Smoking as an Independent Risk Factor for Postoperative Complications in Plastic Surgical Procedures: A Propensity Score-Matched Analysis of 36,454 Patients from the NSQIP Database from 2005 to 2014

Background: Smoking has been associated with wound healing complications and overall morbidity in multiple specialties, including plastic surgery. From 2005 to 2014, smoking prevalence among U.S. adults decreased from 20.9 percent to 16.8 percent. This study aims to investigate whether smoking prevalence among plastic surgery patients paralleled the national trend and whether smoking was an independent risk factor for postoperative complications. Methods: The 2005 to 2014 American College of Surgeons National Surgical Quality Improvement Program database was used to examine smoking prevalence and 30-day postoperative complications in 36,454 patients who underwent common plastic surgical procedures with extensive planes of dissection. Patients were propensity score-matched for demographics and comorbidities. Smokers were stratified by pack-years. Results: Compared to the national trend, a significantly smaller percentage of plastic surgical patients were smokers (p = 0.01), with a less dramatic decline in prevalence. Smokers had significantly increased deep incisional surgical-site infections, incisional dehiscence, and reoperation (p < 0.01 for all). However, superficial surgical-site infection rates were not significantly different (p = 0.18). Smokers with 11 or more pack-years had significantly increased deep surgical-site infection (p < 0.01) and reoperations (p < 0.01). There were no significant differences in graft/prosthesis/flap loss (p = 0.07), bleeding (p = 0.40), sepsis (p = 0.87), or venous thromboembolism (p = 0.16) rates between smokers and nonsmokers. Conclusions: This is the first large-scale propensity score-matched database analysis isolating smoking as a risk factor for postoperative complications in plastic surgical procedures. Smoking was an independent risk factor for deep incisional surgical-site infection, incisional dehiscence, and reoperation. Interestingly, superficial surgical-site infection rates were not significantly different. The authors recommend continued judicious patient selection and preoperative smoking counseling to optimize postoperative outcomes.