Non-Tobacco Nicotine Use and Complications in Free Flap Repair in Head and Neck Cancer

Objective: Assess associations between non-tobacco nicotine usage and free flap repair complications in head and neck cancer (HNC) patients. Study Design: Propensity-matched retrospective cohort study. Methods: The TriNetX database was queried for HNC patients who underwent free flap procedures from 2010 to 2024. Among these patients, the NIC cohort was defined as those with dependence on nicotine prior to surgery, but without the use of cigarettes, chewing tobacco, or other tobacco products. The non-NIC cohort was defined as patients with no nicotine dependence, cigarettes, chewing tobacco, or other tobacco product use prior to surgery. Cohorts were propensity-matched based on demographics and comorbidities. Primary outcomes included free flap failure, blood vessel repair, and other revisionary procedures (associated with wound disruption or repair) within 30 days of the primary reconstruction. Secondary outcomes included infection, pneumonia, cardiopulmonary complications, and hematoma within 30 days. Results: Following propensity matching, 1324 patients were included in each cohort. Across all free flaps, non-tobacco nicotine use was associated with a significantly increased risk of other revision procedures (RR: 1.230 [95% CI: 1.013, 1.493], p = 0.036), sepsis (RR: 1.563 [95% CI: 1.009, 2.419], p = 0.045), fistula (RR: 1.588 [95% CI: 1.041, 2.423], p = 0.032), cardiovascular complications (RR: 1.420 [95% CI: 1.054, 1.914], p = 0.021), pneumonia (RR: 2.055 [95% CI: 1.570, 2.689], p < 0.001), and pulmonary embolism (RR: 2.220 [95% CI: 1.217, 3.933], p = 0.008). Conclusions: Non-tobacco nicotine use is associated with an increased risk of postoperative complications in HNC patients following free flap reconstruction. Screening for non-tobacco nicotine use in surgical candidates may better inform clinical management and counseling. Level of Evidence: III.