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

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. OBJECTIVETo 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 MEASURESPostoperative 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. RESULTSOf 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,, larger defect size (OR, 2.25; 95% CI,, 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,), 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, 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.

A Nationwide Analysis of Early and Late Readmissions following Free Tissue Transfer for Breast Reconstruction

“…In 2019, Wang et al studied the outcomes of flaps and grafts in Mohs reconstruction with respect to smoking and revealed that both active smoking and former smokers were at increased risk for complications. 28 In our analysis, we did not make a distinction between active and former smokers. Stemming from the aforementioned findings, this separation may help future research in determining if such a correlation exists.…”

Complications of cutaneous surgery

“…Necrosis is more commonly encountered following flap reconstruction given that vascularity of the flap is limited to the pedicle 48 . The literature suggests that higher rates of complications occur with flap and graft repairs; large flaps, interpolation flaps, or flap‐graft combinations are more commonly associated with necrosis and other complications 15,49,50 . Causes of complete or partial graft necrosis include hematoma, graft‐bed contact disruption, infection, smoking, and excessive electrocoagulation of the wound base 51 …”

“…In a retrospective analysis of 916 flaps and full‐thickness grafts, heavy smokers (>1 pack/d) developed necrosis three times more frequently than never smokers, low‐level smokers (<1 pack/d), or former smokers 52 . A more recent study also demonstrated that current and former smokers undergoing graft and flap repair following MMS are more likely to experience acute postoperative complications including necrosis 50 . Encouraging patients to stop smoking before surgery and in the postoperative period will likely reduce the risk of acute complications and allow for enhanced wound healing.…”

“…Encouraging patients to stop smoking before surgery and in the postoperative period will likely reduce the risk of acute complications and allow for enhanced wound healing. High dose vitamin C intake for current smokers has also been proposed as a solution to help combat the smoking‐induced oxidative stress on endothelial function and the impaired immune response 50 …”

Management of Complications from Skin Cancer Reconstruction

“…3 There are various risk factors that predispose patients to complications that should be screened for and managed to the best extent possible in every patient, including smoking, immunosuppression, hypertension, diabetes, blood dyscrasias, inflammatory skin disorders, prior radiation therapy, and history of hypertrophic and/or keloid scarring. [4][5][6][7] Here, we assume that the surgeon is aware of and has taken prophylactic measures to mitigate such risk factors preoperatively. The purpose of this narrative review is to provide a range of postoperative management options, and review the evidence for each modality, so that reconstructive surgeons can stay up to date on current literature, as well as understand gaps in the literature for future research.…”