Smoking and Plastic Surgery

Patients who smoke are a problem for plastic surgeons for multiple reasons.  It is a well-documented fact that smokers are much more likely to have wound complications especially with procedures that require undermining the skin such as face lifts and tummy tucks.  Smoking also affects the healing of all incisions whether undermining or not, and I think smoking is one of the causative factors for capsular contracture of breast implants (hardening of the breast implants).  Even those incisions that appear to heal initially are more likely to open after the sutures are removed and usually produce poor scars both in quality and appearance.  In scars that technically heal without “complication,” the period of time it takes for effective healing of incisions is longer than for non-smokers.  Once incisions have failed to heal, primarily the problems escalate.  In addition to poor quality scars, these incisions act as though they have an inadequate blood supply similar to scar healing after radiation therapy.  Open incisions are prone to bacterial infection and require a great deal of time and effort for local wound care.

Inhaled cigarette smoke also causes damage to living tissue causing bronchitis, wheezing, and eventually emphysema.  Intrinsic lung damage complicates the administration of general endotracheal anesthesia and blood oxygenation.  These pulmonary problems with smoking are not exclusive to plastic surgery patients, but nonetheless should be counted in our complication list for smokers.

There are several things that plastic surgeons can recommend to the smoker to mitigate some of the problems caused by smoking thereby reducing but not eliminating complications.  The most important thing a smoker can do is stop smoking.  There is data that suggests stopping smoking for two weeks before surgeries decreases smoking related complications.  A good pre-operative evaluation may uncover some pulmonary related problems such as congestion associated with bronchitis or bronchospasm.  Early recognition and treatment of those problems may reduce the pulmonary related complications.  Personally, I believe that staying away from general anesthesia if possible decreases smoking related risks.  Full monitoring with local anesthesia plus sedation decreases complications for smoking and stabilizes swings in blood pressure for both non-hypertensive and patients with hypertension.

Only those patients who refuse pre-operative instructions and cannot or will not stop smoking should not be accepted as a candidate for elective cosmetic surgery.  It is not clear if the wound problems are secondary to nicotine alone or a combination of nicotine and other toxic substances associated with cigarette smoke.  The data is unclear if using nicotine containing products to stop smoking causes the same level of wound problems associated with smoking.  Chantix® is a good alternative to stop smoking without using replacement nicotine (Nicorette®, etc.)

Patients should be careful to create a healthy non-stressful environment.  Recovery in a smoke-free environment is extremely important as second-hand smoke has been shown to be as harmful as first-hand smoke to wound healing.

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The MidFace Lift

Facial aging is complicated by genetics, environment, sun damage, smoking, and drinking.   There is not a single procedure that works for everyone, therefore it is important that individualized evaluation leads to an operation which is specific for that person.  The uniqueness of all faces as well as the patient’s desires may lead to a slightly different surgical approach for each individual.  Another way to say this is that the one-size-fits-all facelift has become antiquated.  To facilitate individualized care we prefer to look at each part of the face separately leading to a unique surgical treatment plan.

We divide the face into its component parts; forehead, eyes, midface, and neck with primary emphasis on the midface.  Midface aging is characterized by sagging of the facial soft tissues causing a deepening of the nasolabial folds, dark circles beneath the eyes, and the development of marionette lines from the corner of the mouth to the jaw line.  The jaw line becomes less defined as the sagging facial soft tissues drop below the mandible causing jaw line “bubble.”  In addition to the sagging soft tissues aging always involves a loss of volume and a loss skin elasticity.  It is the surgeon’s charge to address individual manifestations of aging for each component part of the face.  Elevating the soft tissues must be done and requires a specific vector or direction of elevation which may be unique for each face.  This maneuver defines the jaw line, improves the deep nasolabial folds, addresses the marionette lines, and elevates the lower eyelid skin.  This procedure is always required and must be performed accurately with minimal incisions.  Elevation of the cheek tissues is so important that it must be done under direct vision with the results being technique dependent.  The incisions are much less obvious than the old facelift scars.  While elevating the cheek and malar tissues some augmentation of the malar prominence (cheek bones) is achieved.  The need for additional volume can be affected by adding autogolous fat to the procedure.  As a rule of thumb, we rarely, if ever, remove fat from the midface but frequently add fat back to replace the soft tissues we lose over time.

The next issue to be addressed is the blending of the cheek elevation with the lower eyelids.  These procedures are typically done together; that is lower blepharoplasty and facelift.  The elegance and effectiveness of the mid-face lift sets up the rejuvenation of the remaining parts of the face.

Read more about Dr. Paul Howard’s Howard Lift Facelifts