By Michael Gellis MD, CMO
BELLEVUE, Wash., – Unless you have recently landed from Mars or are under two years of age, you should have an opinion of cigarette smoking or even the effects of cigarettes on surgery. Regardless of common opinion about smoking, which is usually negative, the prevailing research and published articles always align smoking cigarettes adjacent to skull and crossbones.
Somehow smoking cigarettes is still a major concern for surgeons who are about to operate on a cigarette smoker. However, it is important to separate fact from fiction, common held beliefs from actual scientific findings. If we are to advise patients about the evils of smoking, then it is necessary to understand the science behind smoking, its effect on wound healing and the added risks and complications from cigarette smoking.
The Science of Smoking and Oxygen in Your Blood
The effects of cigarette smoking are immediate, and, yet, long term. The first time smoker usually gets nauseated due to the chemical properties of nicotine. Also, along with the nicotine, carbon monoxide and hydrogen cyanide start circulating in the blood. Nicotine can increase platelet adhesiveness which increases the risk of blood clots especially in the smaller blood vessels. Nicotine also decreases the production of red blood cells, fibroblasts (healing cells), and macrophages, cells that remove microscopic amounts of debris from the body. Carbon monoxide (HCN) lowers oxygen levels by inhibiting oxygen transport and metabolism. HCN slows the enzyme systems which are required for oxidative metabolism and oxygen transport within the cell.
It is believed that smoking before surgery causes the patient to enter surgery in a hypoxic state. The good news is that if you quit smoking by at least two days before surgery, the body eliminates all the carbon monoxide present in the blood and the oxygen levels are restored. Also, nicotine leaves the body within eight to twelve hours.
Less understood are the long term effects of smoking on small blood vessels. According to Truls Ostbye PhD of Duke University School of Medicine, “Smoking is harmful at any age but if you stop smoking before age 35 you may still do pretty well in terms of living longer and having a better quality of life as you reach middle age. By quitting for at least 15 years prior to age 50, you may be able to regain your health as well as people who never smoked.”
Unfortunately small and larger vessels constrict, get smaller, and over time calcify, occasionally becoming permanently occluded. Even in the short term a vessel in spasm will prevent adequate amounts of life saving blood to be carried to and from areas of recent surgery causing delays in healing, poor circulation, clotting of small vessels, prevention of normal lymphatic drainage, and, at times, loss of skin in the more complicated operations such as face lifts and abdominoplasty. Operations that develop flaps of skin depend heavily on the micro circulation which is impaired by the effects of smoking.
Liposuction and the Effects of Smoking
Many patients feel they are stopping smoking to make the surgeon happy. Some don’t stop and tell the surgeon they have stopped. Often they stop for the surgery but start smoking immediately after. Then there is the patient who cheats once a day and feels that they maintain, with a straight face, that they really stopped smoking. If the patient and surgeon are lucky, the patient stops smoking long before the surgery, doesn’t cheat, and never smokes again. But, this is the real world.
It is our obligation to obtain an informed consent from the smoker that would include
• Discussing the effects of smoking on the surgery and wound healing.
• The need to avoid cheating even one time.
• Remaining off cigarettes until the internal wounds had healed.
• A discussion of the risks and complications of smoking directly related to their surgery.
There is no universally agreed time before or after surgery to refrain from smoking. A Canadian research study from an anesthesia group determined that months of cessation was necessary to prepare for surgery. On the other hand we know that nicotine and carbon monoxide cleared the body within two days. Neither study attended to the condition of the microcirculation.
For the purpose of liposuction refraining from smoking without cheating for one week before and two weeks after surgery would be appropriate until better scientific research says differently. Although there is a general medical consensus that the nicotine patch is not helpful for wound healing, there is no scientific evidence supporting that contention. In fact, a study by Yang and Longaker showed the nicotine patch did not cause the same “wound healing defect” found in the subjects that continued to smoke.
Hopefully as the use of cigarettes continues to decrease there will be fewer problems related to the ill effects caused by smoking. In the meantime be understanding of the smoker who also desires liposuction and encourage them to cease smoking for their own better outcome.