Plastic Surgery and Smoking

Abstract

Sir: We read with great interest your publication entitled “Plastic Surgery and Smoking: A Prospective Analysis of Incidence, Compliance, and Complications” by Coon et al. (Plast Reconstr Surg. 2013;131:385–391). We agree with the authors that a methodologic approach to the detection and management of patients using tobacco products can help to optimize outcomes. Smoking is one of the leading risk factors for all diseases worldwide and damages the body irreversibly when patients smoke for many years; patient smoking status affects many aspects of plastic surgery, including patient selection, counseling, management, and outcomes.1 Smoking has negative effects on the cardiovascular, pulmonary, mucous membranes, skin, and muscles.2 The skin of a smoker appears yellowish (with poor tissue under epidermis) and dehydrated, and in most cases with postoperative scars that are not as good. As the authors stated in the article, necrosis is a complication that is created in most patients who are heavy smokers, and generally represents one of the most uncomfortable complications in plastic surgery. But how should these complications be prevented? As doctors, we care about patients’ health and therefore discourage smoking. Patients who are strongly motivated to undergo cosmetic surgery, particularly women, have found a weapon with this strong motivation to help them resist smoking. Knobloch et al.3 affirmed that 4 weeks of abstinence from smoking reduces smoking-associated complications, and Chang et al.4 affirmed that, in patients undergoing free transverse rectus abdominis musculocutaneous flap breast reconstruction, smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery. However, according to our practical experience, we advise patients that ceasing smoking 6 weeks before surgery dramatically improves the postoperative period and decreases the incidence of complications, and 6 months is not long enough to define a patient as nonsmoking. When the medical history of the patient is being obtained at the time of hospitalization for surgery, the important questions are, “Do you smoke? How many cigarettes a day? For how many years?” The answers to these questions can justify alterations in hematology, or data may affect the choice of intervention to implement. According to the World Health Organization, a smoker can no longer be considered as such after 5 years of smoking cessation. For example, mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction.5 Breast reconstruction should be performed with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Patients who wish to undergo plastic surgery are also highly motivated to have a postoperative course without complications, and then decide to stop smoking in the preoperative period. Only a few of them are able to totally eliminate their dependence on smoking. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mauro Barone, M.D. Annalisa Cogliandro, M.D. Paolo Persichetti, M.D., Ph.D. Plastic, Reconstructive, and Aesthetic Surgery Unit Campus Bio-Medico University of Rome Rome, Italy