For the last 5 to 10 years, plastic and aesthetic surgeons have refused to operate on smokers, especially those seeking a facelift, tummy tuck, or breast-lift procedures that require skin to be shifted.

“Nicotine causes the tiny blood vessels in the skin to clamp down or constrict, which reduces blood supply to the skin,” says Darshan Shah, MD, a plastic surgeon in Bakersfield, Calif. "Complications can include poor wound healing, increased risk of infection, longer-lasting bruises, and raised, red scars."

“Twenty-five years ago, it may have been more acceptable for a patient to have undergone surgical procedures while smoking,” says Patrick McMenamin, MD, president-elect of the American Academy of Cosmetic Surgery. “Nowadays if a doctor knew a patient was smoking and they did flap surgery,” he says, referring to an operation where shifting skin is required, “many of us would say that’s malpractice.”

Plastic and aesthetic surgeons recommend quitting smoking a minimum of 2 weeks before and after procedures, though some require longer to be extra safe. Jeffrey Rosenthal, MD, chief of plastic surgery at Bridgeport Hospital in Connecticut, mandates 6 weeks of smoke-free living before eyelid surgery or breast augmentation, and 6 months to 1 year before a tummy tuck.

“Why invest so much money in a cosmetic procedure for enhancement if the patient will not participate and do his or her part to help ensure the best outcome possible?” says Shirley Madhère, MD, a plastic surgeon in Manhattan, NY.

Nancy Irwin, a therapist and clinical hypnotist in Los Angeles, says that plastic surgeons refer 5% to 10% of her clientele.

“They don’t mind dying for cigarettes,” says Irwin, "but if smoking gets in the way of their breast enhancement there’s a problem. They’re putting image before health."

Plastic surgeons cite a few reasons why now, more than ever, they require patients to kick the habit. In recent years, as the number of surgeries has skyrocketed, more people (and smokers) are coming through the doors.

Since most plastic surgery is elective, plastic surgeons have time on their side as opposed to, say, a heart surgeon.

“You can talk to people about quitting smoking, but you may not have a month’s worth of time before you try to save their life with heart surgery,” says Roger Friedenthal, MD, a board-certified plastic surgeon in San Francisco who refuses to operate on smokers.

“I take great pride in my work,” says Rosenthal, who estimates that more than two-thirds of his patients who smoke quit for good. “I want it to look great for you as well as for myself. If they smoke even one cigarette, I run the risk of it not healing. It’s like trying to water your lawn with a crimped hose.”

No doubt some patients lie about kicking the habit.

Some physicians want proof. Samir Pancholi, MD, a board-certified aesthetic surgeon in Las Vegas, obtains a urine test; Madhère asks patients to sign a legal waiver stating whether they have stopped smoking and acknowledging the postoperative risks and potential complications of smoking.

“Some won’t, but will tell you that they have,” says Scot Glasberg, MD, a board-certified plastic surgeon in Manhattan. “These are all adults, and I’m not going to be the person looking over their shoulders.”

[New York Times, August 13, 2008]