Nicotine, blood supply and wound healing after abdominoplasty

Why exposure matters for an abdominal wound

An abdominoplasty lifts and removes abdominal skin and fat, leaving a long incision and a broad area of tissue that must re-establish a reliable blood supply. The lower abdominal skin flap can be vulnerable where its circulation has been altered by dissection and closure tension. Oxygen delivery, immune-cell activity and the building of new tissue all contribute to repair. A disturbance can present as delayed closure, wound separation, skin or fat loss, infection or a need for further treatment; studies do not always group these outcomes in the same way.

Cigarette smoke is a mixture, so its association with impaired healing cannot be assigned to nicotine alone. Sørensen’s systematic review included 177 pathophysiological articles and described smoking-related reductions in tissue oxygenation and aerobic metabolism, weaker inflammatory-cell responses and oxidative bacterial killing, and reduced fibroblast activity and collagen deposition. It distinguished nicotine from smoke: nicotine did not affect the tissue microenvironment in the reviewed studies, while its effects on inflammation and proliferation were described as marginal. This mechanistic review was not a clinical abdominoplasty trial and does not settle the safety of every nicotine product or an individual treatment decision.^[1]

What abdominoplasty cohorts have observed

Retrospective review of 132 operations

Manassa and colleagues reviewed records for 132 full abdominoplasties performed over five years: 121 women and 11 men. Their analysis excluded patients with arteriosclerosis, diabetes or other systemic illness, and operations limited to removal of a pannus. Smoking status was self-reported before surgery; a later telephone interview asked about smoking around the operation. The authors defined a wound-healing problem as one requiring medical intervention, such as debridement, treatment for infection, lavage after fat necrosis or secondary closure after skin loss. Haematoma and seroma were analysed separately.

Of the cohort, 53.8% reported smoking and 46.2% did not; smokers averaged 18.4 cigarettes per day. Before discharge, a wound problem meeting the authors’ definition had occurred in 47.9% of smokers and 14.8% of non-smokers (reported P<0.01). These are the study’s observed proportions, not an individual forecast. The retrospective design, self-reported exposure, small sample and narrow definition limit how precisely the figures can be applied to present-day patients or different surgical techniques.^[2]

Prospective infection study

Araco and colleagues prospectively studied aesthetic abdominoplasty patients, excluding post-bariatric patients and people with active infection, recent antibiotic use or specified systemic conditions. Eighty-four patients were enrolled from February 2004. The abstract reports 13 wound infections (15.5%); 10 (77%) were superficial, and all but one infection occurred among smokers. Cigarettes smoked per day, years of smoking and estimated cumulative cigarette exposure were associated with infection in this small cohort. The abstract reports a relative risk of 12, but does not provide a confidence interval there. That estimate is imprecise and should not be read as a personalised risk multiplier or as evidence that a specific cigarette threshold predicts safety. The study’s cessation instruction was part of its protocol, not a timetable for readers to follow.^[3]

Before-and-after cotinine screening policy

A French retrospective cohort examined a policy that introduced pre-operative urine cotinine testing after 2013 for patients having abdominoplasty with umbilical transposition and liposuction. The abstract reports 235 patients overall, of whom 80 were tested; 21.3% of those tested had a positive result. The screening group had less delayed healing than the no-screening group (20.3% versus 41.5%; P=0.002), and fewer reported complications overall (18.1% versus 42.3%; P<0.001). Under the policy, a positive cotinine result led to cancellation of the operation. This compares care periods and a screening-plus-cancellation policy, not a test that changed wound biology: people with detected exposure did not proceed in the screening group. Selection, cancellation and other changes over time could contribute to the observed gap. Cotinine indicates recent nicotine exposure but does not by itself identify whether it came from cigarettes, vaping or nicotine replacement.^[5]

What pooled smoking evidence adds

Bouhadana and colleagues searched PubMed, Embase and Cochrane, then included 82 studies that could separate aesthetic-surgery outcomes by smoking status. Their random-effects meta-analysis included 19 abdominoplasty or panniculectomy cohorts. In that combined procedure group, smoking was associated with higher odds of any reported complication (odds ratio 1.64, 95% CI 1.44–1.87). For specific outcomes, pooled odds were higher for infection (OR 3.26, 95% CI 1.33–7.98) and delayed wound healing (OR 2.94, 95% CI 1.01–8.60); reoperation was also more frequent. Odds ratios describe relative odds across the included studies; they do not give a person’s absolute probability, and abdominoplasty and panniculectomy were pooled together.^[4]

The authors noted substantial variation in study populations, technique and complication definitions. Smoking status was often self-reported; former smokers were sometimes combined with non-smokers, and studies used different or unstated time windows for that label. Several pooled outcomes had substantial statistical heterogeneity. The review therefore supports an association between smoking and complications across these operations, while leaving the size of risk for a particular patient or technique uncertain.

Nicotine, vaping and practical decisions

Nicotine exposure is not the same question as cigarette smoking

A 2026 single-institution retrospective cohort studied 15,172 adults having cosmetic procedures between July 1992 and February 2024. It classified 1,184 (7.8%) as using one nicotine delivery method for at least two months before surgery, including nicotine replacement and e-cigarettes. The investigators excluded several major confounders, including diabetes, peripheral vascular disease, corticosteroid use, antineoplastic therapy and BMI above 30, and adjusted the analysis for age and procedure type. Any wound complication was reported in 15.2% of nicotine users and 3.8% of non-users; adjusted odds ratios across delivery categories ranged from 5.51 to 13.52. The abstract does not provide the category-specific estimates, counts or follow-up window, and the study did not perform planned head-to-head comparisons between methods. These data cover multiple cosmetic procedures, not abdominoplasty alone. They are an important signal, but cannot establish that nicotine alone caused the complications or show that NRT and vaping carry identical risks.^[6]

Vaping should be disclosed as an exposure, even when someone does not identify as a smoker. Human evidence specific to abdominoplasty remains sparse; experimental, oral-wound and case-report findings cannot be directly translated into an abdominal-flap risk estimate. Nicotine replacement is also a distinct exposure from continued cigarette smoking. The clinical literature in this set does not settle whether a person should stop or change a prescribed cessation aid; that decision belongs in a discussion with the surgical and cessation-care teams.

When budgeting for an abdominoplasty in Turkey, compare the listed tummy tuck cost in Turkey with the scope of surgery and aftercare you expect to need; a price page cannot determine whether an individual is medically suitable for surgery. Follow-up is also part of planning for wound concerns: if comparing a package for abdominoplasty, ask the relevant authorised provider what post-operative contact and wound assessment arrangements are actually offered. A package description does not establish that nicotine testing or cessation support is included, or that healing outcomes will improve.

Before deciding, ask the treating team what they mean by smoking or nicotine exposure, whether they ask about cigarettes, vaping, patches, gum and other products, how they assess wound risks in your case, and what their own policy is if exposure is disclosed or detected. Also clarify who will assess the incision after discharge and how you can obtain urgent advice if healing concerns arise. Do not start, stop or alter nicotine replacement or another prescribed treatment on the basis of these studies alone.

References

1. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Annals of Surgery. 2012;255(6):1069–1079. Published June 2012. doi: 10.1097/SLA.0b013e31824f632d. PMID: 22566015.
2. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers after 132 abdominoplasties. Plastic and Reconstructive Surgery. 2003;111(6):2082–2087; discussion 2088–2089. May 2003. doi: 10.1097/01.PRS.0000057144.62727.C8. PMID: 12711974.
3. Araco A, Gravante G, Sorge R, Araco F, Delogu D, Cervelli V. Wound infections in aesthetic abdominoplasties: the role of smoking. Plastic and Reconstructive Surgery. 2008;121(5):305e–310e. May 2008. doi: 10.1097/PRS.0b013e31816b13c2. PMID: 18453943.
4. Bouhadana G, ElHawary H, Alam P, Gilardino MS. A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis. Plastic Surgery. 2024;32(1):115–126. First published online 18 March 2022. doi: 10.1177/22925503221085083. PMID: 38433792; PMCID: PMC10902487.
5. Delaunay F, Coquerel-Beghin D, Magalon G, Cohen SR, Casanova D, Niddam J, Milliez P-Y, Peillon C, Delpierre V, Auquit-Auckbur I. A preoperative cotininury test for abdominoplasty reduces peri-operative complications. Annales de Chirurgie Plastique Esthétique. 2018;63(4):307–315. Published online 31 May 2018; issue July 2018. doi: 10.1016/j.anplas.2018.03.004. PMID: 29778249.
6. Sifil M, Kahn D. Nicotine Exposure (Including Nicotine Replacement Therapy) and Wound Complications in Plastic Surgery: A Single-Institution Cohort, 1992 to 2024. Plastic and Reconstructive Surgery. 2026;157(6):1004–1010. Published online 23 October 2025; issue 1 June 2026. doi: 10.1097/PRS.0000000000012547. PMID: 41129831.

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