Smoking, vaping and nicotine before a facelift: why surgeons say no, and for how long

I will not perform a facelift on a patient who is still using nicotine. That includes cigarettes, vaping, nicotine patches, gum, lozenges and pouches. Smoking before facelift surgery is the single most predictable cause of the complication surgeons fear most in this operation: skin necrosis, where a patch of the lifted skin dies because its blood supply has failed. It is not a rare theoretical risk. It is a well-recognised, avoidable one.

The rule in my practice is straightforward. Stop all nicotine at least four weeks before surgery and stay off it for at least four weeks afterwards. Six weeks each side is better. If you cannot do that, I would rather not operate, and I will say so plainly. This is not moralising about smoking as a habit. It is about the mechanics of how a facelift heals.

This article explains what nicotine does to the skin during a facelift, why vaping is not a safe alternative, how long the abstinence period needs to be, and how I check.

Why smoking before facelift surgery is so dangerous

To understand the problem, it helps to understand what a facelift physically does to the skin.

During a facelift, the skin of the cheek and neck is lifted away from the tissue beneath it over a wide area. Normally the skin receives blood from two directions: from vessels coming up through the tissue under it, and from a network of small vessels running within the skin itself. Once I lift the skin, the first source is cut. The lifted skin then survives entirely on the second: blood flowing sideways through fine vessels from the edges that are still attached.

This is a fragile arrangement. The skin furthest from its remaining blood supply, which is usually the area just in front of and behind the ear, is living on a small margin. Anything that narrows those vessels or thickens the blood can tip that margin over, and the skin dies. That is skin necrosis.

Nicotine and the other components of tobacco smoke do exactly this, in several ways at once.

What nicotine and smoke do to healing tissue

Nicotine constricts blood vessels

Nicotine causes the small arteries to tighten. In a normal, undisturbed face this is tolerated. In a face where the skin is relying on narrow vessels running sideways from its edges, it can reduce the blood reaching the skin below the level needed to keep it alive. This vessel-narrowing effect is the reason nicotine replacement products are not a safe substitute before surgery.

Carbon monoxide starves tissue of oxygen

Cigarette smoke contains carbon monoxide, which binds to the red blood cells in place of oxygen. The blood that does reach the lifted skin is carrying less oxygen than it should. Healing tissue needs oxygen to build new collagen and new vessels, and without it the wound heals slowly or not at all.

Smoking makes blood more prone to clotting

Smokers have "stickier" blood, and small vessels in a surgical wound are more likely to clot off. This further reduces the supply to skin that is already marginal.

Immune function and infection

Smoking suppresses the body's ability to fight bacteria in a wound. Combined with poor blood flow, this raises the risk of wound infection and of the incision breaking open.

Published series in plastic surgery have consistently reported that smokers have a substantially higher rate of skin necrosis and wound problems after a facelift than non-smokers. I will not attach a precise figure, because reported numbers vary with technique and how smoking was defined, but the direction of the finding is not in dispute.

Skin necrosis after facelift: what it actually looks like

In its mild form, an area of skin behind the ear turns dark, forms a scab and heals from underneath, leaving a wider, thicker scar than it should. In its more serious form, a larger patch of cheek or neck skin dies, needs weeks of dressings, and heals with a visible depressed scar that may need revision surgery. Every experienced facelift surgeon has seen this, and the common thread in a large proportion of cases is nicotine. It is why I take smoking before facelift surgery so seriously in my assessment.

Vaping before surgery and nicotine replacement: not safe alternatives

Vaping

Many patients now tell me they have "quit smoking" and switched to vaping. From a surgical point of view, this does not help.

Most e-cigarette liquids contain nicotine, often in high concentrations, and nicotine is the main agent that narrows blood vessels. Vaping removes the carbon monoxide and tar of cigarette smoke, which matters for the lungs, but not the vessel-constricting effect that threatens facelift skin. There are also unsettled questions about what heated propylene glycol, glycerine and flavourings do to small vessels and wound healing.

Nicotine-free vaping liquid is sometimes suggested as a workaround. I am cautious even here: products are not always labelled accurately, and vaping tends to lead people back to nicotine. Stop vaping completely for the same period as smoking.

Patches, gum, lozenges and pouches count too

This surprises patients, so I want to be clear. Nicotine replacement therapy, meaning patches, gum, lozenges, sprays and oral pouches, delivers nicotine into the bloodstream. It is a good tool for quitting in normal life, but not acceptable in the weeks around a facelift, because the nicotine itself narrows the vessels. Taper off replacement products well before the abstinence period begins, so you are genuinely nicotine-free by the four-week mark.

How long to quit smoking before cosmetic surgery

The timings below are what I ask of my own facelift patients. Different surgeons set slightly different periods, but the principles are widely shared.

ProductStop before surgeryStay off after surgeryCigarettes, cigars, pipeAt least 4 weeks; 6 preferredAt least 4 weeks; 6 preferredVaping (with or without nicotine)At least 4 weeksAt least 4 weeksNicotine patches, gum, lozenges, pouches, spraysAt least 4 weeksAt least 4 weeksCannabis smoked with tobaccoAt least 4 weeksAt least 4 weeks

Why four weeks? A single dose of nicotine affects vessels for hours, but blood stickiness, reduced oxygen carrying and impaired immune function take weeks to recover. Four weeks is generally regarded as the minimum for the body to return to something close to a non-smoker's healing capacity. Longer is better.

The after-surgery period is at least as important. The lifted skin is at its most vulnerable in the first two to three weeks, while new blood vessels are growing into it. A cigarette on day five can undo everything.

How I check for smoking before facelift surgery

I ask every patient directly about smoking, vaping and nicotine products at the first consultation, and again before surgery. I would much rather hear an honest answer. A patient who tells me they have not managed to stop is a patient I can help, by postponing. A patient who hides it is a patient I may harm without knowing why.

I reserve the right to test for cotinine, a breakdown product of nicotine that stays in urine or blood for several days, before surgery. If a test is positive, I postpone. This is not a punishment; I simply will not accept the risk on the patient's behalf. It is one reason I place such emphasis on the pre-operative conversation described in your medications and cosmetic surgery.

Does the type of facelift make a difference?

To some extent. A deep plane facelift lifts the skin together with the deeper layer (the SMAS) as a single thick unit over much of the cheek, rather than separating the skin alone over a wide area. That thicker flap has a better blood supply and, in my experience, is more robust. I discuss this in facelift techniques compared.

However, even a deep plane facelift involves skin-only lifting near the ear, precisely where necrosis tends to occur. A better technique lowers the risk; it does not remove it. Nicotine abstinence is required regardless.

The same applies to a neck lift, blepharoplasty (eyelid surgery), breast lift and tummy tuck, all of which lift skin away from its underlying supply.

What if I genuinely cannot stop?

Some patients tell me honestly that they have tried repeatedly and cannot quit. I respect that, and I want to give a useful answer rather than a lecture.

First, four to six weeks of abstinence is a much smaller task than lifelong quitting, and many patients who cannot quit for good can manage a defined window with a clear reason. Your GP can help with a short programme, and non-nicotine prescription medications such as varenicline or bupropion may be worth discussing with them.

Second, if you truly cannot stop, a facelift is not the right operation for you at this time. I would rather turn a patient away than operate on skin that is likely to fail. Smaller procedures or non-surgical options may carry less risk, and we can discuss those.

Planning your trip to Thailand around this

For Australians and New Zealanders travelling to Bangkok, the abstinence period begins well before you get on the plane. Four weeks before surgery usually means four weeks before you leave home. Stop first, then book.

Australian travel insurance policies generally exclude elective cosmetic surgery abroad and its complications, so a wound problem caused by smoking is not something an insurer will cover. My guidance on length of stay is in how long to stay in Bangkok after a facelift. Since 1 July 2023, Australians also need a GP referral before a cosmetic surgery consultation; that visit is a good opportunity to plan quitting.

Frequently asked questions

How long do I have to stop smoking before a facelift?

For smoking before facelift surgery, my rule is at least four weeks before surgery and at least four weeks after, with six weeks each side preferred. This applies to all forms of nicotine, not only cigarettes.

Can I vape instead of smoking before surgery?

No. Vaping delivers nicotine, which narrows the small blood vessels the lifted skin depends on. Even nicotine-free vaping is something I ask patients to stop, because labelling is unreliable and the habit tends to lead back to nicotine.

Are nicotine patches allowed before cosmetic surgery?

No. Patches, gum, lozenges, sprays and pouches all put nicotine into the bloodstream, and nicotine is the agent that constricts blood vessels. Taper off them so that you are genuinely nicotine-free for the full abstinence period.

What is skin necrosis after a facelift?

It is the death of a patch of the lifted skin because its blood supply has failed. In mild cases it heals with a thicker scar; in serious cases it can leave a depressed, visible scar that needs further surgery. Nicotine use is one of its most common and most avoidable causes.

Will you test me for nicotine before surgery?

I may. A cotinine test detects nicotine use over the previous several days. If it is positive, I postpone the surgery. I ask all patients to be honest, because a delayed operation is far better than a damaged result.

Does smoking affect other procedures too?

Yes. Any operation that lifts skin away from its underlying blood supply, including neck lift, eyelid surgery, breast lift and tummy tuck, is affected. The same abstinence rules apply.

This article is general information, not medical advice. Your own risk depends on your health, your history and the specific operation planned. If you are considering a facelift and want honest advice about nicotine, timing and whether surgery is right for you, you are welcome to book a video consultation with me.