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Nicotine and Plastic Surgery

Woman about to cut cake: What does cutting a cake have to do with nicotine and plastic surgery? Read on

What does cutting a cake have to do with nicotine and plastic surgery? Read on.

Years ago I performed a breast reduction on a woman who smoked a pack of cigarettes a day. At her initial consultation, I described the impact of cigarettes on both wound healing and tissue survival. In fact, I told her, I wouldn’t operate unless she took a long break from smoking. She inhaled her last cigarette and scheduled her surgery six weeks later.

During the operation, her skin was pink, indicating excellent blood flow. When I pressed on the skin with the handle of my tweezers, the skin blanched, as expected, and after I released the pressure, the skin pinked up nicely. Perfect, I thought. She’s going to heal beautifully despite all those years of smoking.

But I was wrong. About a week after surgery, the areolas started to darken. Puzzled, I asked her if she’d started smoking again; she confessed she had. “I guess you really meant it when you said no smoking for six weeks before and six weeks after surgery,” she said.

The dark areas eventually turned black, indicating that the skin and the deeper tissue had died. Death of tissue, called necrosis, isn’t pretty, and when the black, leathery tissue came off, she was left with open wounds.

Fortunately, the open areas were small enough that she didn’t need skin grafts. With dressing changes and time, they healed, leaving white patches of scar in their place. She was lucky that her nipples survived.

What’s Unique about Smoking and Plastic Surgery

During most surgical procedures, like an appendectomy, the surgeon’s scalpel cuts through tissue like a knife slicing through cake. Straight down. However, most plastic surgical procedures are different. In a facelift, for example, the skin is lifted up, then smoothed out and redraped, and the extra skin is removed. Tummy tucks, breast reductions, and breast lifts are the same.

Think of a layer cake. A general surgeon would cut through the cake all the way down to the plate. But a plastic surgeon would cut only through the top layer, and then he’d turn the knife and cut horizontally, right through that middle layer of frosting. He’d lift the top layer of cake partway off the bottom layer, pull, and redrape.

Unlike cake, however, flesh needs a blood supply. Going back to our cake analogy, the blood vessels would arise from the bottom layer, straight up through the frosting, delivering an oxygen-rich blood supply to the top layer of cake. Lifting the top layer, though, would cut right through that blood supply. Now the only way blood can flow into the top layer would be through the portion of the cake that’s still attached. Usually that’s sufficient—unless the patient smokes.

Nicotine’s Effect on Tissues

Nicotine results in vasoconstriction, in which the blood vessels shrink. Think of a garden hose shrinking to the size of a drinking straw. A lush garden would probably dry out with such a hose, and a kiddy pool would take all day to fill. In the body, those shrunken blood vessels restrict the flow of the oxygen-rich blood that’s essential to keeping tissues alive and to heal wounds.

Nicotine and Plastic Surgical Complications

Because plastic surgical procedures often cut through blood supply, there are a number of potential complications associated with nicotine:

  • Skin loss (cosmetic procedures for which this risk is high include facelift, breast reduction, breast lift, tummy tuck, and rhinoplasty)
  • Death of fat cells (fat necrosis)
  • Infections
  • Delayed wound healing
  • Increased scarring
  • Blood clots
  • Increased pain
  • Permanent injury to the small vessels that adds risk even after quitting nicotine.
  • All risks associated with any surgery (stroke, heart attack, pneumonia, etc.)

Nicotine’s Impact on Plastic Surgical Results

Once nicotine wreaks havoc, the aftermath can be significant, and sometimes devastating:

  • Wider, thicker scars
  • Loss of implants
  • Loss of cheek skin, nipples, tummy skin resulting in extensive scarring or the need for skin grafts
  • Firm lumps from fat necrosis in procedures like a breast reduction

No Nicotine, Please!

Cigarette smoke contains around 4,000 different chemicals, and nicotine isn’t the only one that’s bad for wound healing. Carbon monoxide also contributes to tissue oxygen starvation. So switching to a nicotine patch or gum sounds like a great option. The problem is that nicotine, no matter how it enters the body, squeezes blood vessels, so patients need to stop all of the following:

  • e-Cigarettes and Vaping
  • Chewing tobacco
  • Snuff
  • Nicotine gum
  • Nicotine patches
  • Cigarettes, cigars, and pipes
  • Exposure to secondary smoke

Planning Plastic Surgery as a Smoker?

If you’re a smoker, and you’re planning to have plastic surgery, your surgeon may give you an interval of time to quit smoking, usually from 3 to 6 weeks before surgery through 3 to 6 weeks afterwards, depending on various factors. (Of course, quitting forever would be the best goal!)

Because the effect of just one cigarette, even a puff, is enough to turn a successful surgery into a regrettable one, confess to your plastic surgeon if you have a weak moment. He might delay the procedure until you’re truly free of nicotine’s effect to ensure the best possible outcome.

How about after surgery? Develop nerves of steel. Otherwise you could regret that one cigarette for the rest of your life!

If you’ve had success quitting smoking (or know someone who has), I’d love to hear how you did it in the comments below. Your advice could help someone else. Thanks!

Dr. Heather Furnas

About Dr. Heather Furnas

Inspired by watching her plastic surgeon father operate in African bush hospitals, Dr. Heather Furnas followed in his footsteps, training at Stanford and serving on the Harvard clinical faculty. She and her husband, Dr. Paco Canales, practice together in Santa Rosa, California, where they raised their two children. (To learn more about their practice, visit She believes an informed patient is more likely to be a happy patient and is committed to providing that education. If you have any suggestions for topics you'd like to learn more about, she would love to hear from you!

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6 Responses to Nicotine and Plastic Surgery

  1. k says:

    Very good information! There are so many reasons not to smoke.

  2. Abby says:

    Quitting smoking before surgery is a win-win. Patients not only get a great surgical result, but it’s often the push the patient needed to quit smoking forever:).

  3. Julianna says:

    My mother had been a smoker through adolescence into adulthood. When I became pregnant she decided to quit cold turkey. She went through withdrawals at first, but her personal health, her vitality, and knowing that my daughter’s health will never be compromised was enough. I’m so proud of her!!

    • Dr. Heather Furnas says:

      Going cold turkey takes will power, but often those babies are the best motivators. Glad your mom was able to quit! 🙂

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