On smoking and surgery: an honest position.

Every surgeon at NCSS handles smoking status differently. That range of positions is itself the point — and it's why we don't offer a single site-wide policy that pretends the question is simple.

If you have consulted a plastic surgeon anywhere in the country and told them you smoke, you know the range of responses. Some surgeons decline to operate on active smokers entirely. Some require documented cessation for four to six weeks. Some proceed with a discussion of elevated risk. Some ask, some don't.

At Newport Center for Special Surgery, all of these responses exist among our nine affiliated surgeons. We have chosen not to standardize them. This is deliberate.

Why smoking matters for surgery.

Nicotine is a vasoconstrictor. It narrows the small blood vessels that carry oxygen and nutrients to healing tissue, and it does so systemically — not just at the site of exposure. For surgery involving skin flaps (facelift, tummy tuck, breast lift, body lift, brachioplasty), this matters clinically. Skin flaps depend entirely on their remaining blood supply for survival. Compromise that blood supply and the tissue can die — a condition called skin flap necrosis.

The clinical evidence for smoking's impact on flap survival is not controversial. It has been documented across dozens of studies over four decades. Whether a specific patient will experience a complication because of their smoking is impossible to predict. What is predictable is that the population of smokers has substantially worse outcomes for these procedures than the population of non-smokers. That much is settled science.

The range of surgeon responses.

What is not settled — what remains a legitimate matter of clinical judgment — is how a specific surgeon should respond to a specific patient who continues to smoke.

• The absolute-refusal position. Some surgeons, including Dr. Nichter at NCSS, will not perform surgery on active smokers. Their reasoning is straightforward: the elevated risk is not shared equally between surgeon and patient. The surgeon's professional reputation and psychological wellbeing depend partly on outcomes; when a preventable complication occurs, the surgeon carries that too. Refusing to operate on smokers is a form of professional autonomy that also happens to protect the surgeon.
• The documented-cessation position. Many surgeons require verified smoking cessation (sometimes with cotinine testing) for a defined period pre-operatively — commonly four to six weeks, sometimes longer for large-flap surgery. This is the mainstream position in plastic surgery today.
• The informed-proceed position. Some surgeons will operate on smokers who choose to continue smoking, after a candid discussion of the elevated risk. This position rests on a principle of patient autonomy: the patient has been informed, the patient has chosen, and the surgeon is willing to accept the shared risk.

Each of these positions is medically defensible. Each is held by ethical, well-trained plastic surgeons at NCSS and elsewhere.

Why we don't standardize.

An affiliated-surgeon facility could theoretically impose a facility-wide rule: no surgery on smokers, period. Some facilities do. We have chosen not to, for two reasons.

First, imposing a rule on nine independent surgeons would be inappropriate. These are practitioners with their own credentialing, their own professional judgment, and their own relationships with their patients. Their positions on smoking reflect years of clinical thought and experience. Overriding those with a facility policy would be presumptuous.

Second, patients benefit from the range. A patient who smokes and knows they cannot stop before surgery may benefit from consultation with a surgeon in the informed-proceed camp; the same patient after successful cessation may then consult with a surgeon in the documented-cessation camp for a follow-up procedure. The range of positions on our roster serves the range of patients who walk through our door.

What we do standardize.

Regardless of individual surgeon position, three things are consistent at NCSS:

A note on marijuana and vaping.

We are transparent about a common misconception: marijuana and vaping products carry the same vasoconstrictive risks as combustible cigarettes when nicotine is present, and marijuana specifically carries additional airway-inflammation concerns that matter for general anesthesia. The clinical guidance is the same: as much time as possible between last use and surgery.

What to expect if you smoke.

If you are a smoker considering surgery at NCSS, expect to be asked directly. Expect an honest conversation about your specific procedure, your specific risks, and your specific readiness. Expect your surgeon to have a defined position, and expect it to be either that they will not operate on you until you have stopped, or that they will proceed with clear-eyed discussion of the elevated risk.

Neither response is a moral judgment about you. Both are considered clinical positions from surgeons who have thought carefully about how to serve patients like you.

The one thing you should not expect is a surgeon at NCSS who tells you smoking doesn't matter, or one who agrees to a procedure without asking about it first. Those surgeons are not on our roster, for reasons the range of our positions above makes clear.

H. Rand Scott, MD is founder and Medical Director of Newport Center for Special Surgery. Board-certified anesthesiologist, subspecialty training in interventional pain management at Penn State Milton S. Hershey Medical Center. He personally offers a free Rest-Assure pre-operative consultation to every scheduled surgical patient at NCSS.