Smoking and plastic surgery, part II. Clinical implications: a systematic review with meta-analysis

Objectives: Tobacco addiction is a risk factor for complication in plastic surgery. The authors have assembled concrete arguments detailing the risks of perioperative and postoperative complication that are incurred by a patient with continued tobacco intoxication who wishes to undergo a surgical intervention.

Research strategy: Through application of the PRISMA criteria, we have carried out a systematic review of the literature, in which we explored five databases while using predefined keywords. We selected randomized, controlled observational studies on the perioperative and postoperative complications related to tobacco use in actively smoking, abstinent and non-smoking patients.

Data collection and analysis: The levels of evidence for each article were evaluated. Risk of bias was assessed using the Newcastle-Ottawa Scale. Incidence parameters including the Odds Ratio and relative risk were calculated for each complication of which the number of occurrences had been indicated. Meta-analysis of the results was carried out.

Results: We included 60 observational studies. In the cosmetic surgery group, we calculated a combined Odds Ratio of 2.3 [1.51-3.54] P<0.001 for surgical site infections and 2.5 [1.49-4.08] P<0.001 for delayed wound healing. In the bariatric surgery sequelae group, we found a combined Odds Ratio of 3.3 [1.90-5.64] P<0.001 with regard to delayed wound healing and 3.1 [1.39-7.13] P=0.006 for cutaneous necrosis. No proof was provided as to the possible influence of tobacco on the success rate of free flap microsurgery, but it is difficult to extrapolate results on the latter to digital reimplantation.

Conclusions: The review underlines the fact that patients with smoking habits run a significantly heightened risk of cutaneous necrosis, particularly in the event of major detachment (cervico-facial lift, skin-sparing mastectomy, abdominoplasty), of additionally delayed wound healing and of addition surgical site infections. Rigorous preoperative evaluation of smokers could help to diminish these risks.