What are the key risks to emphasize in the consent for a smoker undergoing a rhytidectomy (facelift)?

Smoking-Related Wound Complications Must Be Emphasized in Facelift Consent

For a patient smoking 25 cigarettes per day seeking rhytidectomy, you must emphasize wound breakdown and flap sloughing as the primary risks in the consent process, as smoking dramatically increases these complications through nicotine-induced vasoconstriction and tissue hypoxia.

Critical Risks to Emphasize in Consent

Wound Breakdown and Flap Necrosis (Answer: b and e)

Smoking substantially increases the risk of wound breakdown and skin flap necrosis in facelift procedures, making these the most critical complications to discuss during consent. 1, 2

• Wound complications occur at significantly elevated rates in smokers undergoing reconstructive facial procedures, with smoking being dose-dependently linked to increased wound complications after head and neck surgery 1
• Skin slough and flap necrosis are well-documented complications in smokers undergoing rhytidectomy, particularly with wide undermining techniques 3, 4
• Smoking increases postoperative wound disruption by 65% (OR 1.65,95% CI 1.56-1.75) and surgical site infections by 31% (OR 1.31,95% CI 1.28-1.34) across surgical procedures 5
• At 25 cigarettes per day (approximately 1.25 packs/day), this patient qualifies as a heavy smoker with the highest risk profile for wound complications 1

Mechanism of Smoking-Related Complications

The pathophysiology driving these complications includes:

• Nicotine-induced peripheral vasoconstriction reduces blood flow to skin flaps, creating tissue ischemia that impairs wound healing 2, 3
• Hypoxia and immune system dysfunction from tobacco smoke cause fundamental alterations in the healing process 2
• These effects are particularly pronounced in procedures like rhytidectomy that rely on skin flap viability 4

Smoking Cessation Recommendation (NOT Answer c)

Option c is incorrect—cessation of smoking DECREASES risk, not increases it. You must strongly recommend smoking cessation, not suggest it increases risk.

Optimal Cessation Timeline

• Recommend complete smoking cessation for 4 weeks preoperatively and continuing until primary wound healing (2 weeks postoperatively) to optimize surgical conditions 6, 2
• Evidence suggests 4-8 weeks of preoperative abstinence significantly reduces respiratory and wound-healing complications 6
• For elective facelift procedures specifically, delaying surgery 60-90 days after cessation provides optimal benefit 6
• Complication risk is reduced with smoking cessation of at least 4 weeks prior to reconstructive surgery 1

Cessation Support

• Provide intensive smoking cessation counseling and facilitate nicotine replacement therapy, which doubles short-term abstinence rates 2
• For this heavily dependent patient (25 cigarettes/day), referral to a tobacco specialist is highly recommended 2

Other Risks (Lower Priority for Consent)

Great Auricular Nerve Injury (Answer a)

While great auricular nerve injury is a recognized complication of facelift surgery, it is NOT specifically increased by smoking status and should not be the primary emphasis in a smoker's consent 4. This is a technical surgical risk unrelated to tobacco use.

Antibiotic Prophylaxis (Answer d)

Routine antibiotic use is not the primary issue to emphasize in consent for smokers. The focus should be on the dramatically elevated baseline risk of infection (31% increase) rather than antibiotic coverage 5.

Documentation Strategy for Consent

Document the following specific points in your consent discussion:

• Quantify the patient's smoking history: 25 cigarettes/day = 1.25 packs/day, qualifying as heavy smoking 1
• Explicitly state the significantly increased risk of wound breakdown, skin necrosis, and flap sloughing 2, 5, 3
• Document your strong recommendation for 4-week preoperative cessation and 2-week postoperative abstinence 6, 2
• Note that surgical site infections occur at 31% higher rates in smokers 5
• Consider documenting that some surgeons refuse to perform elective facelifts on active smokers due to unacceptably high complication rates 4, 7

Common Pitfall to Avoid

Do not proceed with elective rhytidectomy without thoroughly documenting this discussion and the patient's understanding of substantially elevated wound complication risks. Some plastic surgeons consider active smoking a relative contraindication to elective facelift procedures given the high rates of flap necrosis 3, 4, 7. If the patient refuses cessation, strongly consider delaying or declining the elective procedure.