Smoking not only induces medical disease but impacts wound healing significantly. Its negative effects are thought to be primarily related to its reduced levels of tissue oxygenation, a critical factor that helps surgical wounds heal. Two major smoke consitutents, nicotine and carbon monoxide, causes peripheral vasoconstriction and decreases the ability of hemoglobin in red blood cells to carry oxygen. Nicotine may also impair the function of fibroblasts and white blood cells to make collagen and fight infection respectively. If you smoke and want to undergo plastic surgery, you would be wise to refrain from smoking at least two weeks before and after surgery to improve your chances of a successful and uncomplicated result. In addition, your anesthesiologist will also appreciate it as the direct effects of cigarette smoke on the lungs are certainly not helpful for your anesthetic and the immediate recovery from it.  

A recent article published on CNN online and picked up by numerous news agencies was entitled’ Smoking May Make Your Nipples Fall Off’. As sensationalized as that headline appears, there is more than just a kernel of truth to it. This is referring specifically to those folks who undergo plastic surgery of the breast, not to just anyone. While smoking is bad enough for your health, there are some real dangers to those undergoing various types of plastic surgery.

To no surprise, smokers and non-smokers alike, everyone knows that the nicotine habit is not a good thing for undergoing surgery. There is the obvious lung function and breathing issues that may be impacted from being put to sleep and the hacking and coughing afterwards as one recovers. It is also fair to say that smokers just aren’t as healthy as many non-smokers and this exposes them to numerous other health issues.

But when it comes to having plastic surgery, there is one effect of smoking that is hidden and unrecognized by patients. Medically stated, it is known as impaired perfusion and oxygenation. Simply put, the blood supply necessary for survival of certain tissues undergoing surgery is lessened. This will make healing slower and sometimes compromised and tissues may even die. The nicotine in cigarettes and the carbon monoxide in cigarette smoke (second hand smoke still counts!) acts as toxins on blood vessels causing them to constrict or shut down, starving the tissues of precious oxygen that they need not only to heal but to live as well. This will also affect the smallest of veins in the tissues, not allowing them to not get the blood flow out of the tissues. Without a good outflow, the whole system backs up ultimately impeding vital inflow of blood as well.

This blood flow in and out is most affected by smoking in operations in which tissues are carried on what we call in plastic surgery long pedicled flaps. In breast reductions and breast lifts, the nipple is carried on a flap of attached breast tissue as it is repositioned during the surgery. The normal blood supply is cut out from the nipple in many directions and only comes in through the attached pedicle, making this the critical connection to the nipple’s survival. Because smoking will diminish even that blood supply, one can see how the blood flow to the nipples may get backed up and not enough oxygen get to them. This can make the nipples die, turn black, and ultimately fall off.

Problems of a near similar magnitude can occur in any cosmetic plastic surgery procedure in which long skin flaps are raised and repositioned, often under tension. (which makes it even worse) Procedures such as facelifts, tummy tucks and any other body contouring procedure that requires skin excision is at risk. While these areas don’t have nipples, the problem will be one of skin edges dying, wounds coming open and a long delayed period of wound healing.

The bottom line is when your plastic surgeon says to stop smoking for a period time before and after your planned surgery, this is not just a suggestion. It is an absolute requirement. To not do so, or to say you tried but couldn’t, places you at considerable risk for a healing problem and an undesired aesthetic outcome.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Amongst the many adverse effects of smoking on the body is its detrimental impact on wound healing. This phenomenon has been recognized since the late 1970s when a correlation between smoking and an increased risk of wound problems in surgery was established. This is quite important in plastic surgery where large skin flaps area raised, resulting in a decreased blood supply to the raised skin as the circulation is cut off from below and skin survival is dependent on blood flow coming in from raised skin only. Cosmetic plastic surgery procedures such as facelifts, tummy tucks, and breast reductions in particular, are particularly prone to healing problems from smoking.

 
For this reason, the identification of smoking on a patient’s history is very important. It is often one of the first things that I look for on the intake medical history after allergies and medications. Whether the amount of tobacco use listed is accurate is up for debate. I figure most patients put down what they would like it to be, not necessarily how much tobacco they are exposed to every day. I strongly urge patients that they must refrain from all tobacco use at least three to four weeks before and after surgery. Some plastic surgeons refuse to operate at all on smoking patients for certain procedures such as a tummy tuck. I even know some that get a nicotine level several days before surgery. I don’t go quite that far but I can understand this concern. No plastic surgeon wants to deal with avoidable complications. On the surface, no patient wants to either but the addiction of smoking is quite strong even in the face of making smart decisions when you are venturing thousands of dollars in an investment in your body.

 
There is little question that smoking affects wound healing. I have seen a disproportionate number of patients who said they stopped smoking, but when they developed wound problems such as a dehiscence (separation of the incision line), they casually admitted that they had not stopped completely or had slipped in a few in the past few days to ‘calm them down’. Although I have no scientific evidence to support it, my feeling is that the effects of smoking probably takes many months (not just 3 or 4 weeks) and even up to a year after quitting to become ‘normal’ from a wound healing standpoint.

 
A recent journal article in Plastic and Reconstructive Surgery (May 2008) now implicates smoking as a cause of increased infections as well. I must say I am not surprised.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis