The Foot and Ankle Tribune

Smoking is a major problem:


More than 1 billion people worldwide smoke and annually, 5.4 million deaths or 1 death every 6 seconds, is due to tobacco smoking. The prevalence of cigarette smoking in England is at a record low with 21% adult smokers in 2008. Nevertheless, smoking is attributable to 80,000 deaths per year in England and an estimated 8.5 million people still smoke in the United Kingdom.

It is now well known that cigarette smoking has adverse effects on the human body, notably its association with lung cancer.

Anecdotal experiences associating wound healing complications with smoking are well documented in the literature. Despite this, there are only a few large clinical trials attempting to elucidate the relationship between tobacco smoking and wound healing. This has resounding implications not only on the surgical patient, the surgeon but the economics of the NHS as well. The repercussions of abnormal wound healing are perhaps best felt in plastic surgery and in podiatry, where aesthetic value is as important as functional value.

A good portion of patients that we perform surgery on are undergoing elective procedures for reduction in pain, ease of fitting in shoes, and to a lesser degree small digit cosmesis to realign a toe or toes. This is imperitive to understand that as the vessels branch from the popliteal fossa to medium and small named vessels, they become even smaller passed the midtarsal joint into the toes. This directly is impacted by the mechanism which nicotine and other chemicals that are found in cigarrette smoke directly and indirectly lead to vasoconstriction which pinches closed the supply to the tissues which have been traumatized by surgery. This leads to delayed wound healing time and thickened scars, and may lead to gangrene and amputation in select cases.

Effects of smoking at a cellular level


There are more than 4,000 chemicals present in a cigarette. Amongst these chemicals, nicotine and carbon monoxide are important contributors to the detrimental effects smoking has on wound healing.

Carbon monoxide has a 200 times greater affinity to haemoglobin than oxygen. This results in tissue hypoxia as the oxygen-haemoglobin saturation curve shifts to the left. Consequently, the wound healing process is impaired due to the hypoxic state in tissues.

Nicotine acts on the dermal-subcutaneous vascular plexus to cause vasoconstriction. This has serious consequences as many random patterned flaps rely heavily on the plexus for survival. Besides inducing a hypoxic state and causing vasoconstriction, smoking also leads to increased platelet aggregation, creating microangiopathic thromboses which are tiny blood clots in the capillaries. This is particularly detrimental at the wound site as healing depends heavily on existing and new capillaries.

High levels of fibrinogen and haemoglobin are found in smokers and coupled with reduced fibrinolytic activity, local perfusion to the wound site is greatly attenuated, resulting in delayed wound healing.

This is supported by the work of Sarin et al who found that smoking one cigarette could reduce blood velocity by 42%.

In summary, if you smoke, you may be greatly compromising the chances your elective surgery will not be without complications.
 
Here is a published algorithm which may answer why you may be denied elective surgery if you smoke, because it is in your best interests: