Author: 
Leslie Branch, MD, Wake Forest Baptist Health

Smoking and Surgery: What You Need to Know

Tobacco use kills approximately five million people annually around the globe. Here in the United States, tobacco use kills 480,000 Americans each year.  The harmful effects of smoking on many systems of the human body are well known and have been widely published. Tobacco use is the leading cause of preventable death in the United States. Smoking and tobacco use increase risk of at least 14 types of cancers, including: lung, oral, throat, bladder, liver, and kidney, among others. A smoking history is also a known risk factor for increased complications with surgery. The nicotine and toxins from tobacco products can cause damage to and constriction of blood vessels. This can decrease the blood supply to healing tissue and increase the risk of wound breakdown, skin loss, and healing complications. While well documented that smoking traditional cigarettes causes these harmful effects, the use of electronic cigarettes, chewing tobacco, and other nicotine products can lead to such adverse health outcomes as well.

In reconstructive surgery from a cancer diagnosis, smoking can be especially harmful since it can delay healing as well as negatively affect the efficacy of other cancer treatments such as radiation and chemotherapy. Smoking can also damage the aesthetic outcome of a reconstruction and increase the need for more surgeries. It has been shown that smoking cessation can result in a 20–30 percent reduction in complications, but this varies depending on the surgery.

In breast cancer reconstruction, smoking has been established as a risk factor for mastectomy flap skin loss, especially in nipple sparing mastectomy (surgery where the nipple is not removed). For example, a 50-year old female who presented with newly diagnosed breast cancer was a good candidate for nipple sparing mastectomy.  Surgery was coordinated with the surgical oncologist and the plastic surgeon for reconstruction.  On the same day as the mastectomy, the plastic surgeon placed an expander under the muscle to help recreate the breast pocket over time. The patient smoked one pack of traditional cigarettes a day and was unable to stop before surgery.  She also continues to smoke after surgery. The day after surgery, her nipple looks darker than normal and over the next week slowly dies with a small amount of skin around it. She must return to the operating room to get the dead skin and nipple removed. In addition, the tissue expander must be removed because of the skin loss and contamination.

Continuing to smoke traditional cigarettes (or use other tobacco products) after a cancer diagnosis, treatment and reconstructive surgery led to the patient mentioned above to losing her nipple and other complications.  Not only did she lose her nipple unnecessarily, she now has to delay tissue expansion and final breast reconstruction. This case is just one example of how smoking can result in more surgeries, complications, and less acceptable reconstructive results. Some patients who continue to smoke or use tobacco products following cancer related reconstructive surgery may have incisions that do not heal properly, requiring weeks to months of dressing changes on wounds that result in a wide or depressed scar. This scenario does not paint a picture of a non-compliant patient, but more so the addictive nature of nicotine in tobacco products and the difficulty in making a successful quit attempt.

Regarding surgery and smoking, a cessation period of at least four to six weeks has been recommended. Some physicians will do a nicotine test prior to surgery to ensure that the patient has been compliant and it is safe to proceed with surgery. Not only will smoking cessation help with reducing surgical complications and increasing the ability for wounds to heal, but it will also benefit overall well-being including heart and brain health. For cessation resources and tips available to you, please visit the CDC Guide for Quitting Smoking Website.