Smoking and surgery
– Not a good marriage!
The patient in the above photo has “delayed healing”. After a garage door falling on his head his surgeon created a skin flap in order to repair the damage. Being a regular smoker this skin flap has now died. Looking at the photo you can see necrosis happening around the edges of the wound. He now requires further surgery in hopes to save his scalp. However unless this patient stops smoking there is a chance the skin places there from further surgery could die again.
We all know we shouldn’t smoke, the media and billboards strategically placed in prime advertising locations spread the message daily. We should all know that smoking causes heart disease, strokes, arterial disease and certain types of cancer.
The evidence is irrefutable, the testimonials of smokers in advertising campaigns on television, confirms this, yet there are some individuals who continue to smoke and so endanger their health.
Smoking and surgery don’t go together. They are an extremely poor marriage. But why is this?
What is in cigarette smoke?
Nicotine is the most obvious and this is the ingredient that causes the” high” and the addiction. However there are many many other noxious chemicals in cigarette smoke including ammonia, Tolune and acetone which are used in things like paint stripper and industrial cleaners.
The long list of toxic chemicals should be enough to make anyone run a mile, however when considering surgery this list can have a tremendous effect on the healing process of surgery.
What happens during surgery?
During surgery a wound is created and that wound has to heal and mature. The initial healing takes place within the first 5 to 6 days whilst the maturation continues for up to 12 or even 18 months.
In the initial phase of healing a tiny blood clot is formed in the wound and this supports and nourishes the in growth of tiny blood vessels called capillaries. The capillaries transport oxygen and collagen that allow the two edges of the wound to come together and bind in a strong but supple scar.
What happens to smokers during the healing process?
In smokers several things happen to inhibit this healing process— some of the chemicals in cigarette smoke cause vasoconstriction or narrowing of the capillaries. This vasoconstriction is so intense it occurs every time cigarette smoke is inhaled.
As a result of the vasoconstriction of oxygen and other nutrients are unable to penetrate to the edge of the wound. The edge of the wound will then start to die – this is called necrosis.
Often this necrosis causes patients to worry- and when smokers are stressed what do they do? Smoke. This causes the necrosis to become more severe, leading to a condition called “delayed healing”.
What is Delayed Healing?
When delayed healing occurs due to smoking it can take many weeks of daily dressings to achieve a healed wound. This healed wound will be of greatly inferior quality to a wound that healed within a few days.
Significant scarring may result and further surgery will inevitably follow to try and improve the situation.
There are certain procedures that are more likely to result in delayed healing in smokers. These are procedures in which skin is tightened and excised such as facelift, neck lifts, tummy tucks, breast reduction, thigh lifts and arm lifts.
Smokers will occasionally say to me “Oh I will accept the risk of delayed healing” because they cannot stop smoking. However as a responsible surgeon I will turn these patients down for surgery because they do not really understand the full implications of delayed healing in these situations.
If a smoker wishes to have one of these skin tightening procedures I will advise that they need to be completely free of cigarettes for a minimum of 12 weeks prior to surgery. Trying to shortcut this smoke free period can be a recipe for disaster.
Dr Patrick Briggs