Postoperative Morbidity of Facial Fracture Repair: A National Big-Data Analysis of 4805 Cases Across 16 Years

BACKGROUND: National data on short-term morbidity after facial fracture repair remain limited, and the trajectory of postoperative risk amid increasing case complexity is unclear. METHODS: Using ACS-NSQIP (2007-2022), we identified 4805 adults undergoing operative repair of mandibular, zygomaticomaxillary complex (ZMC), orbital, LeFort, or multiple fractures performed by plastic or otolaryngologic surgeons. Thirty-day outcomes included superficial, deep, and organ-space surgical site infections, wound dehiscence, and unplanned return to the operating room. Multivariable logistic regression identified independent predictors and assessed temporal trends. RESULTS: The primary 30-day surgical morbidity rate was 6.7%. Complications were most frequent following mandibular fractures and least frequent after ZMC and orbital repairs (P<0.001). Independent predictors of morbidity included smoking [adjusted odds ratio (aOR): 1.43; 95% CI: 1.09-1.89], higher ASA class (ASA II: 1.94; ASA III: 2.78; ASA IV: 3.67; all P<0.05), longer operative time (per hour: aOR: 1.20; 95% CI: 1.17-1.24), and increasing wound contamination. Within NSQIP-captured cases, plastic surgery was associated with lower odds of complications compared with otolaryngology (aOR: 0.74; 95% CI: 0.55-0.98; P=0.034). Despite increasing patient acuity and operative complexity, risk-adjusted morbidity remained stable at ∼6% to 7% annually without a significant temporal trend. CONCLUSIONS: Stable complication rates despite rising complexity likely reflect advances in perioperative care and surgical management. These findings establish contemporary benchmarks and support risk-adjusted strategies targeting modifiable risk factors to sustain outcomes as clinical complexity increases.