (CI) of 95% and p<0.05 denoted significance.

Results: 40,465 plastic surgery procedures were analyzed. 15.7% of patients were smokers. Common breast procedures included implant-based (IBBR, 18%) and autologous (ABR, 7%) breast reconstruction, and reduction mammoplasty (17%). Abdominal (8%), hand/upper extremity (H/UE, 11%), lower extremity (LE, 2%) and craniofacial (CF, 5%) procedures were also common. 84.6% of surgeries were classified as clean. 9.2% of cases had documented peri-operative infections.

8.34% of patients experienced post-operative complications. Smoking increased the likelihood of major surgical (OR 1.37^††), major medical (OR 1.24^*), and overall wound complications (OR 1.49^††), and superficial wound infections (OR 1.40^††). Surgical complications (4.98%) occurred with higher odds after IBBR (OR 1.36^*), H/UE (OR 2.21^†), LE (OR 2.14^†), and CF (OR 2.39^†) procedures. Medical complications (1.81%) were more likely in LE (OR 2.84^†) procedures. Wound complications (3.98%) were more likely in H/UE (OR 2.79^†), LE (OR 2.69^†), and CF (OR 2.56^**) procedures. Specifically, wound dehiscence (OR 1.84^††) was more likely in reduction mammoplasty (OR 2.16^*) and LE (OR 2.69^†) procedures. Wound infections were more likely in H/UE (OR 3.23^†), LE (OR 2.33^**), and CF (OR 2.26^*) procedures.

Conclusions: Smoking increases postoperative complications after plastic surgery procedures with variable effects depending on procedure type.  Understanding complication risks may assist plastic surgeons in counseling patients on the importance of pre-operative smoking cessation.

^*p<0.05

^**p<0.01

^†p<0.001

^††p<0.0001