Nicotine abuse and 30-day perioperative outcomes after fibula free flap reconstruction: An ACS-NSQIP study

Fibula free flap (FFF) reconstruction is a cornerstone of maxillofacial and mandibular reconstruction, particularly for oncologic and traumatic defects. Although smoking is a well-established risk factor for impaired wound healing and microvascular complications, its specific impact on FFF outcomes remains debated. In this multicenter retrospective study, we evaluate the association between smoking and 30-day perioperative outcomes in FFF reconstruction.

A retrospective cohort study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP; 2009-2023). Patients undergoing FFF reconstruction were categorized as smokers or non-smokers. Demographic and perioperative variables were analyzed using chi-squared tests, t-tests, and multivariable logistic regression to assess associations between smoking and surgical complications, overall morbidity, and reoperation or readmission rates.

Among 373 patients, 230 (62%) were male and 143 (38%) were female, with 104 (28%) classified as currently smoking. Male patients comprised a greater proportion of the smoking population than female patients (70% and n = 73 vs. 30% and n = 31, p = 0.04). Patients who smoked were significantly younger (54 ± 14 vs. 58 ± 17 years, p = 0.03) and had lower BMI (26 ± 6.4 vs. 28 ± 6.5 kg/m², p = 0.01) than non-smokers. Operative time (606 ± 215 min), hospital length of stay (11 ± 6.8 days), and overall complication rates (64%vs. 60%, p = 0.42) did not significantly differ between groups. Systemic vascular events such as stroke, myocardial infarction, pulmonary embolism, and deep vein thrombosis were rare and occurred at similar rates in smokers and non-smokers. However, patients who smoked exhibited higher rates of surgical complications (37%vs. 23%, p = 0.01), particularly with increased rates of superficial incisional infections (17%vs. 9.7%, p = 0.04) and dehiscence (13%vs. 5.2%, p = 0.01). Multivariate analysis confirmed smoking as an independent predictor of surgical complications (OR 2.3, 95% CI 1.3-4.0, p = 0.01), but not of overall complications (OR 1.4, 95% CI 0.78-2.4, p = 0.28), medical complications (OR 0.87, 95% CI 0.51-1.5, p = 0.61), reoperation (OR 0.93, 95% CI 0.48-1.8, p = 0.83), or readmission (OR 1.3, 95% CI 0.61-2.8, p = 0.50).

A correlation between smoking and risk of surgical complications in FFF reconstruction is identified, although overall complications are seen to not differ. These findings highlight the importance of preoperative smoking cessation counseling and risk stratification to optimize surgical outcomes.