When to Stop Smoking Before Surgery (and Yes, We Test for Nicotine)

When should you stop smoking if you're planning on having an elective surgery? It's a question I get constantly, and the honest answer has three parts: why, when, and what happens if you tell us you quit and you haven't.

We have our patients stop smoking for a variety of reasons. The two big ones:

1. Pulmonary complications. Smoking can increase your risk of lung complications just from having any procedure at all.
2. Healing complications. This is the one that's especially problematic in certain plastic surgery procedures, like facelifts, breast lifts, or a mastectomy.

Those operations depend on the blood supply to skin that has been lifted and moved. It's the same reason smoking comes up when I talk about nipple blood supply in a breast reduction and about who is a good candidate for nerve grafting during reconstruction.

In plastic surgery, we're removing tissue and moving tissue around. In the biggest procedures, we completely remove a piece of tissue from your body, put it somewhere else, and sew tiny blood vessels together. So the area we operate on is starting from behind: it isn't getting its normal blood supply, which already causes issues with healing.

Then cigarettes do three things that are super problematic for healing:

1. Free radicals. You're inhaling free radicals, which damage your lungs. Damaged lungs don't move oxygen into the blood the way we'd like, so less oxygen gets to the areas that are healing. And in theory, while your body is busy healing free radical damage, it isn't focusing on healing your wounds.
2. Carbon monoxide. Cigarette smoke contains carbon monoxide, which binds to your blood cells and doesn't let them carry oxygen. That's even less oxygen in your blood for your surgical site to heal with.
3. Nicotine. Nicotine is a vasoconstrictor. It constricts blood vessels, and that can reduce blood flow to the areas that are healing. It's also why this applies to any nicotine product, not just cigarettes.

The cosmetic procedures where you'll hear plastic surgeons say absolutely no smoking, and where we're going to test you for nicotine, are facelifts, breast lifts, breast reductions, and tummy tucks. Those are the big ones.

Any type of lifting procedure is a setup for problems with smokers, because we're often removing tissue and rotating tissue.

In general, if you are a smoker, or if you use any nicotine products at all, to be honest, we're going to want you to stop at least four weeks before surgery.

Even more benefit is shown if you stop eight weeks or more before surgery. But at least four.

Four weeks is the floor, not the target. If you're given specific instructions for your procedure, those are the ones to follow.

As a patient, this can be really rough, because smoking is very, very hard to stop.

It's definitely something to talk to your primary doctor about if you're thinking about elective surgery. There are a variety of different options, even medications, that can help you stop.

And you want to start earlier than that four weeks, because you might struggle for the first couple of weeks. In general, I tell patients to start at least six weeks before their surgery.

That gives you a couple of weeks to see what works for you, and then, hopefully, that good four weeks of no smoking and no nicotine products before surgery.

The timeline doesn't end on the day of surgery. You don't want to smoke until you're well healed. That can be three weeks, and it can be three months. It really depends on the situation.

I want my patients to stay off for at least one to two months afterward, and longer if they're having any type of healing trouble.

I always tell patients this, because patients are surprised: we do check you for nicotine before surgery.

I know this feels yucky. Patients don't like it, because it feels like we don't trust you. But here's what actually happens:

It is so, so important with certain surgeries that there's no nicotine on board, because the complications can be absolutely horrific in plastic surgery, and we just don't want to take those risks with you.

So we are going to check your nicotine, almost certainly at your pre-op appointment, or even the day of surgery.

It is so important that you're honest with your team if you're unable to quit, because there are options we can help recommend for you.

Telling us ahead of time gives us the chance to help, which is the whole point of a pre-op evaluation that takes your health seriously. (It's also why I tell people that a consultation is not the time to be embarrassed about habits like smoking.)

• Stop smoking and all nicotine products at least four weeks before surgery. Eight weeks or more is better
• Start quitting at least six weeks out, so you have a couple of weeks to find what works
• Stay off after surgery, too: at least one to two months, and longer if you're having trouble healing
• Smoking hurts healing three ways: lung damage from free radicals, carbon monoxide crowding oxygen out of your blood, and nicotine narrowing your blood vessels
• Talk to your primary doctor. There are options, including medications, that help
• Expect to be tested for nicotine at your pre-op appointment or on the day of surgery
• If you can't quit, say so. We can help, but only if we know

And of course, we would love for you to stop and never start again. It's always best for your overall health, not just for your surgery.