|
 Dr. Chatham |
Also telling was a trial conducted by the Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Oh., which found that patients' smoking history influenced the surgical approach taken in post-mastectomy reconstruction.3
REALITY CHECKThe fact that patients smoke — and may not stop despite mandates from their doctors to do so — raises a number of questions about how surgeons might best manage such patients.
Donn R. Chatham, M.D., president, American Academy of Facial Plastic & Reconstructive Surgery, and practitioner, Chatham Facial Plastic Surgery, Louisville, Ky., doesn't preclude smokers from undergoing elective surgeries. But he does make absolutely sure his patients truly understand the risks.
"All healing depends upon blood flow to the healing site," he says he emphasizes during consultations.
"When circulation is reduced, the oxygen and other nutrients that tissue depends on are reduced, and the cells cannot regenerate and recover as well as they should. We tell our patients who smoke about this."
Edward Pechter, M.D., a board-certified plastic surgeon and assistant clinical professor of plastic surgery at the University of California, Los Angeles, concurs with Dr. Chatham regarding the critical importance of patient education — but he also feels that patient denial is a significant factor.
"Smokers seem to know that smoking is bad for them," he says, "although they tend to be unaware of the specific risks and believe they won't personally suffer an adverse surgical outcome because of smoking." Taking that into consideration, how can physicians better influence their patients?
Dr. Pechter says, "Surgeons should ideally counsel all of their smoking patients to quit completely and direct them to resources, whether pharmacological or psychological, to help them achieve this goal. Of course, some doctors are more zealous than others in promoting this message."
Dr. Chatham agrees that education is crucial, and that anything that can help smokers remain abstinent, at least in the peri-operative period, is a step in the right direction. Unfortunately, he notes that often the very tools some patients may employ to help themselves go smoke-free have risks similar to lighting up itself.
"Using nicotine patches or gum may reduce optimal healing — even when patients are not actively smoking."
Dr. Pechter has also had to convey this harsh reality to potential aesthetic surgical patients trying to kick the habit.
"Nicotine patches may be helpful to wean a patient from smoking, but nicotine has the same detrimental effect on wound healing, regardless of how it's delivered."
DEFENSIVE DECISIONS
One could defend the position that surgeons could, or even should, defer smokers, or deny them elective surgery altogether. But, is it reasonable — or ethical — to deny surgeries to smokers?
"As a practical matter, [patients] have the right to make decisions that aren't perfectly logical to others, and the addictive nature of smoking must be taken into consideration," Dr. Pechter contends.
"Many people who want to quit simply aren't able to do so. I don't believe smokers should be denied surgery so long as they understand the increased dangers. Unfortunately, some patients who claim they accept the risks may sing a different tune should they actually experience a complication — no matter how extensive or well-documented the pre-operative education was."
