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Original Investigation
Jan/Feb 2019

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
  • 2Department of Surgery, Rutgers New Jersey Medical School, Newark
  • 3Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
JAMA Facial Plast Surg. 2019;21(1):20-26. doi:10.1001/jamafacial.2018.1176
Key Points

Question  Does smoking increase the risk of complications associated with head and neck microvascular reconstructive surgery?

Findings  This population database study of 2193 patients found that perioperative smoking was associated with increased rates of wound breakdown and reoperation within 30 days. The degree of risk did not correlate with number of pack-years smoked.

Meaning  Smoking cessation prior to head and neck free flap surgery may decrease postoperative morbidity.


Importance  Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck.

Objective  To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck.

Design, Setting, and Participants  In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018.

Main Outcomes and Measures  Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked.

Results  Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications.

Conclusions and Relevance  Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit.

Level of Evidence  NA.