What the research shows
Smoking cuts the oxygen that reaches healing skin. Nicotine narrows the small skin vessels and makes blood more likely to clot in them, and carbon monoxide and cyanide in smoke reduce the oxygen that reaches the tissue (Silverstein 1992). Under the microscope, smokers and former smokers had more blocked small vessels in facelift skin than nonsmokers of the same age (Riefkohl 1986).
Smokers lose skin more often after a facelift. A 1984 study found that a significant share of skin loss after facelift was due to smoking (Rees 1984). A later review put the risk of skin death in facelift smokers at many times that of nonsmokers (Knobloch 2008). A pooled analysis across plastic surgery found smoking raised infection, slow healing and skin loss, while its estimate for facelifts alone was too uncertain to be conclusive (Theocharidis 2018).
Smoking after surgery matters too. Among smokers, skin loss was tied to failing to stay off cigarettes after the operation (Riefkohl 1986). A review found four weeks without smoking lowers smoking-related complications, and noted that patients usually underreport how much they smoke; a cotinine test can confirm smoking in the past few days (Knobloch 2008). Asking patients to stop has lasting value: in one practice, half of smokers admitted they had not fully stopped before surgery, but many had quit or cut down years later (Van Slyke 2017).
Surgeons protect the skin by limiting how far they lift it. One group used limited skin undermining in all patients, about a third of them smokers, and saw no skin loss (Webster 1986). The lifted skin depends on small vessels below the cheekbone and beside the nose and mouth, and a cadaver study advises not undermining past the fold beside the nose (Wolff 2005). Raising the SMAS with the skin did not change the blood supply to the side of the flap (Whetzel 1997). In nonsmokers, a deep plane dissection did not reduce skin blood flow (Swanson 2015).
Where surgeons disagree
- How large the facelift risk is. One review reports a many-fold higher risk of skin death (Knobloch 2008); a later pooled analysis could not confirm a clear rise in total facelift complications (Theocharidis 2018). Both conclude that smoking harms healing.
- How long to stop. Animal work set two weeks without cigarettes as the minimum (Chen 2002); a clinical review sets four weeks (Knobloch 2008).
What is new
- Laser resurfacing during a facelift is safe when the lifted skin is treated at lower energy than the rest of the face; full-thickness skin loss was rare (Wen 2026). In an earlier pooled series, the one case of full-thickness flap loss was in a smoker (Koch 2002).
- Oral niacin and nitroglycerin paste, which widen blood vessels, were given to nicotine users after facelift; most developed no signs of poor skin blood flow, and early signs improved within days in others. The study had no control group (Shirazi 2025).
- No published study has measured cannabis and facelift healing; combined cannabis and tobacco use raised complications in other facial surgery (Naimi 2026).
What is still unknown
- The exact facelift risk: no trial has compared smokers with nonsmokers, and studies report tobacco use unevenly (Theocharidis 2018).
- The effect of cannabis, vaping and nicotine products without smoke on facelift skin (Naimi 2026).
Key papers
- Rees 1984: first linked smoking to skin loss after facelift.
- Riefkohl 1986: smokers' skin vessels are more blocked; smoking after surgery predicts skin loss.
- Webster 1986: limited undermining avoided skin loss in smokers.
- Silverstein 1992: how smoke slows wound healing.
- Whetzel 1997: which artery feeds the lifted cheek skin.
- Knobloch 2008: four weeks without smoking lowers complications.
- Theocharidis 2018: pooled smoking risks across cosmetic surgery.
- Wen 2026: safe settings for laser during a facelift.