Smoking after rhinoplasty: what the evidence shows, before and after surgery

Why surgeons ask you to stop

Healing tissue needs a good blood supply and oxygen. Cigarette smoke carries carbon monoxide, which takes the place of oxygen in the blood, and nicotine narrows small blood vessels.

The World Health Organization lists the effects that matter around an operation: smokers have a higher risk of problems with the heart and lungs, of complications with anaesthesia, and of delayed or poor wound healing, which in turn raises the risk of infection.

In an open rhinoplasty, the skin over the nose is lifted and laid back down at the end of the operation, and it depends on its blood supply to heal in place. Smoking also tends to bring coughing, and coughing and sniffing put pressure on a nose that is healing.

What the evidence shows

Across surgery. A meta-analysis published in 2012 pooled 140 studies with 479,150 patients across many kinds of operation. Smokers had about twice the odds of a wound complication as non-smokers, and higher odds of a wound infection. Former smokers had fewer healing problems than current smokers. In four randomised trials, stop-smoking programmes around the time of surgery cut wound infections, though they did not reduce other healing problems. We could read only the summary of this study.

In rhinoplasty. The most relevant study is recent. It looked back at 1,884 open rhinoplasties done by one surgeon in New York between 2014 and 2022, each followed for at least a year. Eighty patients were active smokers, a group that included anyone who had smoked or vaped in the four weeks before surgery or did so afterwards.

• A second operation was needed by 3 of the 80 smokers (3.8 per cent) and by 3.3 per cent of non-smokers. The difference was not significant.
• Extra antibiotics for a skin infection were needed by 3 of the 80 smokers (3.8 per cent) and 1.6 per cent of non-smokers. All of these infections cleared, and the difference was not significant.
• No patient in any group had an open wound, a wound that would not heal, or skin loss.

The authors conclude that active smoking "does not appear to be a strict contraindication for rhinoplasty", and they still recommend stopping. The study has limits they name themselves: 80 smokers is a small group, smoking was self-reported and not tested, the results come from one surgeon's technique, and the paper does not describe what smokers were asked to do before surgery.

Reading the two together. Rhinoplasty may carry less risk from smoking than larger operations do. But no study suggests smoking helps, the general evidence is large and consistent, and stopping before surgery reduced infections in trials. The advice does not change: stop, and stay stopped.

Before surgery: how long, and what helps

The World Health Organization says smokers who quit about four weeks or more before surgery have a lower risk of complications, and that every smoke-free week after those four improves outcomes by 19 per cent. Longer is better, and stopping for good is best.

In the UK, NHS stop smoking services are free. They offer support for the first months, usually up to 12 weeks, and can provide nicotine replacement such as patches or gum, and in some areas a free vape starter pack. In England the Smokefree National Helpline is 0300 123 1044; Scotland, Wales and Northern Ireland have their own.

Tell your surgeon honestly how much you smoke or vape. It changes the plan, not whether you are welcome.

If you are travelling for surgery, count the four weeks back from the date of the operation, not the date of the flight, and ask the clinic to put its smoking rule in writing before you book. The before you travel checklist and the recovery preparation checklist cover the rest of what to arrange.

After surgery: how long, and why the numbers differ

The clinic pages we read give anything from two to six weeks before smoking again, and none says where its figure comes from. That is because no study has fixed a safe day to restart after rhinoplasty. The figures are surgeons' rules, built on the general evidence and their own experience.

Healing goes on for months after the splint comes off, so a later restart is better than an earlier one, and not restarting at all is best. What each stage of recovery involves is set out in rhinoplasty recovery day by day.

Vapes, patches, gum and shisha

Vapes. The NHS says e-cigarettes do not burn tobacco and do not produce tar or carbon monoxide, and that vaping is likely to be far less harmful than smoking. It also says vaping is not completely risk-free, and most vapes contain nicotine. A review published in 2017 found no study in people comparing surgical complications in vapers and smokers. So a vape is better than a cigarette around surgery, but it is not the same as stopping, and it has not been studied in rhinoplasty.

Nicotine patches and gum. These deliver nicotine without smoke. NHS stop smoking services offer them to help people quit. Whether to use them in the weeks just before and after an operation is a question for your surgeon; we did not find a study of nicotine replacement in rhinoplasty patients.

Shisha. Shisha is easy to find in Istanbul, and it is easy for a visitor to try during recovery. The World Health Organization's office for the Eastern Mediterranean describes waterpipe smoking as "as harmful and as addictive as cigarettes". Treat it as smoking.

Cannabis. Smoking cannabis also brings smoke into a healing nose. The same advice applies.

If you have already smoked

Do not hide it. Tell your surgeon, so they can check the nose with that in mind, and stop again.

Watch for the warning signs after surgery, and contact your surgeon or a local doctor if any appear.

The same advice applies after septoplasty, the operation to straighten the wall inside the nose. Its recovery is covered in our post on septoplasty recovery.