The effects of smoking on wound healing

Smoking is an important and preventable lifestyle factor that affects both the rate and quality of wound healing, and it significantly increases the risk of postoperative, wound-related complications (Manassa et al, 2003). Since the 1940s, there has been increasing evidence that smoking has a negative impact on both wound healing and tissue repair (Sorensen, 2012), with longer-term complications, such as fistulas and incisional hernia, linked to smoking (Sorensen et al, 2005). Many investigations have reported that smokers have more postoperative complications than nonsmokers (Kean, 2010). For example, in patients undergoing elective abdominoplasty, 48% of smokers were found to experience problems with necrosis, infection or skin sloughing, compared with only 15% of non-smokers (Manassa et al, 2003). In an investigation into elective breast surgery, smoking was shown to increase the risk of mastectomy flap and abdominal wall necrosis following flap reconstruction, with a significant increase in wound healing problems following reduction mammaplasty (Chan et al, 2006). The problems with smoking are especially profound following aesthetic surgery. Smokers undergoing facelifts were found to suffer more likely from skin slough, had significantly higher overall complication and tissue necrosis rates, and often required further surgery (Rees et al, 1984). A randomised controlled trial (RCT) examining the effects of smoking on wound healing complications involved 78 healthy volunteers with uniform elective incisional wounds. The results showed a higher rate of wound infection in the current smoking group, with 12% of wounds infected compared with only 2% of wounds in the never-smoking group. There was also a significant difference in wound dehiscence, with 12% of the smokers’ wounds breaking down in the absence of infection, compared with no dehiscence in the non-smokers. There were no wound-healing differences between the abstaining smokers and the continuing smokers after 4, 8 or 12 weeks (Sorensen et al, 2003). These complications, in turn, result in longer hospital stays, higher rates of intensive care unit admission, greater need for repeat surgery and higher overall cost of care. Smoking at the time of surgery is also associated with inferior long-term surgical outcomes and decreased overall patient satisfaction with the procedure (Khullar and Maa, 2013). These effects also have serious financial implications during the first year after hospital discharge (Warner et al, 2014).