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Original Investigation
June 13, 2019

Association of Smoking and Other Factors With the Outcome of Mohs Reconstruction Using Flaps or Grafts

Author Affiliations
  • 1Department of Dermatology, St Louis University, St Louis, Missouri
  • 2St Louis University School of Medicine, St Louis, Missouri
  • 3Department of Dermatology, University of Minnesota, Minneapolis
JAMA Facial Plast Surg. Published online June 13, 2019. doi:10.1001/jamafacial.2019.0243
Key Points

Question  Is smoking associated with an increased risk of acute and long-term postoperative complications after Mohs reconstruction with a flap or graft?

Findings  In this case-control study of 1008 patients undergoing Mohs reconstruction repaired by flap or graft, both current and former smoking were associated with an increased risk of acute complications. However, there was not a similar association between smoking status and long-term complications.

Meaning  This study suggests that smoking is an important lifestyle factor to consider for preoperative planning; these results may allow the surgeon to better quantify the magnitude of risk.

Abstract

Importance  Smoking, a common lifestyle trait, is considered by many surgeons to be a major risk factor for postoperative complications. However, in the literature on local reconstruction, the association between smoking and the rate of postoperative complications after cutaneous tissue transfer is not well characterized.

Objective  To study the outcomes of flaps and grafts used in Mohs micrographic surgery reconstruction with respect to smoking status and patient-specific and surgery-specific variables.

Design, Setting, and Participants  This retrospective case-control study was conducted at a single tertiary referral center among 1008 patients who underwent Mohs reconstruction repaired by flap or graft between July 1, 2012, and June 30, 2016, and were selected via consecutive sampling. Cases with incomplete records or those in which a single flap or graft was used to repair multiple defects were excluded. Data analysis was performed from September 2017 to January 2018.

Main Outcomes and Measures  Postoperative acute and long-term complications. Acute complications included postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention. Long-term complications included functional or cosmetic outcomes that prompted the patient to request or the surgeon to offer additional intervention.

Results  Of the 1008 patients included in the study (396 women and 612 men), the median (SD) age was 70 (12) years (range, 21-90 years). A total of 128 patients (12.7%) were current smokers, 385 (38.2%) were former smokers, and 495 (49.1%) were never smokers. On multivariate logistic regression, current smoking (odds ratio [OR], 9.58; 95% CI, 3.63-25.3), former smoking (OR, 3.64; 95% CI, 1.41-9.38), larger defect size (OR, 2.25; 95% CI, 1.58-3.20), and the use of free cartilage graft (OR, 8.19; 95% CI, 2.02-33.1) were associated with increased risks of acute complications. For long-term complications, central face location (OR, 25.4; 95% CI, 6.16-106.5), use of interpolation flap or flap-graft combination (OR, 3.49; 95% CI, 1.81-6.74), larger flap size (OR, 1.42; 95% CI, 1.09-1.87), and basal cell carcinomas or other basaloid tumors (OR, 3.43; 95% CI, 1.03-11.5) were associated with an increased risk, whereas increased age (OR, 0.66 per 10-year interval; 95% CI, 0.54-0.80) was associated with decreased risk.

Conclusions and Relevance  This study suggests that both current and former smokers are at increased risk for acute postsurgical complications but that smoking status is not associated with long-term complications. These findings may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling.

Level of Evidence  3.

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