Plastic surgery patients who smoke

I am afraid I have a prejudice that people who smoke are not very smart. (I myself smoked two packs of Camels a day for fifteen years!) But the key is not to be judgemental. True nicotine addicts cannot help it, anyway. It's only about surgical safety. So it depends on the operation.

Breast augmentation, liposuction, rhinoplasty (nose surgery), and eyelid surgery can be performed safely in smokers. I do not do face lifts, tummy tucks, breast lifts, or breast reductions in smokers except in unusual circumstances.

Of course, plastic surgeons try to help their patients quit smoking. But this is too much of a generalization. You are dealing with two distinct groups of smokers:

• People who are physically addicted to nicotine are pretty intractable. (Some experts feel that nicotine is more addictive than heroin.) Even addiction specialists have a high failure rate with this group. So they are probably going to be beyond what a well intentioned plastic surgeon can do.

• On the other hand, there are many smokers who are not physically addicted, and it is fairly easy to motivate this group to stop smoking - at least during the pre- and post-operative period. I explain that I am only concerned with their health and that I will not operate on them unless they stop smoking for at least one month.

Plastic surgeons are doctors of medicine first before they specialize in surgery. As such, the care of the whole patient is always their concern so efforts are directed at guiding their patients toward healthy lifestyle choices such as cessation of smoking, proper diet, exercise, and weight management.

Specifically, with regard to smoking, it is critical that patients be off all nicotine products for a month before and a month after certain kinds of surgeries. These are surgeries that require extensive undermining of the skin to achieve their results. The most common of these are facelifts, breast lifts and reductions, and tummy tucks. By undermining the skin to lift it, the blood supply to the skin is partially compromised but not to the point where it will die. In the smoker, however, the nicotine constricts the blood vessels and can tip the fine balance of blood flow in these procedures toward the point where the skin may die and result in terrible scars and an extremely poor result. It is the nicotine that is the culprit here so gums and patches are just the same as actually smoking.

Also second-hand smoke has been shown to potentially cause the same healing problems so avoiding other smokers is also critical.

In procedures where the risk of skin death is minimal even in a smoker, such as eyelid lifts and breast augmentations, the safe conduct of anesthesia is vastly improved by not smoking. If a doctor has instructed a patient to not smoke, they must take this seriously!

Smoking tobacco of any kind puts the plastic surgery patient at risk for severe complications.  The goal of any board certified plastic surgeon is to minimize risk to our patients, especially for elective cosmetic surgery.  Most patients understand this fact and will work with me to stop smoking, including referral to smoking cessation clinics, their primary doctor, or holistic approaches, such as acupuncture.

I have had several patients over the years come back to me, with their significant other, and thank me for helping them to stop smoking.  One husband said, "The surgery was worth it to get my wife to stop smoking alone; I have tried everything! It has been more than a year and she looks great and does not smoke anymore!"

Plastic Surgery can be a powerful thing if patients do their homework; safety comes first!

Smoking is a definite no no for surgery. I always review this with patients. Patients that smoke have a significantly higher risk of complications as compared to those that do not. 

There is no question that when I am doing a flap of skin (tummy tuck, facelift, mastopexy or reduction of the breast), I require patients to stop smoking for three weeks before the procedure. The effects of smoking are almost gone in three weeks.

Smoking introduces carbon monoxide into your system, which steals oxygen from the tissues, as well as nicotine, which crimps down on the blood vessels. There are many side effects, including longer healing time, worsened scars and more complications in patients who smoke.

There are things that you can do to mitigate the effects of smoking, such as modify your SMAS facelift to pull more on the deep tissues and less on the skin, or take the tension off of the deep tissues of the abdominoplasty. But, we are trying to stack the deck in our favor, not in the favor of having more complications. I have for years put people on oxygen after a flap surgery just to increase the oxygen in the tissues for a few days.

Using patches or gum sounds good, but you still have the effects of the nicotine from these products. I remember a well-intentioned internist who tried to be very nice to my patient by ordering the patch after her tummy tuck, just to watch the lower area in the midline necrose a section of skin about the size of a baseball.

Complications that arise because of the choices that our patient makes is something that we would like to help avoid. Most board certified plastic surgeons and members of the American Society for Aesthetic Plastic Surgery who I know and respect really want their patients to have better outcomes, so they will require their patients to quit smoking for at least 3 weeks before the procedure in order to decrease the potential problems.

There are procedures that do not have flaps, such as liposuction, that I don't make as big a fuss over if patients smoke before surgery, even though they also have higher complication rates (like pneumonia after anesthesia, or spontaneous pnemothorax - dropped lung). There are no studies showing more capsular contractures with breast augmentation in those who smoke, but in my practice, I have noticed that patients who smoke seem to be more likely to end up with hard breasts after augmentation.

So the short answer is that you will get better healing and fewer complications if you maximize the oxygen going to your tissues by not smoking.  Conversely, if you smoke and thus deprive your tissues of oxygen, you are at greater risk for more complications and worsened scarring.