By Dr Scott J Turner, Specialist Plastic Surgeon | Sydney & Brisbane
Choosing to undergo facelift surgery represents a significant commitment to your appearance and well-being. Among the most critical steps you can take to support your safety and surgical outcomes is eliminating tobacco and nicotine products well before your procedure. Dr Scott J Turner, Specialist Plastic Surgeon practising across Sydney and Brisbane, has observed firsthand how smoking can substantially interfere with healing, elevate complication rates, and compromise the results patients hope to achieve from facial surgery.
This comprehensive guide outlines why nicotine cessation proves essential for safe facelift and neck lift procedures and what this means for your surgical outcomes.
Table of contents
Understanding How Tobacco Affects Surgical Healing
Compromised Circulation and Tissue Oxygenation
Tobacco smoke introduces thousands of harmful compounds into the bloodstream. Three substances prove particularly damaging to the healing process:
Nicotine: This potent vasoconstrictor may diminish blood flow to facial tissues by 30-40%, potentially depriving healing skin of vital oxygen and nutrients. Even brief exposure to nicotine can suppress tissue oxygen levels for extended periods, creating conditions unfavourable for proper wound healing.
Carbon Monoxide: This compound attaches to haemoglobin with approximately 200 times greater affinity than oxygen, potentially reducing your blood’s capacity to transport oxygen to surgical sites precisely when healing tissues require it most. In individuals who smoke heavily, this effect can substantially impair oxygen delivery to repositioned tissues.
Hydrogen Cyanide: This substance may directly inhibit cellular oxygen utilisation, compounding the oxygen deficit already created by nicotine and carbon monoxide exposure.
Implications for Facial Surgery
During facelift or neck lift procedures, facial skin undergoes careful elevation and repositioning. These elevated skin segments depend entirely on sufficient blood supply from underlying tissues for survival and proper healing. Blood must traverse small vessels within the subdermal vascular network to reach repositioned skin effectively.
In patients who do not smoke, the body typically establishes new circulatory pathways efficiently. In those who smoke, this essential process may become severely impaired, potentially creating oxygen-depleted conditions where healthy tissue healing cannot proceed normally. This principle applies across all facial procedures, including deep plane facelifts, vertical facelifts, and mini facelifts.
Effects on Cellular Repair Mechanisms
Smoking may also compromise the fundamental cellular processes required for healing:
Fibroblast Function: These cells generate collagen and facilitate tissue repair. Smoking may reduce their numbers and impair their activity, potentially slowing the wound healing process.
Collagen Production: Tobacco use may decrease the synthesis of the strong, healthy collagen essential for proper wound closure and optimal scar formation.
Immune Response: White blood cells may become less effective at preventing infection, with some studies suggesting bacteria-fighting capacity may be reduced by approximately 50%.
Potential Complications for Patients Who Smoke
Skin Necrosis: The Primary Concern
Skin necrosis—the death of tissue due to insufficient blood supply—represents the most significant complication facing patients who smoke when undergoing facelift surgery. Research indicates that smokers may experience up to 12.5 times higher risk of developing necrosis compared with non-smokers.
Areas commonly at risk include the postauricular region (behind the ears), near the ear canal (tragal incision sites), and the submental area (beneath the chin). These locations represent the tissues furthest from the blood supply following surgical repositioning.
When necrosis develops, consequences may include open wounds necessitating extended wound care over many weeks, requirement for additional surgical procedures, permanent scarring, and substantially compromised aesthetic outcomes. For comprehensive information, consult our guide on risks and complications following facelift surgery.
Other Significant Complications
Elevated Infection Risk: Studies suggest patients who smoke may experience infection rates two to three times higher than non-smokers, with some research reporting 12% infection rates among smokers compared with approximately 2% in non-smoking patients.
Unfavourable Scarring: Impaired collagen synthesis may result in wider, thicker, raised, or discoloured scars that can compromise the aesthetic objectives of facial surgery.
Prolonged Healing: Nicotine exposure alone may potentially extend healing time by 20-25%, prolonging recovery and delaying the appearance of final results. Learn more about expectations in our guide to recovery following facelift surgery.
Wound Separation: Research suggests approximately 12% of patients who smoke may experience wound dehiscence (wounds separating) compared with 0% among non-smoking patients.
Anaesthetic and General Health Considerations
Smoking may also increase risks during the surgical procedure itself, including elevated rates of respiratory complications, increased anaesthetic requirements, heightened blood clot risk, and greater cardiovascular stress throughout the operation.
Why Vaping and E-Cigarettes Pose Similar Risks
A prevalent misunderstanding among patients is that transitioning from traditional cigarettes to e-cigarettes or vaping devices represents a “safer” alternative before surgery. This assumption is incorrect.
Nicotine Remains the Central Problem
Whilst e-cigarettes eliminate combustion byproducts such as tar and carbon monoxide, they deliver the primary vascular offender: nicotine. The vasoconstriction caused by nicotine—regardless of delivery method—creates identical threats to skin flap survival.
Contemporary “pod-mod” vaping devices frequently deliver substantially higher nicotine concentrations than traditional cigarettes. The highly bioavailable nicotine salts utilised in these devices permit rapid saturation of nicotinic receptors, potentially inducing significant vasoconstriction.
Research has demonstrated that a single vaping session may cause acute endothelial dysfunction and vascular stiffness comparable to combustible cigarettes. Case reports have documented extensive skin flap necrosis in patients who used e-cigarettes around the time of surgery, confirming that the absence of smoke does not eliminate ischaemic risk.
Cessation Timeline: When to Stop
Pre-Operative Requirements
Minimum 6-8 weeks before surgery: Complete cessation of all nicotine products is essential. Leading medical organisations consistently advocate this timeline.
Each additional week of cessation may contribute to a 19% improvement in reducing postoperative complications.
Post-Operative Continuation
Throughout the recovery period (12+ weeks): Continued abstinence during healing is equally critical. The body’s repair processes—including new blood vessel formation, collagen deposition, and tissue remodelling—remain susceptible to nicotine’s harmful effects for months following surgery.
How Quickly Your Body Recovers
Your body may begin recovering from smoking damage remarkably quickly. Oxygen-carrying capacity may begin normalising within 72 hours. Proper fibroblast activity may start restoring within three weeks. Healthy collagen production may begin re-establishing within six weeks. Lung function may improve within six to eight weeks, potentially reducing anaesthetic risks.
Studies indicate that stopping smoking may reduce overall post-surgical complications by 50% and decrease wound-related problems by up to 70%.
All Nicotine Products Must Be Eliminated
Smoking cessation means eliminating all nicotine sources, not merely cigarettes. This includes e-cigarettes and vaping devices, nicotine patches and gums, smokeless tobacco products, and significant second-hand smoke exposure.
One study comparing complication rates found that patients using nicotine replacement therapy or e-cigarettes had complication rates of approximately 50%, compared with 25% in active smokers and 6% in abstinent patients. This suggests that nicotine replacement may present at least equivalent risk to continued smoking for skin flap survival.
Alternative cessation support: Patients requiring assistance may wish to discuss non-nicotine medications (such as Champix or Zyban) with their GP, keeping their surgeon informed.
Pre-Surgical Verification and Testing
Many plastic surgeons, including Dr Turner, may utilise cotinine testing to verify nicotine-free status before proceeding with elective facial procedures. Cotinine, a nicotine metabolite, remains detectable for several days following nicotine exposure. This objective testing serves as a safety verification measure. A positive result may require postponing surgery until complete cessation can be confirmed.
Complete transparency regarding smoking habits is essential for your safety. Your surgical team requires accurate information to assess your individual risk profile, plan the safest surgical approach, and determine whether proceeding with surgery is advisable.
Research suggests that approximately 16-26% of patients who identify as “non-smokers” or “former smokers” test positive for active nicotine metabolites, underscoring the importance of objective verification for patient safety.
Moving Forward with Your Facelift Consultation
A facelift represents a significant investment of time, resources, and emotional energy. Smoking cessation is among the most powerful steps you can take to protect this investment by minimising the risk of serious complications and maximising the likelihood of achieving your desired outcomes.
This principle applies equally to all facial procedures, whether you are considering a deep plane facelift, ponytail facelift, neck lift, or blepharoplasty.
During your consultation at our Sydney or Brisbane clinics, Dr Scott J Turner will discuss your individual risk factors and develop a personalised surgical plan tailored to your specific circumstances and goals.
For additional information on surgical preparation, visit our resource on preparing for surgery. Patients travelling from regional areas or interstate may find our out-of-town patients page helpful.
Ready to discuss your facelift surgery options? Contact us today to schedule your consultation with Dr Scott J Turner, Specialist Plastic Surgeon.
