Cannabis Use Disorder Linked to More Pain and Wound Problems After Body-Contouring Surgery

As cannabis legalization sweeps across the United States and Europe, surgeons are confronting an uncomfortable question: what does routine marijuana use do to a healing surgical wound? A new multicenter study published in BMC Plastic and Reconstructive Surgery offers one of the most detailed answers to date, finding that patients with a documented diagnosis of cannabis use disorder who underwent panniculectomy—a procedure that removes excess abdominal skin and fat, typically after massive weight loss—experienced significantly more postoperative pain and skin-related complications than carefully matched controls.

The research team, led by Jonathan Mokhtar of Mohammed Bin Rashid University of Medicine and Health Sciences and colleagues at institutions including Case Western Reserve University and the Cleveland Clinic, mined the TriNetX Research Network, a federated database of de-identified electronic health records drawn from more than 100 healthcare organizations. From an initial pool of 31,288 adults who underwent infraumbilical panniculectomy between January 2010 and April 2025, the investigators identified 801 patients with an ICD-10 diagnosis of cannabis use disorder recorded within six months before surgery. After 1:1 propensity score matching on age, sex, race or ethnicity, body mass index, and comorbidities including diabetes, hypertension, chronic obstructive pulmonary disease, nicotine dependence, and alcohol use, 798 matched pairs remained for analysis.

Propensity matching is the statistical workhorse that gives observational studies like this one their credibility. Because patients are not randomized to cannabis use, the researchers had to construct comparison groups that were as similar as possible in every measurable respect except the exposure of interest. They used greedy nearest-neighbor matching with a caliper of 0.2 standard deviations of the logit of the propensity score, and after matching, all covariates showed standardized differences below the conventional 0.1 threshold, indicating well-balanced cohorts. The matched population had a mean age of 43.2 years, was 80.3 percent female, and had a mean body mass index of 32.1, with comorbid conditions such as diabetes and nicotine dependence distributed almost identically between the two groups.

The headline result concerns pain. Patients with cannabis use disorder experienced clinically significant postprocedural pain at a rate of 14.0 percent, compared with 7.8 percent among controls—a risk ratio of 1.82, meaning an 82 percent relative increase in risk. Expressed another way, the absolute risk difference was 6.27 percentage points, yielding a number needed to harm of 16: for every 16 patients with cannabis use disorder undergoing the procedure, one additional case of significant postoperative pain could be expected. The authors defined postprocedural pain using diagnostic codes indicating pain severe enough to require documentation or intervention, not the routine discomfort expected after major abdominal surgery.

Wound-related outcomes told a similar story. Postprocedural skin complications, which included infections of the skin and subcutaneous tissue as well as conditions such as panniculitis and disorders of skin appendages, occurred in 10.0 percent of the cannabis use disorder cohort versus 6.8 percent of controls, corresponding to a risk ratio of 1.48. Secondary outcomes—hospital readmission, sepsis or gangrene, hematoma or seroma, venous thromboembolism, and pulmonary embolism—showed numerically higher rates in the cannabis group but did not reach statistical significance. A Kaplan-Meier time-to-event analysis found complication-free survival of 85.1 percent at 90 days in the cannabis group versus 87.6 percent in controls, a difference that did not achieve significance on log-rank testing.

Why might cannabis impair surgical recovery? The answer lies in the endocannabinoid system. Delta-9-tetrahydrocannabinol and cannabidiol act on CB1 and CB2 receptors to modulate immune responses, nociception, angiogenesis, inflammation, vascular tone, and hemostasis—all core elements of postoperative healing. Preclinical work summarized by the authors indicates that cannabinoids can impair platelet aggregation, delay fibroblast proliferation, disrupt angiogenesis, inhibit neutrophil chemotaxis, impair collagen synthesis, and interfere with re-epithelialization. In vitro studies have demonstrated anticoagulant effects, with THC suppressing thrombin-induced clot formation at measurable concentrations. Notably, these effects appear dose- and context-dependent: low-dose or topical cannabidiol may even have pro-reparative properties, while systemic or high-dose THC is consistently associated with delayed tissue regeneration.

The pain finding is particularly intriguing because it runs counter to cannabis’s popular reputation as an analgesic. Chronic cannabis users may develop altered nociceptive thresholds and cross-tolerance with opioids, potentially requiring modified pain regimens after surgery. Prior large database studies support this concern: cannabis users have been shown to report higher postoperative pain scores, greater opioid consumption, and increased postoperative nausea and vomiting. The new study also performed a stratified analysis by nicotine dependence, finding that the association between cannabis use disorder and postoperative pain persisted in both nicotine-dependent patients, where the risk ratio was 1.96, and non-nicotine-dependent patients, where it was 1.73. This consistency across subgroups suggests cannabis is an independent risk factor rather than a proxy for smoking-related harm, though the authors caution that overlapping pathophysiology between inhaled cannabis and nicotine makes fully disentangling their contributions difficult.

The study arrives at a moment of rapidly shifting context. As of June 2025, medical marijuana is legal in 40 U.S. states and recreational cannabis in 24, and more than half of Americans report having used marijuana at least once. Among adults aged 18 to 35—the demographic most likely to seek body-contouring procedures—past-year use approaches 30 percent. Meanwhile, product potency has climbed dramatically: the average THC content of cannabis in the European Union reached 24.8 percent in 2022, more than double that of traditional herbal cannabis, and higher potency is linked to greater dependence risk. Synthetic cannabinoids add a further, largely unquantified layer of perioperative risk, given their high-affinity binding to cannabinoid receptors and their association with cardiovascular and neurological toxicity.

The authors are candid about limitations. Reliance on ICD-10 coding captures only diagnosed cannabis use disorder—just 2.6 percent of the initial cohort, well below the general population prevalence—meaning the findings apply to patients with clinically recognized, likely more severe patterns of use and cannot be generalized to occasional or recreational users. The database provides no information on dose, frequency, route of administration, or formulation, and retrospective coding in a stigmatized area invites both under-reporting and misclassification. Panniculectomy, with its large soft-tissue envelope, high wound tension, and elevated baseline complication rate, is a sensitive model for detecting risk factors, but results may not translate to procedures with lower tissue demands.

Nevertheless, the clinical implications are actionable. The American Society of Regional Anesthesia and Pain Medicine has already issued consensus guidelines recommending routine preoperative cannabis screening, documentation of route and frequency, patient counseling, and consideration of abstinence for at least two weeks before elective procedures, particularly when cannabis is inhaled. Building on their findings, the study team proposes a five-step perioperative checklist: screen all patients and characterize route of administration; document frequency, dose, duration, and concurrent nicotine use; counsel on wound-healing and infection risks; recommend cessation two to four weeks before elective body contouring; and tailor analgesic plans to account for altered pain processing in chronic users. As cannabis use continues to normalize, the authors argue, incorporating such screening into preoperative risk assessment is no longer optional—it is an essential safeguard for procedures that place extraordinary demands on the body’s capacity to heal.

Subject of Research: The association between cannabis use disorder and postoperative complications after panniculectomy.

Article Title: Association of cannabis use disorder with postoperative complications following panniculectomy: a multicenter propensity-matched analysis

Article References: Mokhtar, J., Ha, J. Y., Almeida, V. F. A., Lellouch, A. G., Vyas, K. S., Doh, S. J., & Duraes, E. F. R. (2026). Association of cannabis use disorder with postoperative complications following panniculectomy: a multicenter propensity-matched analysis. BMC Plastic and Reconstructive Surgery, 2(1), Article 1. https://doi.org/10.1186/s44452-026-00013-z

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00013-z

Keywords: cannabis use disorder, panniculectomy, postoperative complications, wound healing, propensity score matching, body contouring, cannabinoids, perioperative risk, plastic surgery, pain management, TriNetX, nicotine co-use