Rod J. Rohrich, M.D.

“Heavy smokers can reasonably be denied elective aesthetic surgery unless they stop. . . . a suitable ad¬monition to the smoking patient would be WARNING … SM0KING CAN BE HAZARDOUS TO YOUR FACELIFT.” Thomas D., Rees, M.D.

Numerous scientific and medical data have been gathered to support the fact that the use of tobacco adversely affects all aspects of an individual’s health. We can enhance the overall quantity and quality of our patients’ lives by educating and encouraging them to avoid the use of tobacco in all forms.

Smoking is problematic in plastic surgery as well. It impairs wound healing, causes significant adverse outcomes, and increases the complication rate in elective plastic surgery and in cosmetic surgery.

In my own experience, smoking is detrimental to the patient physician relationship as well. Simply stated, it sets the stage for failure. I will not perform cosmetic surgery on a patient who smokes and refuses to stop at least 4 weeks prior to his or her surgical procedure, especially if the procedure requires the undermining of skin flaps. Several areas of the patient-physician relationship are compromised. Let’s analyze these in detail.

The Patient

How does it compromise the patient? Smoking compromises the longevity and quality of life. When a patient who smokes consults me about improving his or her physical appearance with cosmetic surgery, I have to wonder why it’s not equally important to improve the status of his or her overall health. The cessation of smoking for as little as 6 months has been shown to tremendously improve overall health. Patients who are opposed to stopping smoking are a paradox. It does not seem appropriate to perform cosmetic surgery on a patient who wants to improve his or her appearance but is unwilling to eliminate a major factor detrimental to overall health. The cessation of smoking improves the quality and quantity of the patient’s life more than anything I as a plastic surgeon can accomplish.

The Surgeon

How does patient smoking compromise the surgeon? How often do we hear our patients tell us that if they choose to continue smoking, they will stand accountable for the problems and complications that may arise postoperatively? The transfer of blame in life and medicine is not that simple. As soon as you take on that patient, the onus is on you, the surgeon. You cannot shift that responsibility postoperatively. Besides, the patient should not be expected to understand the dynamics of wound healing. When the patient has a postoperative skin slough, whether it’s a facelift, abdominoplasty, or breast surgery that requires undermining flaps, an adverse outcome becomes the surgeon’s responsibility.

The Procedure

How does it compromise the procedure and the result? From both patients who smoke and physicians, I commonly bear that “a lesser procedure was performed” or “less undermining was done.” By operating on a person who smokes, you are subjecting that patient not only to a lesser procedure but also to a lesser result. Now both the procedure and the result are compromised.

Patients who are not willing to stop smoking at least 4 weeks preoperatively should be encouraged to seek a healthier life style prior to proceeding with any elective surgical procedure, especially cosmetic surgery. These patients have higher rates of morbidity and complication. They have more postoperative pulmonary problems, skin loss, flap impairment, and delayed wound healing. I do not want to subject my patients or myself to these significantly increased risks. I recognize and support scientific data that smoking is detrimental to our patients’ health and ability to heal after surgery. As a plastic surgeon and a physician, I advise my patients to seek the benefits of professional counseling if needed to stop smoking, and I support them in their endeavor. I will not operate on a patient who will not stop smoking prior to cosmetic surgery.

Should we perform elective surgery or cosmetic surgery on patients who refuse to quit smoking preoperatively? Should we cancel their surgery or submit them to nicotine tests if we think they have not complied with the requirements? Surgical patients who believe they don’t need to participate in the responsibility for their overall care and result are at increased risk. We must guide our patients to stop smoking in the preliminary stages of surgical planning. If they refuse, they should not be considered candidates for cosmetic surgery. Then, we will all sleep better at night!

Rod J. Rohrich, M.D.Department of Plastic and Reconstructive Surgery UT Southwestern Medical Center