By Dr Scott J Turner, Specialist Plastic Surgeon (FRACS) | Bondi Junction, Sydney
If you smoke and you’re planning facelift surgery in Sydney, here’s where I’d start. Not the incision approach, not the recovery timeline. This.
Nicotine is the most preventable risk factor I deal with in facelift surgery — and one patients routinely underestimate. At my Bondi Junction clinic, it comes up in every consultation with anyone who uses tobacco or nicotine products. Every single one. Because the consequences of not having this conversation are genuinely serious.
Explore topics on this page
What Smoking Does to Healing Skin
Here’s the basic anatomy worth understanding. When I perform a facelift, I lift and reposition facial skin away from the underlying structures. That elevated skin then has to survive on blood supply coming through very small subdermal vessels. We’re talking tiny. And those vessels need to be working well.
Nicotine causes them to constrict. Blood flow drops. Oxygen delivery to the repositioned tissue drops with it.
Carbon monoxide from cigarette smoke makes things worse — it binds to haemoglobin at a rate roughly 200 times higher than oxygen does. So not only is less blood reaching the tissue, the blood that does arrive is carrying less oxygen. Both mechanisms active at the same time, right when the skin most needs support.
Several peer-reviewed studies in plastic surgery literature have confirmed dramatically higher complication rates in smokers undergoing facial surgery compared with non-smokers. What I see in clinic aligns with that research.
The Complication That Concerns Me Most
Skin necrosis. Tissue death from insufficient blood supply. It’s the worst outcome in facelift surgery, and smokers face a risk roughly ten to twelve times higher than non-smokers. Not a small statistical uptick — a fundamentally different risk category.
The zones most at risk are predictable: behind the ears, around the tragus, under the chin. These are the areas furthest from reliable circulation once the skin has been repositioned. In non-smokers, new vascular connections form efficiently. In smokers, that process can fail outright.
What follows when necrosis occurs is difficult. Open wounds that take weeks to close. Additional procedures. Permanent scarring in the exact areas where facelift surgery is designed to be discreet.
It can fundamentally change what’s possible to achieve. Read through the facelift surgery risks and complications page if you want a fuller picture.
Other Complications Worth Understanding
Necrosis gets the most attention, but it’s not the only concern.
Increased Infection Risk
Smokers undergoing facial surgery show infection rates two to three times those of non-smokers in the published literature. Immune cell function is impaired, tissue oxygenation is reduced, and bacteria exploit both. Wound dehiscence — wounds that separate rather than heal closed — occurs in around 12% of smokers in some studies. In non-smokers, that figure approaches zero.
Poor Scar Quality and Wound Healing
Collagen synthesis is disrupted when nicotine is present. The collagen that forms tends to be less organised, which translates to scars that are thicker, wider, or more visible than they should be. For procedures like SMAS facelift, deep plane facelift, or Vertical Restore Facelift — where incisions run close to the ear and hairline — that matters enormously.
Recovery also takes longer. The facelift recovery timeline is already something patients need to plan around; nicotine stretches it out further.
Vaping Isn’t a Safe Alternative
I get asked about this constantly. Patients make the switch from cigarettes to vaping in the weeks before surgery, thinking they’ve addressed the problem. They haven’t.
The substance causing the surgical risk is nicotine — not tar, not combustion products. Nicotine. Vaping delivers it. Pod-style devices often deliver it in higher concentrations than traditional cigarettes. A single session has been shown to produce measurable vascular dysfunction comparable to smoking.
Case reports in the surgical literature document extensive skin flap necrosis in patients who were vaping around the time of their procedure. No smoke doesn’t mean no risk.
Patches, gums, and lozenges fall into the same category. Counterintuitively, patients using nicotine replacement therapy at the time of surgery appear to have complication rates similar to active smokers — because the nicotine itself is the problem. Every source needs to stop.
When to Stop, and for How Long
Six to eight weeks before surgery, minimum. That’s the standard I apply. It’s not arbitrary — it reflects how long the vascular system takes to begin recovering meaningfully.
Blood oxygen-carrying capacity starts improving within 72 hours of cessation. Fibroblast function and collagen production begin recovering within a few weeks. Each additional week without nicotine reduces overall complication risk further.
After surgery, cessation needs to continue through recovery — at least twelve weeks post-operatively. Healing isn’t complete when you leave hospital. New vessels are still forming, collagen is still being laid down, tissues are still remodelling. Restarting nicotine midway through that process undermines it.
Struggling to stop? Non-nicotine options like varenicline or bupropion can help. Talk to your GP well before your surgical date — not the week before.
How Surgeons Screen for Smoking Before Facelift Surgery
I use cotinine testing before proceeding with elective facial surgery. Cotinine is what nicotine metabolises into, and it stays detectable in urine or saliva for several days after any exposure.
Why test rather than just ask? Because research shows between 16 and 26 percent of patients who self-report as non-smokers or ex-smokers return a positive cotinine result. That’s a significant proportion. Objective verification protects the patient — it’s the only way to know the information I’m basing surgical decisions on is accurate.
A positive result means postponing. There’s no workaround. The risks of proceeding with active nicotine are too serious.
Before Your Consultation
Whether you’re looking at a neck lift, ponytail facelift, revision facelift, or one of the deeper facelift techniques — smoking cessation has to start before you book, not after. The six-to-eight-week window runs from your last nicotine exposure. Not from the date you decided to quit.
Book a facelift consultation in Bondi Junction with Dr Scott J Turner, Specialist Plastic Surgeon, to talk through your goals and what pre-surgical preparation looks like for your situation. Interstate or regional patients can find relevant information on the out-of-town patients page.
