Plastic Surgery Patients Who Smoke

How do plastic surgeons feel about operating on patients who smoke? Do plastic surgeons try and help patients quit? Are more doctors actively trying to get patients to stop smoking or offer smoking cessation programs or patches or thing like that?

Doctor Answers 16

Smoking cessation and cosmetic surgery

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Any patient who comes to me for elective, cosmetic surgery who smokes receives education on smoking cessation. Usually, the information and recommendations imparted to patients depends upon their medical status, the type of operation they are seeking, and their age.

For example, a healthy 28-year-old woman for breast augmentation is counseled that smoking is harmful to her health in many ways, including the way her scars will heal because of the blood vessel constriction caused by nicotine. But smoking in her case is not an absolute contraindication for surgery given the nature of breast augmentation, well vascularized nature of the breasts and absence of any "flap" dissection in this procedure. The most important thing, I tell her, is that this is definitely a habit that she does not want to keep, as it can cause permanent damage to her lungs, heart, skin and peripheral blood supply to her legs and arms.

On the flip side, a 60-year-old woman who is a two pack-a-day smoker who comes to me for a facelift is counseled on smoking cessation and told that without stopping at least two to three weeks before surgery, I may not perform the surgery. This is because the skin flaps that are created during a facelift can actually die from the harmful effects of nicotine and smoke, leaving scars on the face and open wounds that can be devastating to both the patient and surgeon.

A nicotine test done by urine sample can be used to check to see if a patient is still smoking, but I generally trust my patients and what they tell me with regard to when they quit; otherwise, I may not deem them a suitable surgical candidate if I feel communication is not open and trust is an issue.

Psychotherapy, nicotine patches and gum, Chantix, and Zyban have all been described and used for smoking cessation. I usually help my patient set a stop date and coach them to use their upcoming surgery as a motivation to really quit for good, and have the patient's primary care doctor help out with prescribing any medication like Chantix or Zyban given the need for monitoring side effects and their general medical status. I have referred patients for psychotherapy, biofeedback, and meditation, as I believe these holistic approaches can help greatly; we all tend to do better with things when we get our mind on the right track.

Since my father is a smoker and has been for many, many years, I am especially sensitive to this issue as I have witnessed his premature physical decline over the past years. With my patients, I am sensitive and aware that it is "easier said than done" for me to tell them to quit cold turkey two weeks before surgery, and that they need a lot more than just a verbal dictum.

The best part about quitting is getting rid of the harmful toxins that are delivered every day to the lungs and vital organs of the smoker; this is a habit that is extremely addictive but can really cause a myriad of health problems. I try to be there to support their smoking cessation and really provide positive reinforcement because in the end, they are the ones who will end up feeling better, looking healthier, and having a successful surgery with much less risk of complications.

Hope this helps!

Dr . Jennifer Walden

Surgery and smoking

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Here are the major points of smoking Tobacco or Marijuana before or after surgery:
1. There is nicotine in tobacco, but not in marijuana. However, most joints are rolled with marijuana and tobacco combination. Nicotine is a vasoconstrictor that decreases blood flow to the tissues. This is the major problems that can cause a very bad outcome in some surgeries. In a breast augmentation, there is not a lot of risk as there are not a lot of incisions which decrease blood flow to the tissues. In a breast lift or tummy tuck, on the other hand, there is much longer and more involved incisions. The decrease in blood flow to the tissues in combination with the decrease in blood flow from the nicotine can cause tissue to die. This can cause part of the breast or nipple, or in the case of a tummy tuck, part of the belly tissue to die, resulting in a very bad outcome. Marijuana without tobacco does not cause this problem, or marijuana in an edible fashion. Vaporizers do not decrease the amount of nicotine in tobacco, only decrease the smoke.
2. There is carbon monoxide in both tobacco smoke and marijuana smoke. Carbon monoxide decreases the oxygen carrying capacity of hemoglobin in the blood. This is different from the vasoconstrictor effect, but has the same result of having the risk of tissue death in conjunction with surgeries that decrease the blood flow to tissues such as breast lifts and tummy tucks, as opposed to an augmentation alone that does not decrease blood flow to as great of an extent. Again, edible forms of marijuana do not have smoke, and thus carbon monoxide poisoning.
3. Coughing. Both tobacco and marijuana smoke disrupt the lining of the lungs and bronchi and can lead to coughing episodes. Coughing episodes can lead to internal bleeding after surgery that can lead to hematomas and complications, and again a bad outcome. Again, edible forms of marijuana does not have this effect.
4. Anesthesia effects. Marijuana can have drug interactions with certain anesthetic drugs. Thus it is important to tell your anesthesiologist about your marijuana use.
In conclusion, Smoking, whether it be tobacco or marijuana, is detrimental to your surgery outcome. Edible marijuana is much less so, but be honest about your use with your surgeon and anesthesiologist so that you can have the best outcome. In general, you should quite smoking many weeks, ideally 6 weeks before surgery, and not smoke for at least 2 weeks after surgery.
Best wishes,
Pablo Prichard, MD

Pablo Prichard, MD
Phoenix Plastic Surgeon
4.9 out of 5 stars 42 reviews

Some cosmetic operations can be done safely on smokers

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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.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

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What scientific literature tells about plastic surgery and smoking

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After careful examination of the scientific literature, I was able to find the following to have deleterious effects on wound healing and wound repair:

1. Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue. Vasoconstriction means constriction of blood vessels, namely arteries that supply nutrients and oxygen to our tissues. Less blood flow means less oxygen and nutrients to the tissue that are trying to repair the injury. Less oxygen and nutrients means that there is an increased likelihood for wound infection and subsequent scarring.

2. Carbon monoxide diminishes oxygen transport and metabolism in injured and healthy tissue. The carbon monoxide competes with oxygen on the 'oxygen transport molecule', also known as hemoglobin. So, instead of oxygen delivery by the hemoglobing molecule, carbon monoxide is delivered to the tissue. Unfortunately, carbon monoxide has tight binding to the hemoglobin molecule and is less likely to be replaced by oxygen.

3. Hydrogen cyanide inhibits the enzyme systems necessary for oxidative metabolism and oxygen transport at the cellular level. These enzyme systems are important for the metabolism of oxygen at the level of the tissue where there is need for this oxygen for critical tissue repair and wound healing. After surgery, wounds are in constant flux and healing continues for weeks. As a matter of fact, wound remodeling continues for 6 months after a surgical incision is made and therefore, smoking in general should be prevented during this critical time period. Practically, however, most patients resume smoking after surgery.

4. Smokers have a higher incidence of unsatisfactory healing after face-lift, rhinoplasty (nose job), blepharoplasty (eyelid surgery) and breast augmentation.

5. Smokers should be advised to stop smoking 3 weeks prior to elective cosmetic surgery or any traumatic injury requiring reconstructive surgery. If at all possible, do not smoke for at least 4 weeks after surgery.

So, if you are deciding to have plastic or reconstructive surgery, stop smoking for at least 3 weeks before surgery and 4 weeks after surgery. This will improve your likelihood of a successful procedure with optimal wound healing conditions.

Smoking and plastic surgery

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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.

Dan Mills, MD
Orange County Plastic Surgeon
4.8 out of 5 stars 35 reviews

Plastic surgeons are doctors of medicine first before...

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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!

Plastic Surgery may curb the smoking habit

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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!

Julius W. Few, MD
Chicago Plastic Surgeon

Butt Out! Why Risk Having Your Plastic Surgery Results Go Up In Smoke?

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Every responsible Plastic Surgeon advises his patients to quit smoking at least three weeks before and two weeks after an anticipated surgical procedure. Ideally, patients should quit smoking entirely, or better still should never take up the habit in the first place. I find it confounding that otherwise intelligent people in this day and age begin or continue to smoke in seeming total disregard of the wealth of information available which directly links smoking to premature death as a consequence of heart and lung disease. Nevertheless, this public health issue also has a direct bearing on a patient’s readiness for cosmetic or reconstructive surgery. Many plastic surgery procedures, including face lifts, breast lifts and reductions, and tummy tucks, involve elevation of large areas of skin which are supplied in some cases by a fragile circulatory system of small arteries and veins. Cigarette smoke and its various toxic components cause constriction of these small blood vessels as well as reduced oxygen carrying capacity, thereby compromising this fragile circulation within these elevated flaps of skin. Under normal circumstances (that is, before the flaps are raised), smoking does not create any noticeable decrease in circulation, however after surgery, the diminished blood flow can have catastrophic effects in terms of loss of skin or underlying tissue. Besides the risk of skin or tissue loss as a consequence of smoking, there are additional risks that smoking poses for the patient contemplating plastic surgery. Smokers generally have more mucus production and reactivity of their airways, and coughing in the post-operative period after delicate surgery such as eyelid surgery, rhinoplasty, and face lift surgery may be associated with a greater risk of post-operative bleeding or hematoma. The diminished oxygen carrying capacity of the blood may result in delayed or compromised wound healing. In addition, smokers are more likely to develop Deep Venous Thrombosis (DVT) which can lead to Pulmonary Embolus (PE), a potentially life-threatening complication, the risk of which increases in women using birth control pills who also smoke. Nicotine patches or nicotine gum are no less harmful to the patient than smoking, and should be included in the policy of strict abstinence from all nicotine-containing products, including cigarettes, at least three weeks before and two weeks after a plastic surgical procedure. If there is enough lead-time before the surgery, and patients wish to quit smoking, there are other medications and behavioral therapy modalities that are available to assist the patient through the detoxification process, and I recommend these to all smokers. Human nature being what it is, some patients will continue to smoke up to and through the surgery and recovery process. As part of my informed consent, I require patients who smoke to sign an acknowledgement that continued smoking may result in wound healing complications beyond my control, for which the patient assumes personal responsibility. For high-risk patients and procedures, I reserve the right to cancel the operation. When it comes to plastic surgery, every precaution should be taken by both the patient and the surgeon to insure that the beautiful and hard-earned results don’t go up in smoke. So when it comes to smoking, the best policy is to “Butt Out!”

Athleo Louis Cambre, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 6 reviews

Plastic surgery patients who smoke?

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Hello! Thank you for your question! The issue with nicotine is that it also acts as a vasoconstrictor, clamping down of blood vessels. Blood supply is always of great concern during any surgical procedure, but especially in such procedures as breast procedures and a tummy tuck where the viability of the nipple, belly button, and skin flaps are obviously important. Since the vascularity to the area is already tenuous with the dissection of the abdominal tissue as well as cutting around the areas, maximizing blood flow to the tissue is critical.

Typically, we recommend at least 6 weeks of smoking cessation prior to and at least 6 weeks after any surgical procedure. The longer, the better. Nicotine always increases the risk for infection, skin flap necrosis, and wound complications, as well as other health consequences. There is an increase pulmonary risk with the anesthesia and postop lung infections. The most devastating consequence of infection, especially since the tissue is tightened, is increased. This along with wound healing and scarring.  Some surgeons will refuse to operate on smokers and often check urine or blood levels prior. I would discuss this with your surgeon prior to your procedure.  Hope that this helps! Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 28 reviews

Smokers and Surgery

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I have particularly strong feelings about this issue which I convey to my patients at the time of the initial consultation.  I will not perform a Facelift on an active smoker due to the increase risk of hematoma, infection, and skin slough.  Nicotine decrease blood flow to the skin and the carbon monoxide inhaled while smoking diminishes the red blood cells' oxygen carrying capacity. In my practice, patients seeking a Facelift who are active smokers are asked to stop smoking for 6 weeks before and after the procedure.  In addition, these patients must sign an affidavit stating they have stopped smoking and that they are fully informed about the associated risks which are listed on the form.  It is a forgone conclusion that smoking adversely affects all organ systems in the body, diminishes energy levels, and has no redeeming qualities.  I have seen a number of patients successfully stop smoking in preparation for surgery and remain tobacco free for years.  The majority of these patients stopped "cold turkey" or used medications such as chantix to control their desire for nicotine.

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon
4.9 out of 5 stars 104 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.