Electronic searches were conducted in PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and ScienceDirect up to November 7, 2025, using the keywords listed in Table 1. In addition, the reference lists of all included articles were manually screened to identify further potentially relevant studies. Two reviewers (GC and AA) independently screened titles and abstracts, followed by full-text assessment based on predefined eligibility criteria to determine final study inclusion. When required information was missing, study authors were contacted for clarification, and any disagreements between reviewers were resolved through discussion with a third reviewer.

Original research articles published in English that examined the association between smoking and wound healing outcomes following facial procedures were included. Eligible study designs comprised observational studies, including cross-sectional, case-control, and cohort studies. The population (P) consisted of patients of any age or sex undergoing any facial procedure resulting in a facial wound, including but not limited to surgical incisions (e.g., plastic surgery, dermatologic surgery, maxillofacial surgery), traumatic wounds (e.g., lacerations, abrasions), wounds from reconstructive procedures (e.g., skin grafts and flaps), biopsies, and excisions. The intervention/exposure (I) was active cigarette smoking or a documented history of smoking, encompassing current and former smokers, particularly where pack-years or smoking cessation periods were clearly defined. The comparison (C) included non-smokers or individuals with a documented history of smoking cessation for a specified period before the procedure. The outcomes (O) of interest included wound healing outcomes and complications following facial procedures, such as skin slough, wound dehiscence, postoperative infection, flap or graft necrosis, general complication rates in facial reconstruction, impaired healing, changes in epidermal nerve fiber density, neural antigen prevalence, or capillary robustness as indicators of healing potential, as well as donor-site complications.

Review articles, case reports, conference abstracts, and editorials were excluded. Interventional and qualitative studies were also excluded, as were studies focusing solely on non-facial anatomical sites without separable facial wound data. Studies in which smoking status was not clearly defined or quantifiable, or that did not report wound healing outcomes or complications in relation to smoking, were excluded. Studies examining other forms of tobacco use (e.g., smokeless tobacco, e-cigarettes, vaping) without separable data specific to cigarette smoking were excluded. Animal studies, in vitro studies, computational models, and studies published in languages other than English were also excluded.

Data extraction was performed independently by two reviewers (GC and AA) using a standardized, predesigned data-extraction template. Extracted study characteristics included first author, year of publication, country of origin, and study design. Participant characteristics included total sample size, age range or mean age, sex distribution, and the specific facial procedure(s) performed. Smoking parameters were extracted where available, including smoking status definitions (e.g., active, current, former), smoking duration or quantity (e.g., pack-years), and definitions of comparison groups (e.g., non-smokers, former smokers). Outcome data included the incidence or rate of skin slough, wound dehiscence, postoperative infections, flap or graft necrosis, overall complication rates (e.g., in nasal reconstruction), measures of impaired healing, quantitative data on epidermal nerve fiber density, neural antigen prevalence, capillary robustness, and incidence or rate of donor-site complications. Statistical analysis results, including reported measures of association (e.g., odds ratios [ORs], relative risks, hazard ratios, p-values, and confidence intervals [CIs]) linking smoking to outcomes, were also extracted, along with the authors’ conclusions relevant to smoking and wound healing. Synthesized results were organized and presented in tabular format to facilitate comparison and clarity (Table 2).

Risk of bias was assessed by two reviewers independently using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists for Cohort Studies [11] and Analytical Cross-sectional Studies [12]. Any discrepancies in assessments were resolved through consensus.

During the initial screening process, 129 records were identified through electronic database searches. Of these, 66 records were retrieved from PubMed, 40 from Scopus, 4 from Science-Direct, and 19 from the Cochrane Library. After duplicate removal, 102 records were screened based on titles, abstracts, and keywords. Full-text eligibility assessment was performed for 25 articles. Based on the exclusion reasons outlined in Table 3, 16 articles were excluded [13-28], and nine studies met the inclusion criteria and were included in the final review (Fig. 1) [1-7,9,10].

The characteristics of the included studies are summarized in Table 2. All nine studies were observational in design, including six retrospective cohort studies [1,3-6,9], two prospective cohort studies [2,7], and one retrospective clinical study on trauma [10]. Most studies originated from the United States (n=8), with one conducted in Finland. Sample sizes varied substantially, ranging from 8 to 1,550 patients and collectively representing more than 4,125 participants. The facial procedures evaluated included rhytidectomy [1-3,7], facial reconstructive surgery following Mohs excision [4,9], upper blepharoplasty [5], mandibular fracture repair [10], and donor-site healing in head and neck reconstruction [6].

Definitions of smoking status varied across studies, with most differentiating between current, former, and non-smokers. Two studies quantified smoking exposure using packs per day or years smoked [1,2]. Smoking cessation protocols or recommendations were reported in six studies [1-3,5,6,9]. Preoperative cessation advice ranged from 1 day to several weeks, while postoperative cessation periods of 5 days to 3 weeks were encouraged to minimize complications [1-3]. Several additional studies also reported data related to smoking cessation practices or history [4,5,9,10].

Most studies reported that active smoking was associated with significantly higher wound-complication rates, particularly skin flap necrosis and sloughing, as demonstrated in facelift cohorts [1-3]. Infection and wound dehiscence were commonly observed in reconstructive and cosmetic cohorts [4,5,9]. Delayed healing and impaired vascularity were observed in trauma and pilot studies [7,10]. However, Reece et al. [6] found no significant difference in donor-site healing (p=0.33). Among the four facelift studies, Rees et al. [1] reported that smokers had 12.46 times higher odds of skin slough than non-smokers. Riefkohl et al. [2] identified significant associations between smoking and vascular occlusion (p=0.03), as well as between severe vascular disease and skin slough (p=0.02); patients who continued smoking postoperatively experienced significantly higher rates of skin necrosis (p=0.006). Webster et al. [3] observed a markedly higher incidence of flap necrosis among smokers than among non-smokers, particularly when wide undermining techniques were used; however, no slough was observed in 407 patients treated with a conservative surgical approach. Both studies examining facial reconstructive surgery identified smoking as an independent risk factor for surgical site infection and overall complication risk. Miller et al. [9] reported an OR of 6.67 (p=0.001), while Halani et al. [4] reported an OR of 1.78 (95% CI, 1.10–2.90; p=0.02). Homer et al. [5] also demonstrated a strong association between lifetime smoking history and wound dehiscence following blepharoplasty (p<0.0001). Similarly, Snall et al. [10] reported poorer outcomes among smokers with mandibular fractures, although the association did not reach statistical significance (p=0.27). In a pilot clinical study involving eight patients, Ardeshirpour et al. [7] observed that the single smoker exhibited the lowest epidermal nerve fiber density (14.2/mm²) and reduced vascularity, suggesting compromised microcirculation. Conversely, Reece et al. [6] found no statistically significant association between smoking status and donor-site complications (p=0.33).

Despite heterogeneity in surgical techniques and study designs, active smoking was consistently associated with poorer wound healing across a range of facial procedures. Quantitatively, reported effect estimates ranged from approximately 1.8-fold increased risk (OR, 1.78) [4] to nearly 12-fold increased risk (approximately 12-fold higher risk of skin slough) [1], with an OR of 6.67 reported for postoperative infection [9]. The most frequently reported adverse outcomes were flap necrosis or slough, infection, and wound dehiscence. Earlier facelift series predominantly highlighted gross necrosis and sloughing, whereas more recent reconstructive and cosmetic cohorts focused on infection, delayed epithelialization, and impaired tissue quality. Notably, a small number of studies reported no statistically significant association in specific clinical contexts [6,10].

Nearly all included studies emphasized the importance of perioperative smoking cessation. Recommended abstinence periods ranged from 1 day to several weeks preoperatively, with postoperative cessation periods of at least 1–3 weeks advised to optimize tissue oxygenation and vascular recovery [1-3]. Patients who abstained from smoking before surgery experienced fewer complications than active smokers, supporting structured smoking cessation counselling as a key component of preoperative optimization for facial surgical patients [1,2,4,9].

Overall, the risk of bias across included studies was moderate, with more recent publications demonstrating greater methodological rigor. Most cohort studies clearly defined smoking exposure and reliably measured outcomes, whereas earlier facelift studies lacked standardized exposure definitions and did not consistently adjust for confounding variables (Table 4). Four studies—by Halani et al. [4], Miller et al. [9], Snall et al. [10], and Reece et al. [6]—were rated as low risk of bias because they incorporated multivariable analyses and complete follow-up. In contrast, older facelift studies exhibited moderate risk of bias [1-3]. The small pilot study was judged to have a high risk of bias due to its limited sample size (Table 5) [7]. Overall, the body of evidence is moderately robust and internally consistent, supporting an adverse impact of smoking on wound healing outcomes following facial procedures.

The deleterious effects of smoking on wound healing are well documented. Nicotine-induced vasoconstriction, carbon monoxide– mediated reductions in oxygen delivery, impaired neutrophil function, and reduced fibroblast proliferation collectively disrupt all phases of the wound healing process. The pilot study by Ardeshirpour et al. [7] offers mechanistic insight by demonstrating reduced epidermal nerve fiber density and diminished dermal capillary loops in a smoker, findings that support a microvascular basis for impaired cutaneous recovery. Classic facelift studies further highlight the vulnerability of facial skin flaps, particularly those with delicate perfusion, to these microcirculatory insults [1-3].

Evidence of smoking-related impairment was most pronounced in facelift studies. In 2017, Ardeshirpour et al. [7], in their pilot investigation of neural and vascular characteristics, reported that a 25-pack-year smoker exhibited the lowest epidermal nerve fiber density. The association between smoking and impaired healing in mandibular fractures was also examined by Snall et al. in 2013 [10]. Although smoking did not emerge as a statistically significant factor in that study, impaired healing was correlated with older age, a variable often associated with cumulative smoking exposure. In contrast, Reece et al. [6] evaluated donor-site outcomes following rectus abdominis flap harvest for head and neck reconstruction and concluded that smoking history did not significantly influence complication rates, suggesting that smoking alone should not preclude reconstructive surgery when clinically indicated. The association between smoking and adverse outcomes was especially pronounced in older facelift literature. Rees et al. [1], Riefkohl et al. [2], and Webster et al. [3] consistently reported disproportionately elevated rates of skin slough and flap necrosis among smokers, with Rees et al. demonstrating a nearly 12-fold increased risk of skin loss. More recent reconstructive facial surgery studies also support these findings. Miller et al. [9] identified smoking as one of the strongest independent predictors of postoperative infection (OR, 6.67), while Halani et al. [4] similarly reported increased complication rates among active smokers. Homer et al. [5] further demonstrated a strong correlation between lifetime smoking history and postoperative wound dehiscence following upper blepharoplasty. The impact of smoking was less consistent in trauma and donor-site studies. Snall et al. [10] observed poorer healing outcomes among smokers following mandibular fracture repair, although the association did not reach statistical significance, likely reflecting limited statistical power. Similarly, Reece et al. [6] found no difference in donor-site complications after rectus abdominis flap harvest (p=0.33), suggesting that the influence of smoking may vary according to procedure type and tissue characteristics. Nevertheless, even in these studies, smokers tended to experience less favorable outcomes.

The findings of this review are consistent with broader surgical literature demonstrating that smoking adversely affects skin perfusion, graft survival, epithelialization, and immune function [18,22,26]. Prior studies in periodontal and cutaneous surgery similarly report delayed healing and higher complication rates among smokers [28]. The magnitude of risk observed in older facelift cohorts, with up to an approximately 12-fold increase in necrosis, exceeds that reported in many contemporary series, potentially reflecting advances in flap design, surgical technique, and perioperative patient optimization [1-3]. The absence of statistically significant associations in some recent studies, such as donor-site healing after musculocutaneous flap harvest, may be attributable to the inherently richer vascularity of these tissues, reduced mechanical tension at closure, and improvements in perioperative care. However, most contemporary cohorts did not describe structured smoking-cessation programs, leaving the contribution of formal cessation interventions incompletely defined [6].

Among the studies included in this review, formal smoking cessation recommendations were most clearly articulated in the classic facelift literature [1-3]. These studies emphasized that abstinence from smoking, particularly during the immediate postoperative period, substantially reduces the risk of flap necrosis. For example, Riefkohl et al. [2] reported significantly higher rates of skin slough among patients who continued smoking after surgery. Although more recent reconstructive, oculoplastic, and trauma-related cohorts did not outline structured cessation protocols, the broader surgical literature strongly supports perioperative abstinence to optimize tissue oxygenation and microvascular recovery. Current best practice generally recommends that patients undergoing elective facial procedures stop smoking at least 2–4 weeks before surgery and remain abstinent for 1–3 weeks postoperatively to reduce complication risk. These recommendations underscore the importance of providing patients with clear, structured preoperative counselling and practical support for smoking cessation.

One of the principal strengths of this review is the breadth of facial procedures it encompasses, which allows for a comprehensive evaluation of how smoking influences outcomes across plastic, oculoplastic, dermatologic, maxillofacial, and reconstructive surgery. By integrating both older foundational studies and more recent evidence, the review provides a valuable longitudinal perspective on how the impact of smoking, as well as surgical approaches, has evolved over time. However, several limitations warrant consideration. Most included studies were observational in design, which limits causal inference. Definitions of smoking exposure varied widely across studies, and objective verification methods (e.g., cotinine testing) were not employed in any included investigation. Earlier facelift studies often lacked adjustment for potential confounders, whereas more recent studies utilized multivariate analyses but continued to rely primarily on self-reported smoking status. Procedural heterogeneity, variation in surgeon experience, and differences in postoperative care further complicate direct comparisons across studies. Finally, publication bias cannot be excluded, as studies reporting negative or neutral findings may be underrepresented in the published literature.

Overall, these findings underscore the importance of clear and proactive preoperative counselling regarding the adverse effects of smoking on wound healing in facial surgery. Surgeons should systematically assess each patient’s smoking history, offer practical support for smoking cessation, and consider modifying operative strategies, particularly for procedures that depend heavily on reliable flap perfusion. Although smoking should not automatically exclude patients from urgent or reconstructive procedures, as demonstrated by Reece et al. [6], patients should be clearly informed of their elevated risk of postoperative complications. Such counselling enables patients to make fully informed decisions and supports optimization of perioperative care.

Future research should prioritize the incorporation of objective measures of smoking exposure, such as cotinine or carbon monoxide testing, to enhance the accuracy of exposure assessment. The use of standardized definitions for wound healing complications and procedure-specific risk stratification frameworks would improve comparability across studies. Well-designed prospective cohort studies and randomized trials evaluating structured perioperative smoking cessation interventions are also needed to better determine their true impact on surgical outcomes. In addition, further investigation into biological markers of microvascular compromise, including the neurovascular changes described by Ardeshirpour et al. [7], may facilitate the identification of high-risk patients and contribute to more refined preoperative risk assessment.