Tobacco, the Enemy of Plastic Surgery

November 15th is the Great American Smokeout.  This national acknowledgement of how important a problem tobacco use is in healthcare is greeted with open arms by those of us who deal with the negative impact of smoking every day.  The catastrophic effects of tobacco smoking have been widely studied and documented.  Tobacco is so dangerous that it must be sold with a warning label from the surgeon general’s office. Despite all of this, tobacco smoking remains a frighteningly popular habit in the U.S.  It is introduced early to our children, and has been woven into the fabric of living in our country. The allure of smoking cigarettes remains so great that intelligent people will risk cancer, heart disease, vascular disease, lung disease, and premature death to continue the practice.

The effects of smoking on plastic surgery are so significant that one should not even consider an elective aesthetic surgery while continuing to smoke.  I have even stressed that passive smokers risk many of the same negative outcomes as the person holding the cigarette.  This fact has been documented in scientific studies, and has now led to significant legislation limiting smoking in enclosed spaces.

All organ systems, including unborn babies, are negatively affected by smoking.  In the surgical subspecialties, smoking presents problems which are insurmountable.  Surgery that is performed even in areas of robust blood supply experience a thirteen fold increase in wound healing complications when compared to nonsmokers. Smoking clearly retards the healing process.

Tobacco not only delivers an active drug called nicotine to the body, but it also markedly decreases oxygen by replacing it with carbon monoxide. Carbon monoxide is a potent cellular killer.  Nicotine produces a collapse of blood vessels limiting vital nutrition to injured body parts.  It has also been implicated as a factor in worsening the control of pain and anxiety.  Other chemicals in the smoke plume, like tars, are directly injurious and create free radicals which initiate the changes needed for tumor growth.  All of these factors contribute to a prolonged healing from even minor injuries, but can be devastating to a surgical intervention.

Plastic surgery in particular, is a discipline in which the healing model is pushed as far as it can safely go.  Particularly in aesthetic surgery, snug skin closures are often part of the intervention.  Plastic surgeons are trained to make critical judgments at the time of surgery regarding skin tension.  Smoking just one cigarette after surgery can precipitate a cascade of microscopic events which can not be turned around by any drug or further surgery.  This can lead to tissue loss, defeat of the surgical intervention, and disastrous wound healing complications with unsightly scarring.

Patients need to be fully aware of the risks that tobacco abuse presents in the short and long term.  Tobacco needs to be considered with other known factors which contribute to poor healing, like nutrition, diabetes, radiation exposure, and chronic steroid use.  Preoperative discussions should be frank.  Patients must commit to complete smoking cessation at least one month prior to any elective operative intervention.  We insist that our smoking patients read and sign a smoking cessation agreement at their first visit. This should communicate the rigidity of the nonsmoking policy.  Patients should also be aware of the financial burden that can follow a surgery which has been compromised by failure to comply with the nonsmoking restriction.  It should be clear that this burden will be theirs alone.

Unfortunately, nicotine gum or patches are not recommended for surgical patients.  These contain the same active ingredient as tobacco and should be stopped one month prior to surgery. There are several new drugs which hold some promise in treating this stubborn problem, and we always recommend integrating one’s primary care physician into the process. There are also many support groups which are available to ease the process of tobacco withdrawal.

We, in medicine, are fully aware that smoking is a very difficult habit to break easily. However, it is very important that our smoking population understand the risks that it carries before planning an elective surgery.  November 15, 2007--- THE GREAT AMERICAN SMOKEOUT!  Make it your day to KICK THE HABIT.