Skin cancer surgery on referral

Smoking and skin surgery

Do smokers get more complications following skin surgery?



Prospective study of skin surgery in smokers versus non smokers


Dixon AJ, Dixon MP, Dixon JB, Del Mar CB.


Smoking may increase complications following minor surgery leading many clinicians to urge patients to refrain from smoking before and after surgery.


To study the association between smoking and complications following skin surgery.


In a 5 year prospective observational study 7224 lesions were excised on 4197 patients. Patients were not instructed regarding smoking. All complications were recorded.


439 smokers (10.5%) underwent 646 procedures (9%) 3758 non smokers (89.5%) underwent 6578 procedures (91%). Smokers were younger (55 years old ± 16) than non smokers (66 ± 17) p<0.001.

Infection incidence was not significantly different, 1.9% (12/646) in smokers compared with 2.2% (146/6578) in non smokers (p=0.55). There were 2 bleeds with smokers (0.3%) versus 50 in non smokers (0.8%) (p= 0.2)

The incidence of wound dehiscence in non smokers (3) was not different to non smokers (21), (p=0.54) However the incidence of scar contour distortion in smokers (3) was greater than non smokers (2), OR 15.3 (95%CI 2.5 – 92)

Total complication incidence was similar, 3.6% in smokers versus 4.0% in non smokers (p=0.58).

2371 flaps resulted in 14 (0.6%) cases of end flap necrosis but smokers were not at increased risk.

The case - control analysis compared each smoker with two non smokers matched for age, sex, postal code and outdoor occupational exposure. This again demonstrated no difference in infection, scar complication, bleed, dehiscence, end flap necrosis or total complication incidence.


The study involved only one surgeon in a Southern Australian locale. Only 10.5 % of patients were smokers. These data may not generalize to other settings.


Smokers and non smokers suffer skin surgery complications similarly. The increased risk of contour distortion identified was difficult to interpret. Advice to cease smoking in the short term to improve outcomes with skin cancer surgery is not supported by these data.



Smoking has been regarded as a risk factor for poor outcomes following skin surgery. Studies have suggested that skin wound healing and flap necrosis is worse in smokers than non smokers1-3. Ex-smokers are said to have no greater complications than smokers4.


Silverstein5 has explained that smokers have reduced skin blood flow because nicotine is a vasoconstrictor. Nicotine causes platelet aggregation and hence the risk of micro thromboses. Carbon monoxide reduces oxygen transfer and other contaminants of smoking effect the oxygen transport at the cellular level. Skin collagen production is reduced in smokers6. Silverstein has therefore recommended that smokers be advised to cease smoking before and after elective surgery, especially skin surgery5. As such, our greatest concern relates to smokers who continue to smoke immediately before and after their elective skin surgery.



We sought to evaluate whether active smokers suffer more complications following skin surgery compared with non smokers and ex smokers. These complications include: infection, flap necrosis, scar complications and wound dehiscence.



This prospective observational study involved patients and their lesions excised from July 2002 to July 2007 at a referral based centre in Geelong, Australia. Patients were asked on enrolment whether they were smokers, non smokers or ex-smokers.


Lesions managed by curettage, cryotherapy and / or topical applications were excluded. One surgeon (AD) performed all procedures in one of two operating rooms at either Skincanceronly Centre or Geelong Private Hospital.


Patients were not asked to cease smoking for their surgery or following surgery. A separate undercover area for smoking was made available outside the reception area. Post operative instructions did not include advice about smoking.


Details of all excised lesions were recorded. All wounds were closed with nylon or polyamide interrupted skin sutures. Patients were followed up at least until removal of sutures. All complications were recorded for all procedures. The criteria and definitions of complications used in this study and further details of methodology and follow up have been previously described by us in earlier published studies on infection7 and bleeding8 outcomes following skin surgery.



Demographic details were presented as percentage or mean ± standard deviation (SD) as appropriate. Chi-square method (Fisher exact) was used to test the significance of differences between proportions and categorical variables. In addition this method was also used to assess univariate risk of smoking and these were presented as odds ratios with 95% confidence intervals. Multivariate analysis was tested using binary logistic regression (forward and backward) and odds ratio beta-coefficients with 95% confidence intervals are shown. This factored the possible confounders of age, gender, body site location, procedure type, socio-economic background and Diabetes. The SPSS 14.0.2 statistical software was used for all statistical analysis. A further case control analysis was undertaken where each procedure on a smoker was compared with two procedures on non smoking cohorts matched for age, sex, postal code and outdoor occupational exposure. Postal code and indoor versus outdoor occupation were considered indicators of socioeconomic type. A p-value of less than 0.05 was considered statistically significant.




A total of 7,224 skin lesions from 4,197 patients were treated by excision in the five year study period.  The average age of patients was 64.5 years ± 17 (median = 67 years). 3,235 procedures were on females (45%).


10.5% of patients (439) were active smokers and they underwent 646 procedures. Smokers were younger (55 ± 16) than non smokers (66 ± 17) p<0.001. The median age of smokers was 54 and of non smokers was 68.

39% of smokers were female and they had 249/646 (38.5%) of all the procedures on smokers. Smokers were more likely to be male than non smokers (p=0.007).


The 7,224 lesions excised included 1,857 SCCs (25.7%), 1,833 BCCs (25.4%), 952 actinic keratoses (13.2%), 394 melanoma and other malignancies (5.5%) and 136 dysplastic melanocytic naevi (1.9%). 32.8% of defects were closed with a skin flap repair (2,371/ 7,224). 140 skin grafts were performed, (1.9%)



286 complications (3.96%) were experienced following the 7,224 excisions including; 158 infections (2.2%), 52 post operative bleeds (0.7%) and 24 wound dehiscences (0.35%).

There were 19 cases (0.26%) of skin necrosis at the wound edge. 14 cases of skin necrosis were end flap necrosis on 2,371 random pattern skin flaps (0.6%) and 5 cases were on wounds closed directly.  


33 other complications occurred (0.46%) including dressing allergy (7), persistent wound elevation or depression (5), hypertrophy / keloid (4), contact dermatitis, persistent pain, proud flesh and subcutaneous fibrosis.


Smokers suffered 23 complications (3.6%), comparable with the incidence (263 / 6,578 = 4.0%) in non smokers, (p=0.58).


Specifically, smokers suffered 12 infections (1.9%) and 2 bleeds (0.3%). In each case this was not significantly different to the incidence in non smokers, 2.2% (p=0.55), 0.8% (p=0.2).

Smokers had a similar incidence of scar complications 1.2% (8 / 646) compared with non smokers 0.6% (39 / 6578) (p=0.05). These complications included wound dehiscence (3), end flap necrosis (2), wound depression (2) and elevation (1).


Matched non patients:

Table 1 demonstrates there was no difference in complications between non smokers matched 2:1 with smokers.


Multivariate analysis:

Smoking was not a risk factor for infection, bleeding, end flap necrosis, wound dehiscence or scar hypertrophy / keloid. We also tested for skin edge necrosis with or without dehiscence and found smoking was not predictive. (not shown)


Of 5 cases of contour distortion, 3 occurred in smokers. OR 15.3 (95%CI 2.5 – 92). 1:200 smokers and <1:3000 non-smokers. All 5 were in women. Controlling for gender did not influence the relationship with smoking.



Smokers face greater complications following breast reconstruction surgery than non smokers9, 10. Elsewhere major reconstructions and myocutaneous flap repairs have also been shown to fare worse in smokers11-14.


This is the largest prospective study to date of the complications faced by smokers versus non smokers undergoing skin surgery. The data shows surprisingly little difference in outcomes. Indeed the only difference that could be identified by multivariate analysis was contour distortion. Smoking was predictive of wound depression or elevation following skin surgery. Skin tends to correct for distortions over the months following surgery and the poorer skin perfusion and oxygen transfer problems expected in smokers15 may impede this correction. Yet this problem of contour distortion of the scar was seen in only 0.5% of smokers. The validity of this finding is not known given there were very small numbers of this subjective complication.



These data relate to a single surgeon in a temperate climate in Southern Australia. Only 10.5% of our patients declared themselves as smokers. The true percentage of smokers may be underreported though fewer Australians smoke than many other Western countries. The data pertaining to this locale and surgeon may not generalize to other skin surgical circumstances. Data on numbers of cigarettes smoked was not obtained.



Smokers and non smokers suffer skin surgery complications similarly. The increased risk of contour distortion identified in smokers was difficult to interpret. Advice to cease smoking in the short term to improve outcomes with skin cancer surgery is not supported by these data. The authors are all non smokers and actively encourage our smoking patients not to smoke for other health reasons.



Table 1: Comparison of complications in smokers compared 1:2 with non smoking cohorts matched for age, sex, postal code and outdoor occupation.


All smokers

1:2 Matched non smokers

p value

chi square

All non smokers

All patients

Number of patients






Average age

55 ± 16

55 ± 16


66 ± 17

64.5 ± 17

Female patients










Post operative infection





p = 0.73





Post operative bleeding





p = 0.37





Wound Dehiscence





p = 0.54





Wound edge (inc. flap) necrosis





p = 0.75





Dressing allergy






Wound depression / elevation






Hypertrophy and keloid






Other local complications #






Total complications





p = 0.43





# Other local complications include contact dermatitis, persistent pain, proud flesh, granuloma, subcutaneous fibrosis.

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2.         Siana JE, Rex S, Gottrup F. The effect of cigarette smoking on wound healing. Scand J Plast Reconstr Surg Hand Surg 1989;23:207-9.

3.         Goldminz D, Bennett RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol 1991;127:1012-5.

4.         Kinsella JB, Rassekh CH, Wassmuth ZD, Hokanson JA, Calhoun KH. Smoking increases facial skin flap complications. Ann Otol Rhinol Laryngol 1999;108:139-42.

5.         Silverstein P. Smoking and wound healing. Am J Med 1992;93:22S-24S.

6.         Knuutinen A, Kokkonen N, Risteli J, Vahakangas K, Kallioinen M, Salo T, Sorsa T, Oikarinen A. Smoking affects collagen synthesis and extracellular matrix turnover in human skin. Br J Dermatol 2002;146:588-94.

7.         Dixon AJ, Dixon MP, Dixon JB. Randomized clinical trial of the effect of applying ointment to surgical wounds before occlusive dressing. Br J Surg 2006;93:937-43.

8.         Dixon AJ, Dixon MP, Dixon JB. Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy. Br J Surg 2007;94:1356-60.

9.         Pinsolle V, Grinfeder C, Mathoulin-Pelissier S, Faucher A. Complications analysis of 266 immediate breast reconstructions. J Plast Reconstr Aesthet Surg 2006;59:1017-24.

10.       Sorensen LT, Horby J, Friis E, Pilsgaard B, Jorgensen T. Smoking as a risk factor for wound healing and infection in breast cancer surgery. Eur J Surg Oncol 2002;28:815-20.

11.       Lovich SF, Arnold PG. The effect of smoking on muscle transposition. Plast Reconstr Surg 1994;93:825-8.

12.       Kroll SS, Goepfert H, Jones M, Guillamondegui O, Schusterman M. Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 1990;25:93-7.

13.       Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr Surg 2003;111:2082-7; discussion 2088-9.

14.       Woerdeman LA, Hage JJ, Hofland MM, Rutgers EJ. A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria. Plast Reconstr Surg 2007;119:455-63.

15.       Black CE, Huang N, Neligan PC, Levine RH, Lipa JE, Lintlop S, Forrest CR, Pang CY. Effect of nicotine on vasoconstrictor and vasodilator responses in human skin vasculature. Am J Physiol Regul Integr Comp Physiol 2001;281:R1097-104.