Stopping Smoking Before Surgery

 Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Physicians and surgeons all agree on the link between smoking and postoperative complications.  We don’t agree (or know) how much time is required between cessation of smoking and surgery for optimal risk reduction.

Dr.Thomas Fiala wrote a nice blog post, Smoking Cessation and surgical complications, recently  discussing the 3rd reference article below.

Smokers that quit smoking before surgery had 41% fewer complications. The researchers found that each week of cessation increases the effect by 19%.

Trials of at least 4 weeks' smoking cessation had a significantly larger treatment effect than shorter trials (P = .04).

Smokers that quit had lower rates of total complications, fewer wound healing complications, and fewer pulmonary complications.

The first two articles referenced below were evaluated in an article written by Michael Smith for MedPage Today:  Smokers Who Quit Preop Seem to Do Okay Postop.  Those two articles looked at pulmonary complications not wound healing complications.

There was also no significant benefit or harm when the analysis was restricted to the three studies with biochemical validation of quitting, the researchers reported. The relative risk was 0.57, with a 95% confidence interval from 0.16 to 2.01.

As noted by Clara and Chow (2nd reference, review of 1st reference article) (bold emphasis is mine):

While the review performed by Myers et al provides valuable information, it does not definitively answer the question raise……

Physicians should ideally try to get their patients to stop smoking several months prior to their surgery. The appropriate advice regarding the optimal timing of smoking cessation for patients seen close to their scheduled surgery awaits further research.

I tend to agree with Dr. Fiala who writes, “There is no safe minimum number of cigarettes that you can sneak before surgery. Even a couple can do you in.”

Related posts
Smoking in Facial Aesthetic Surgery Patients (December 28, 2009)


REFERENCES

1.  Stopping smoking shortly before surgery and postoperative complications: A systematic review and meta-analysis; Katie Myers; Peter Hajek; Charles Hinds; Hayden McRobbie; Arch Intern Med. 2011;0(2011):archinternmed.2011.97.

2.  The optimal timing of smoking cessation before surgery; Clara K. Chow; P. J. Devereaux; Arch Intern Med. 2011;0(2011):archinternmed.2011.88.

3.  Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis; Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO; The American Journal of Medicine - February 2011 (Vol. 124, Issue 2, Pages 144-154.e8, DOI: 10.1016/j.amjmed.2010.09.013)

Primary Breast Abscess Risk Factors

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.

 

A recent article in the July issue of the Journal of the American College of Surgeons (full reference below) looked at the risk factors for developing a breast abscess.

It is a case control study of 68 patients with a primary breast abscess. Several (36/68) developed a recurrence as defined by the need for repeated drainage within 6 months.

They found

Univariate analysis indicated that smoking (odds ratio [OR] 8.0 [95% CI 3.4 to 19.4]), obesity (OR 3.6 [95% CI 1.5 to 9.2]), diabetes mellitus (OR 5.7 [95% CI 1.1 to 54.9]), and nipple piercing (OR 10.2 [95% CI 1.3 to 454.4]) were significant risk factors for development of primary breast abscess.

Recurrent breast abscess occurred in 36 (53%) patients. Multivariate logistic regression identified significant OR for an increase in recurrence related to age (OR 1.08 [95% CI 1.01 to 1.15] per year), smoking (OR 14.73 [95% CI 3.18 to 68.22]), surgical treatment (11.94 [95% CI 1.08 to 131.72]), and a decrease in recurrence after MRSA infections (OR 0.02 [95% CI 0.00 to 0.72]).

I think perhaps this article has too small a number of individuals, but find their numbers interesting.
The eMedicine overview (second reference below) does not even address possible infections from nipple piercing, suggesting:

Mastitis is usually seen in lactating women, but the presence in a nonlactating woman should spur evaluation for an inflammatory carcinoma or new-onset diabetes.⁶

Causes of primary breast infections are most likely to be Staphylococcus aureus and streptococcal species. Nonpuerperal abscesses typically contain mixed flora (S aureus, streptococcal species) and anaerobes.

The eMedicine article does recognize a correlation between breast infection and smoking:

A study by Schafer et al found a significant correlation between cigarette smoking and subareolar breast abscess.¹²

So while the article may have a small number of individuals, it is probably safe to say that being overweight, having diabetes mellitus, and smoking all make your risk of having a breast infection higher. By how much is more difficult to say.

REFERENCE

Risk Factors for Development and Recurrence of Primary Breast Abscesses; Vinod Gollapalli, Junlin Liao, Amela Dudakovic, Sonia L. Sugg, Carol E.H. Scott-Conner, Ronald J. Weigel; Journal of the American College of Surgeons - July 2010 (Vol. 211, Issue 1, Pages 41-48, DOI: 10.1016/j.jamcollsurg.2010.04.007)

Breast Abscess and Masses; eMedicine article, May 13, 2010; Andrew C Miller, MD, Tajinderpal S Saraon, MD, and Mark A Silverberg, MD, FACEP, MMB

World No Tobacco Day

Updated 3/2017 -- photos and all links removed as many no longer active.

Today is Memorial Day in the United States.  It is also the day the  the World Health Organization (WHO) has chosen to bring worldwide focus on tobacco use prevention and cessation.  The theme of World No Tobacco Day 2010 is  "Gender and tobacco with an emphasis on marketing to women."

According to WHO, women comprise about 20% of the world's more than 1 billion smokers.  Young girls/women are often the target of  the tobacco industry marketing. 

As with tanning, young girls don’t often respond to being told about the serious health risks (cancer, COPD, emphysema, heart disease, stroke, etc) as they still feel invincible.  So perhaps instead of telling them that the adverse health effects from cigarette smoking account for an estimated 443,000 deaths, or nearly 1 of every 5 deaths, each year in the United States, we should focus on how smoking isn’t good for their looks.

So perhaps as WHO’s posters suggest, we should focus on how smoking is UGLY.  How smoking  can discolor their teeth and fingertips.  Perhaps we should focus on how smoking increases wrinkling and premature aging of the skin.

Perhaps if we show them the effects of mouth and throat cancer which are visible in a way that lung cancer isn’t, they might get it.

Sources
World Health Organization
Quit Smoking (US Dept of Health)
Centers for Disease Control and Prevention

Smoking in Facial Aesthetic Surgery Patients

Just finished reading a CME article on “Aesthetic  Surgery of the Face and Neck” in the Nov/Dec issue of the Aesthetic Surgery Journal (the first article referenced below).  Nice review article, but I want to just concentrate on the section on smoking.  This is the time of year when many resolutions are made, and often to quit smoking is one of them. 

One of the major things to avoid pre- and post-facial surgery is smoking.  The other major one is platelet inhibitors (ie aspirin, NSAIDs, and certain herbals).

The logic for smoking avoidance is because “tobacco smoke is an aerosol of particulate matter, volatile acids and gases.  The overall cellular effect of these inhaled or absorbed byproducts is to produce an environment of relative tissue hypoxia, and delayed wound healing mediated by vasoconstriction, abnormal cellular function, and thrombogenesis.” [second reference]

The reported incidence of facelift skin flap necrosis is 12.5 times greater in smoker than nonsmokers.  This risk is too high for elective surgery, so no surgeon will knowingly operate on the face of a smoker electively.

Even smoking one cigarette has been shown to cause temporary vascular spasm which can last up to one hours.  This vascular spasm can result in 24-42% decrease in blood flow.  This can lead to skin necrosis, poor wound healing, and increase infection.

The current recommendation for elective facial surgery is smokers is patients remain nicotine-free for four weeks before surgery and for four weeks after surgery.

Patients often underreport their smoking.  To “test” their truthfulness, a salivary rapid test (NicAlert) has been developed which test for cotinine, the metabolic breakdown product of nicotine.

I would encourage all smokers to quit just for general health benefits.  Keep trying.  If one method doesn’t work for you, work with your primary care physician to find one that does.

 

 

REFERENCE

Aesthetic Surgery of the Face and Neck; Aesthetic Surgery Journal, November 2009, Vol. 29, Issue 6, Pages 449-463; Fritz E. Barton (DOI: 10.1016/j.asj.2009.08.021)

Clearing the Smoke:  the Scientific Rationale for Tobacco Abstention with Plastic Surgery; Plastic and Reconstructive Surgery. 108(4):1063-1073, September 15, 2001; Krueger, Jeffery K.; Rohrich, Rodney J.

The Effect of Cigarette Smoking on Skin-Flap Survival in the Face Lift Patient; Plastic and Reconstructive Surgery. 73(6):911-915, June 1984; Rees, Thomas D.; Liverett, David M.; Guy, Cary L.

Planning Elective Operations on Patients Who Smoke: Survey of North American Plastic Surgeons; Plastic and Reconstructive Surgery. 109(1):350-355, January 2002; Rohrich, Rod J.; Coberly, Dana M.; Krueger, Jeffery K.; Brown, and Spencer A.