The evils of nicotine: an evidence-based guide to smoking and plastic surgery.

As nearly 1 of 5 adult Americans are smokers, plastic surgeons should be familiar with the effect of smoking on perioperative risk, the importance of smoking cessation, and the tools to help patients quit. Cigarette smoke contains over 250 known toxins, including nicotine, carbon monoxide, hydrogen cyanide, and nitric oxide, which all are known to impair wound healing, through multiple mechanisms. The relationship of smoking and delayed postoperative wound healing has been established in numerous prospective and retrospective cohort studies (level 2 and 3 evidence), and has been demonstrated across a wide range of surgical disciplines and procedures, including many common plastic surgical procedures. The ameliorating effects of cessation are supported by level 1 evidence, which suggests that the optimal duration of preoperative cessation is 4 weeks or longer. Nicotine replacement therapy and smoking cessation medications are effective aids for quitting and should be familiar to plastic surgeons.