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Smoking cessation prior to elective plastic surgery: why, when and how?


Tobacco is a serious nuisance in plastic surgery, mainly through the effects of its inhaled constituents on wound healing physiology. While there are thousands of chemical compounds in the inhaled smoke, the most prominent ones are nicotine, carbon monoxide and hydrogen cyanide, which are partially responsible for impaired wound healing through decreased oxygen delivery and utilization, and deranged collagen deposition [1]. Our aim is to summarize the existing literature on the effects of smoking in various plastic surgical procedures, and on the correct timing and available methods of preoperative smoking cessation.

Materials and methods

A literature review of PubMed was performed. The inclusion criteria were: articles on the effects of smoking on wound healing, plastic surgery and hand surgery, on the timing of preoperative smoking cessation and on methods of smoking cessation. The search terms used in combinations were “smoking”, “plastic surgery”, “wound healing”, “hand surgery”, “smoking cessation”.


In facelift procedures, skin slough is an important complication and there is a strong association between smoking and higher skin slough rates [2]. A similar relationship can be identified in abdominoplasty, as smokers suffer from a higher percentage of wound healing complications [3]. Complications like T-junction necrosis and infections were also higher in smokers who underwent breast reduction [4]. Regarding breast reconstruction, two studies showed higher rates of reconstructive failure and overall complications in smokers [5]. However, no significant difference was found regarding flap loss and vascular thrombosis between smokers and non-smokers [6]. In microsurgical free flap transfer, the relationship visited above is prevalent, with higher wound healing-related complication rates for smokers. [7]. In hand surgery, it has been shown that smoking post-replantation decreases digital blood flow significantly [8]. A meta-analysis showed the detrimental effect of smoking on the success rate of digit replantation (61.1% in smokers vs. 96.7% in non-smokers) [9]. While there is no consensus regarding the optimal smoke-free period preoperatively, many authors agree that 4 weeks are capable of reducing the rates of smoking-related complications satisfactorily. Some authors support the use of cotinine measurement, as patient history can prove notoriously inaccurate [10]. In order to improve the low cessation rate achieved by no intervention (about 1 in 8) [11], nicotine replacement therapy and medication can be used effectively [12].


Smoking is an independent risk factor for wound healing complications, but not for free flap loss. Smokers who are candidates for plastic surgery should cease smoking for an adequate amount of time preoperatively. Nicotine replacement therapy and medication are effective in assisting their smoking cessation efforts.


  1. Silverstein P: Smoking and wound healing. Am J Med. 1992, 93 (1a): 22-24.

    Article  Google Scholar 

  2. Rees TD, Liverett DM, Guy CL: The Effect of Cigarette Smoking on Skin-Flap Survival in the Face Lift Patient. Plastic and Reconstructive Surgery. 1984, 73 (6): 911-915. 10.1097/00006534-198406000-00009.

    CAS  Article  PubMed  Google Scholar 

  3. Manassa EH, Hertl CH, Olbrisch RR: Wound Healing Problems in Smokers and Nonsmokers after 132 Abdominoplasties. Plastic and Reconstructive Surgery. 2003, 111 (6): 2082-2087. 10.1097/01.PRS.0000057144.62727.C8.

    Article  PubMed  Google Scholar 

  4. Bikhchandani J, Varma SK, Henderson HP: Is it justified to refuse breast reduction to smokers? Journal of plastic, reconstructive & aesthetic surgery. JPRAS. 2007, 60 (9): 1050-1054.

    CAS  PubMed  Google Scholar 

  5. McCarthy CM, Mehrara BJ, Riedel E, Davidge K, Hinson A, Disa JJ, Cordeiro PG, Pusic AL: Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg. 2008, 121 (6): 1886-92. 10.1097/PRS.0b013e31817151c4.

    CAS  Article  PubMed  Google Scholar 

  6. Chang DW, Reece GP, Wang B, Robb GL, Miller MJ, Evans GR, Langstein HN, Kroll SS: Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000, 105 (7): 2374-80. 10.1097/00006534-200006000-00010.

    CAS  Article  PubMed  Google Scholar 

  7. Chang LD, Buncke G, Slezak S, Buncke HJ: Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg. 1996, 12 (7): 467-74. 10.1055/s-2007-1006620.

    CAS  Article  PubMed  Google Scholar 

  8. Van Adrichem LN, Hovius SE, van Strik R, van der Meulen JC: The acute effect of cigarette smoking on the microcirculation of a replanted digit. J Hand Surg Am. 1992, 17 (2): 230-4. 10.1016/0363-5023(92)90397-8.

    CAS  Article  PubMed  Google Scholar 

  9. Dec W: A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg. 2006, 10 (3): 124-9. 10.1097/01.bth.0000225005.64605.17.

    Article  PubMed  Google Scholar 

  10. Payne CE, Southern SJ: Urinary point-of-care test for smoking in the pre-operative assessment of patients undergoing elective plastic surgery. J Plast Reconstr Aesthet Surg. 2006, 59 (11): 1156-61. 10.1016/j.bjps.2005.12.053.

    CAS  Article  PubMed  Google Scholar 

  11. Rinker B: The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Ann Plast Surg. 2013, 70 (5): 599-605. 10.1097/SAP.0b013e3182764fcd.

    CAS  Article  PubMed  Google Scholar 

  12. Mahvan T, Namdar R, Voorhees K, Smith PC, Ackerman W: Clinical Inquiry: which smoking cessation interventions work best?. J Fam Pract. 2011, 60 (7): 430-1.

    PubMed  Google Scholar 

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Correspondence to Vasileios Theocharidis.

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Theocharidis, V., Economopoulos, K.P. Smoking cessation prior to elective plastic surgery: why, when and how?. Tob. Induced Dis. 12, A18 (2014).

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  • Smoking Cessation
  • Nicotine Replacement Therapy
  • Cotinine
  • Flap Loss
  • Wound Healing Complication