“I quit smoking for this.” Patients say it at the consult and they mean it. They have done the hard thing.
Then I ask about the pouches.
“Any type of nicotine is the same, and this is something patients don’t realize. They think that because we say smoking, we just want them to stop smoking. But any other form, like Zyn or dip or vaping, the patches and the gum, they all have nicotine.”
The wound does not care how the nicotine arrived. It only knows that the smallest vessels feeding it have closed.
“They have the same effect, which is they constrict the small capillaries that carry the nutrients and the growth factors and cells to the scar area to repair and heal. When these vessels clamp down, the flow of blood to these areas is decreased to the extent that we may have wound openings or even skin death.”
Skin death. I use the words on purpose, because I have seen it and patients have not.
“We see the complications most often in tummy tucks, where there can be loss of skin in the inferior portion, in breast surgeries, where there can be loss of the nipple and areolar complex or breast skin, and in facelifts, where there can be necrosis of the skin flaps that we elevate. These all end up with bad scarring.”
Those three operations are the ones I refuse.
“If I know a patient is smoking, I will refuse to do most procedures, but especially any facelift or neck lift, any breast lift or breast reduction, and tummy tucks. All these procedures rely on flaps and capillary blood flow.”
A flap is skin I lift and move while it stays attached at one edge. That edge is its whole blood supply until new vessels grow in. Nicotine is the thing that stops them growing.
The rule itself is short.
“We want patients off of nicotine at least two weeks before and two weeks after, preferably two weeks or longer before and none after.”
I do not test for it as a routine.
“I don’t nicotine test patients routinely, unless there is a question or a doubt. I do communicate very strongly with patients about what the consequences can be, and I trust that my patients are responsible adults who will comply, because they don’t want to have complications.”
Two more questions come up in the same breath, and they have different answers.
Cannabis first. It is not a nicotine problem.
“Marijuana and cannabis vapes are a little bit different. They don’t usually have nicotine, but the smoke itself does cause airway reactivity and can interfere with general anesthesia. So I also recommend at least two weeks before and two weeks after to stay away from it.”
Same window. Different organ. The airway belongs to the anesthesiologist, and I do not argue with anesthesiologists.
Then the partner. Someone always asks about the partner.
“Secondhand smoking is just as bad as firsthand smoking, as the nicotine effect will clamp down the capillaries. So patients should stay away from partners that smoke. We don’t want to do a nicotine replacement during recovery because the nicotine will have the same effect in a gum or a patch as if the patient was smoking.”
So no patch, no gum, and no sleeping next to someone who smokes, for two weeks on either side of the date.
When the answer about the pouches is yes, the surgery moves. Not cancelled, moved. Patients are annoyed for about a week and grateful for the rest of their lives, because the alternative is a scar I cannot fix.
That is the whole post. The wound does not care how the nicotine arrived.
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