Smoking and Plastic surgery don’t mix

smoking before plastic surgery

If you have ever looked at cigarette packaging, you will know that cigarette smoking is hazardous to your health. Tobacco use is estimated to cause 35% of all cancers, 33% of all heart attacks and strokes, and 90% of chronic obstructive pulmonary disease, including emphysema. 

If you are planning on having plastic surgery – either cosmetic or reconstructive, you will be advised to stop smoking.

But why? And how? 

I will explain the science behind the advice and give you some tips to help your quit smoking before your plastic surgery.


Cigarette smoke contains over 4000 constituents. The culprits responsible for plastic surgery wound healing complications are nicotine, carbon monoxide, and hydrogen cyanide.

Enemy number one is nicotine. Nicotine acts as a vasoconstrictor, meaning it shuts off the flow of blood in your blood vessels. Blood carries oxygen to all the cells in the body, keeping them alive. Nicotine also increases the stickiness of platelet in the blood, which can lead to clot formation within the blood vessels. This will block blood flow and stop blood delivery. Nicotine also interferes with the development of the cells needed in wound healing such as fibroblasts and macrophages. 

Enemy number two is carbon monoxide. Carbon monoxide (CO) prevents the blood system from effectively carrying oxygen around the body. Carbon monoxide competes with oxygen for a ride on haemoglobin in the red blood cells. It is a much stronger competitor than oxygen, 200 times stronger in fact, So it easily takes the place of oxygen in the red blood cells and further reduces oxygen delivery to the wound. 

Enemy number three is hydrogen cyanide. It stops the cellular machinery within cells of the body, effectively choking off oxygen within the cell.

While wound healing is a big concern for plastic surgeons, it is not the only thing harmed by cigarette smoking. Smoking increases the risk of anaesthesia. Cigarette smoking negatively effects both the respiratory system and the cardiovascular system. This can lead to longer time in hospital, additional treatments, and a longer recovery period.


Plastic surgery procedures invariably involve lifting, nipping or tucking skin. Nicotine, along with carbon monoxide and hydrogen cyanide, cause a decrease in blood flow through the tiny blood vessels in the skin and a decrease in oxygen reaching the cells. 

Without adequate blood flow and oxygen, skin cells will die. This can lead to a host of problems:

  • skin necrosis (medical word for cellular death), 

  • wound healing problems, 

  • wound break-down, 

  • flap necrosis, 

  • infection, 

  • the need for re-operation and 

  • increased risk of a poor aesthetic result!

Smoking is not a good omen.


Electronic cigarettes or vaping, has become a popular alternative to tobacco cigarette smoking. While it does contain somewhat fewer harmful substances, it still contains nicotine. And as we have seen, nicotine is the number one enemy of wound healing. Studies have shown that electronic cigarettes are as toxic to skin flap survival as tobacco cigarettes. 


The longer the better! Although there is no consensus guideline, 4 weeks before surgery and 4 weeks after cosmetic or reconstructive plastic surgery is the minimum. And most anaesthetists suggest not smoking for 2-3 months before elective surgery to reduce anaesthetic risks. 

Some plastic surgeons will do a cotinine urine level before elective plastic surgery. Cotinine is the break-down product of nicotine. This test is done to make absolutely sure that the deleterious levels of nicotine are decreased prior to surgery.


  1. Make a plan to quit, set a deadline, and stick to it

  2. Harness peer pressure – spend time with non-smoking friends and enlist the support of family

  3. Get professional help from a psychologist trained in cognitive behavioural therapy or addiction treatment

  4. Nicotine replacement therapy – gum, patches or sprays will help to decrease nicotine withdrawal symptoms and will help you to quit smoking. But the nicotine is still a problem for wound healing and should be weaned 4 weeks before your surgery

  5. Non-nicotine replacement therapy – bupropion hydrochloride (Zyban), antidepressants and clonadine. Discuss the need for prescription medications with your doctor

  6. Identify your smoking triggers and actively avoid them

  7. Change your diet – certain food and drinks make cigarettes taste better, such as fizzy drinks, alcohol, caffeine, cheese and red meat.  While others such as fruit, vegetables and tomato juice don’t combine well

  8. Exercise – increased physical activity will help counter cravings and help with any potential weight gain

  9. Keep your hands and mouth busy – fidget with worry beads, a stress ball or a spinner. Chew gum or suck on lolly pops or lozenges

  10. Reward yourself regularly for your achievements! ​

Cigarette smoking and plastic surgery don’t mix well. Hopefully with more understanding of the reasons, the risks of smoking and some useful tips on how to quit, you will give yourself a head-start to achieving your smoke free goal before having plastic surgery. If you want to read more about how to prepare for plastic surgery, download the Plastic surgery companion – a patient guide.


Ann Plast Surg. 2017 Mar 1. doi: 10.1097/SAP.0000000000000998. Electronic Cigarettes Are as Toxic to Skin Flap Survival as Tobacco Cigarettes.Rau AS1, Reinikovaite V, Schmidt EP, Taraseviciene-Stewart L, Deleyiannis FW.

Wound Healing: Part I. Basic Science Janis, Jeffrey E. MD; Harrison, Bridget MD Plastic & Reconstructive Surgery: September 2016 – Volume 138 – Issue 3S – p 9S–17S

Clin Med Res. 2003 Jul; 1(3): 201–216. Tobacco Cessation in Primary Care: Maximizing Intervention Strategies John D. Anczak, MHS, PA-C and Robert A. Nogler, II, MD