We all know that smoking is bad. As physicians, most of us routinely counsel our patients to stop smoking. However, I have found that many patients referred to me don’t understand why I will refuse to perform a surgical procedure unless they have quit smoking – before and after surgery.
Occasionally, a patient may become angry because she feels that she has wasted her time and money only to be told that she is not a surgical candidate – after all, her GYN still performed the hysterectomy and she healed without complications. I would like to take this opportunity to emphasize why many plastic surgeons will not operate on smokers.
Plastic surgical procedures are unique – most procedures are elective and are performed to improve a patient’s quality of life. In other words, reconstructing a breast after cancer will help with the patient’s self-esteem, or a breast reduction surgery will help improve a patient’s symptoms of back pain or neck pain; but neither of these procedures will prolong or save a patient’s life like many general surgical procedures will. Because of this difference, patients and physicians have high expectations with little tolerance for complications. Furthermore, as plastic surgeons, we can elect not to operate on patients who are high risk – any surgical complication will ultimately be a detriment to a patient’s quality of life rather than an improvement.
Additionally, most plastic surgical procedures involve undermining of tissue or leaving just the right amount of tissue behind to ensure an adequate blood supply. For example, in a breast reduction, the nipple/areola complex is left attached to a pedicle of breast tissue to ensure its blood supply, the surrounding skin flaps are undermined, and the remaining breast tissue is removed. Similarly, in a mastectomy with immediate reconstruction, skin flaps are undermined to allow the breast tissue to be removed and then an implant is placed to reconstruct the breast. These types of procedures usually stress the tissues to their limits with regards to blood supply and oxygen delivery as it is.
While most patients expect me to discuss the risks of lung cancer, I’m not so much concerned about those risks as the effects of nicotine and tobacco on wound healing after surgery. Nicotine causes vasoconstriction, a decreased rate of wound epithelialization, and a decreased rate of collagen deposition – all of which are necessary for wound healing. Furthermore, nicotine is also associated with increased platelet adhesiveness – this could complicate any type of microvascular procedure. Carbon monoxide is also a byproduct of tobacco smoke which results in decreased oxygen carrying capacity thereby reducing tissue delivery of oxygen. In summary, tobacco smoke and nicotine contribute to decreased blood flow, impaired wound healing and reduced skin flap survival.
The literature says smokers have significant complication rates after many plastic surgical procedures. Studies have shown that smokers are 12.5 times more likely to have skin necrosis following facelifts; similarly, there is 27.5% incidence of abdominoplasty flap and umbilical necrosis in smokers. Studies have also reported up to a 33% incidence of implant loss in smokers in patients who have had immediate breast reconstruction with implants. When autologous tissue—such as the TRAM flap or DIEP flap—is used for the reconstruction, smokers still have a higher risk of mastectomy flap necrosis, abdominal flap necrosis, and hernias.
How does this manifest clinically in our patients? In breast reconstruction patients, I have seen skin necrosis of mastectomy flaps resulting in a return to the operating room or ultimate loss of the implant. For breast reduction patients who smoke, I have seen skin necrosis requiring skin grafts or loss of the nipple. For abdominoplasty patients, I have also seen skin necrosis with delayed healing. All of these complications are difficult for both the patient and the surgeon which is why most plastic surgeons will require a patient to quit smoking prior to surgery.
The next question my patients will ask is, “How long do I have to quit smoking before surgery?” Unfortunately, there is no good answer. Most plastic surgeons will demand a minimum of a 4-week tobacco and nicotine free period before AND after surgery. Some data suggests that this interval is not enough to counteract the adverse effects of these products – particularly in long-term and heavy smokers.
As I said earlier, as physicians, many of us will counsel our patients on smoking cessation. The purpose of this article is to reiterate the surgical consequences of smoking and nicotine use. Options available for smoking cessation include pharmacological and behavioral therapies. It may take the combined efforts of the plastic surgeon and the primary care physician to achieve this goal. Nevertheless, men and women considering plastic surgery—whether it be cosmetic or reconstructive—should consider and stop smoking prior to surgery.