Why Is Smoking Dangerous When Having Surgery?

First, for the purposes of this article, when I refer to the term “smoking”, I am including using any substance that contains the chemical nicotine. This includes, but is not limited to cigarettes, electronic (“e”) cigarettes, vaping, cigars, chewing tobacco and nicotine patches.

When a surgeon makes an incision into, or sutures living tissue, he/she does it with one expectation: that the tissue will heal. Healing wounds have a few basic requirements: oxygen, protein, and protection from infection. Certainly, there are other things necessary: vitamins, minerals, hormones and other biologically active materials, but for the purpose of this discussion, I am going to limit the discussion to the first three.

When a wound is healing, there is a delivery system for the oxygen, protein and protection from infection. The process is similar to supporting troops on the front lines during a conflict. Troops need fuel, food and equipment to protect them from the enemy. Oxygen is the fuel, protein is the food (the building blocks for new tissue) and protection from infection (the enemy) is the latter. Red blood cells transport oxygen, amino acids in the bloodstream are the basic building blocks for protein and white blood cells fight infection. The common denominator is that an adequate supply of circulation of blood to a wound is the only way it will ever heal. A system of transportation and delivery of critically needed items is essential whether you are healing a wound or fighting a battle.

If you want a wound to heal, then you must ensure that there is adequate circulation of blood. If you want to see complications of wound healing, really, really bad complications, then just do something to cut the circulation. Plastic surgery is all about the knowledge of anatomy and circulation. As tissues are elevated from their natural bed, rotated, moved, stretched, rearranged, some of its circulation is lost. As most tissue has a redundant supply of circulation, this is not an issue. The surgeon is constantly assessing and predicting the circulation to these tissues. He/she does so on the assumption that there is going to be no other compromise of blood circulation other than what as a surgeon knows to be well tolerated by the tissue during the procedure at hand. In other words, the circulation to the tissues have built in redundancy so that a surgical procedure can reduce some circulation to a wound (this occurs when tissue is intentionally cut during the performance of surgery) and still there is enough blood flow to expect normal wound healing. The classic example of this is abdominoplasty (tummy tuck). In the performance of this procedure, the surgeon elevates the abdominal skin off the muscles, dividing (eliminating)  the circulation from the muscles to the skin. The remaining circulation to the skin comes from the skin on the sides of the body where the elevated abdominal skin remains attached.

Should the available circulation not meet the nutritional needs for wound healing (oxygen and protein) the wound will not heal. Should the oxygen delivery be less than is required for the tissue to merely survive, then the tissue will die (i.e. skin necrosis). If there is not enough infection fighting cells delivered to the healing wound, then infection may result.

What has all this got to do with smoking? Nicotine is a chemical that is a vaso-constrictor (Vaso means blood vessel and constrict means to narrow). So, when you use nicotine, your blood vessels narrow and the delivery of blood to a healing wound diminishes. This is like closing off three lanes of a four lane highway. When the diminution of circulation reaches a critical level, in plain terms, wounds fall apart, tissue dies and infection sets in. Not a good thing. As a cosmetic surgery patient, you are investing a lot. You have nothing medically wrong with you. You are submitting to a surgical procedure, subjecting yourself to certain risks, investing time off from work, your family activities as well as committing financial resources. These days, surgical risks are minimized, outcomes are usually quite good, patient satisfaction is high and everyone is happy. However, when you smoke, you place everything in jeopardy. You risk a result that instead of making a physical improvement, may result in physical detriment, complications, infections and further surgeries. This makes no sense.

Smoking and oral contraceptives: When a patient is taking oral contraceptives, there is a slightly increased risk of blood clots forming in the large veins of the legs during surgery which can result in a fatality later on in the peri-operative period should the clot break off and travel to the lungs. However, when a woman smokes and takes oral contraceptives, this risk increases considerably. If a woman is smoking and taking oral contraceptives, I prefer not to perform surgery until at least the smoking is stopped.

A note on e-cigarettes and vaping. Many patients are under the belief that they can stop smoking cigarettes and use e-cigarettes or vaping up until their surgery date. This is generally incorrect. Most of the e-cigarettes and vaping still contain nicotine. There are some that are nicotine-free. I would still advise against using them before and after your surgery. The problem with nicotine free e-cigarettes and vaping is that these contain propylene glycol and glycerol. These are normally non-toxic substances, but the process of vaping produces toxic substances which have been shown to affect blood vessel function. My strong recommendation is no e-cigarettes and vaping.

It is for these reasons that you are being asked to abstain from nicotine, e-cigarettes and vaping both before and after your surgery. It’s just not worth the risk!

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