August 14, 2008

Skin Deep

Want a Face-Lift? First, Better Stop Smoking

By ABBY ELLIN

LISA MORRISON has always considered herself a pillar of health. She ate only organic food, exercised often and meditated. The only glitch in her otherwise exemplary existence was the pack of Marlboros that she had inhaled daily since age 18.

By the time Ms. Morrison, now 50, went to see Dr. Vincent Giampapa, a board-certified plastic surgeon in Montclair, N.J., she had tried everything to quit for the sake of her health. "Acupuncture, the patch, hypnosis," she said. "Nothing worked."

Nothing, that is, until 2007, when Dr. Giampapa told her she would have to toss her beloved cigarettes if she wanted a neck- and eye-lift. "The doctor strongly suggested that if I wanted to heal properly I needed to quit," Ms. Morrison said. "When you start talking about your face, it becomes motivating."

Each year, roughly 40 to 45 percent of the 45 million smokers nationwide try to quit, according to Dr. Michael Fiore, the director of the University of Wisconsin Center for Tobacco Research and Intervention, in Madison. Only about 5 percent quit for life.

But these days, the growing number of cosmetic-surgery patients are motivated to quit for other reasons: vanity, and the threat of not being able to get a coveted new face, stomach or pair of breasts.

"When someone hears this from an internist or cardiologist who says it's really bad for you, it increases your risk of lung cancer, it's bad for your heart, people tend to blow that off if they're feeling well," said Dr. Alan Gold, the president of the American Society for Aesthetic Plastic Surgery. "But if they have a medical problem and are not going for just a routine checkup, they may tend to listen to that advice more.

"With plastic surgery it's a little bit different. People are desirous of an elective procedure, and that's their main objective in coming in. It's something they truly want."

For the last 5 to 10 years, many plastic and cosmetic surgeons have refused to operate on smokers, especially those seeking a face-lift, 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," said Dr. Darshan Shah, 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," said Dr. Patrick McMenamin, the president-elect of the American Academy of Cosmetic Surgery. "Nowadays if a doctor knew a patient was smoking and they did flap surgery," he said, referring to an operation where shifting skin is required, "many of us would say that's malpractice."

Plastic and cosmetic surgeons recommend quitting a minimum of two weeks before and after procedures, though some require longer to be extra safe. (Smokers also run the risk of infection and respiratory complications during anesthesia). For instance, Dr. Jeffrey Rosenthal, the chief of plastic surgery at Bridgeport Hospital in Connecticut, mandates six weeks of smoke-free living before eyelid surgery or breast augmentation, and six months to a year before a tummy tuck.

They also take it upon themselves to devise smoking cessation plans, prescribe drugs like Wellbutrin or Chantix and recommend hypnotists or support groups.

"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?" said Dr. Shirley Madhère, a plastic surgeon in Manhattan.

Nancy Irwin, a therapist and clinical hypnotist in Los Angeles, said that plastic surgeons refer 5 to 10 percent of her clientele. "They don't mind dying for cigarettes," she said of her patients, but if smoking gets in the way of their breast enhancement, "there's a problem."

"They're putting image before health," she said.

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 operations has skyrocketed — roughly 11.7 million cosmetic surgical and nonsurgical procedures were performed nationwide in 2007, up from 3 million in 1997, according to the American Society for Aesthetic Plastic Surgery — 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," said Dr. Roger Friedenthal, a board-certified plastic surgeon in San Francisco who refuses to operate on smokers.

The arsenal of non-nicotine antismoking aids have grown, too. "With the advent of things like Chantix, we have a much higher success rate," Dr. Shah said. (A caveat: this year, the Food and Drug Administration issued a warning against the drug, claiming it can cause depression and suicidal tendencies in some patients.)

Then there's the matter of the cosmetic surgeon's reputation. It can't help business if a cigarette-loving patient ends up looking like the Bride of Frankenstein.

"I take great pride in my work," said Dr. Rosenthal of Bridgeport Hospital, 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."

But all surgeons — and not just plastic or cosmetic — are increasingly urging patients to stop smoking before surgery, be it a face-lift or to repair an anterior cruciate ligament, Dr. Fiore said. It's not as if cosmetic surgeons are responsible for a major uptick in smoking cessation, he said, adding "this is not a prime driver of quitting in America."

No doubt some patients lie about kicking the habit. "Some won't, but will tell you that they have," said Dr. Scot Glasberg, a board-certified plastic surgeon in Manhattan. "These are all adults, and I'm not going to be the person looking over their shoulders."

The fact that some plastic surgeons do no more than check the condition of their patient's skin and smell for nicotine provides a substantial loophole.

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

Fear motivated Carolyn Davis, 42, a reformed social smoker in Sacramento, to quit cold turkey before her breast augmentation in 2005. "This was like the first major surgery I'd had as an adult," she said, "so when my doctor, who I respect, tells me not to smoke and here are some reasons why — then I have to respect that." (In the four years since surgery, she relapsed for just two days, she said.)

Dr. Pancholi, who is certified by the American Board of Cosmetic Surgery, takes scare tactics a step further. He shows patients graphic postoperative pictures of smokers who didn't heed his advice to quit. "They see the wound opening up, turning red or black, the edges start coming apart," he said. "They see the skin graft we use to put it back together."

Margaret Pyles, 42, a human resources director for youth homes in Bakersfield, first went to Dr. Shah in 2004, looking to have a breast reduction. He told her that she needed to quit a minimum of 30 days before the surgery. A pack-a-day smoker since 16, she couldn't face battling her addiction yet again.

But once her back pain grew constant, and her abdominal muscles too flabby for her taste, Ms. Pyles went back to Dr. Shah last month for a breast reduction and lift as well as a tummy tuck and liposuction. But not before she quit smoking with the help of Chantix and a hypnotist Dr. Shah recommended.

Both helped her overcome nicotine, she said, but fear really kept her on track. "I was afraid the anesthesia would go wrong, or I'd wake up coughing my head off and split my guts open," she said. "And I was able to stop."

Ms. Pyles, who has not lit up again, is thrilled that her desire to turn back the clock may help prolong her life. "I was so focused on wanting the breast reduction more than I wanted the cigarette," she said.

Copyright 2008 The New York Times Company