How do smoking and nicotine affect healing after a hair transplant?

Why does smoking affect healing after a hair transplant?

Smoking can slow healing after a hair transplant and make problems such as wound infection more likely. Infection after a hair transplant is uncommon; smoking is one of the factors that can affect this likelihood, and one that you can change.

In a hair transplant, many small wounds form as the grafts (small pieces of tissue carrying one or more hair roots) are taken from the donor area, and a small channel is opened for each graft in the recipient area. Closing these wounds, nourishing the grafts in their new place and protecting the area against germs all depend largely on the blood that reaches it: blood carries oxygen, nutrients and immune cells to the tissue. We describe the structure of a graft in our article on what a graft is.

The scalp is rich in blood vessels, which is one reason why small wounds there usually heal well. Smoking, however, can reduce the blood and oxygen reaching the skin, and it can also affect how the cells that protect and repair the wound work. How strong the effect is varies from person to person; how much and for how long you have smoked, and your general health, can play a part.

In what ways does smoking affect healing?

Nicotine narrows blood vessels

Nicotine increases the release of adrenaline and noradrenaline (catecholamines) in the body. These substances make the small blood vessels in the skin narrow (vasoconstriction), so less blood reaches the skin. The effect starts again after every cigarette and lasts for a while; if you smoke often throughout the day, your skin may receive less blood for most of the day.

Nicotine and some substances in smoke can also make blood platelets (thrombocytes) more likely to stick together. This can make it harder for blood to flow through very small vessels.

Carbon monoxide reduces the oxygen the blood carries

The smoke produced when tobacco burns contains carbon monoxide. Carbon monoxide binds to hemoglobin (the protein that carries oxygen) in red blood cells much more tightly than oxygen does. As a result, the blood can carry less oxygen, and hemoglobin also releases its oxygen into the tissue less easily. In an area where the blood vessels have already narrowed, this means that even less oxygen reaches the healing tissue.

The immune system and tissue repair

Smoking can impair the work of the immune cells that protect the wound against germs and the function of the cells (fibroblasts) that produce the new tissue that closes the wound. The production of collagen, the building block of new tissue, may also fall. How much of these effects is due to nicotine and how much to the other substances in smoke has not yet been fully worked out.

What does this mean for the transplanted grafts and the donor area?

When a graft is removed, it is cut off from the small blood vessels that fed it. That is why, in the first days after it is placed, it is thought to be nourished by fluid seeping from the surrounding tissue. Over the following days, it connects with the small vessels around it, and its blood supply begins to return. During this period, it is important for the tissue around the graft to have a good blood supply; factors that reduce blood flow and oxygen can make this process harder.

The small wounds in the donor area close on their own without stitches, and this process also depends on the blood and oxygen reaching the area. Both the return of the graft’s blood supply and the closing of the wounds take time; that is why it matters that your break from smoking continues after the procedure as well.

What does research show?

The effect of smoking on wound healing has long been studied in other surgical procedures. Many studies have shown that problems such as delayed wound healing, wound infection and the wound edges coming apart are more common in people who smoke than in people who do not. The clearest benefit of taking a break from smoking before surgery is seen for wound infection; its effect on other healing problems is less clear.

For hair transplants specifically, however, the evidence is limited. There are no large studies that clearly show how much smoking affects whether the grafts take hold. Sources on hair transplants list smoking among the factors linked with rare healing problems in the recipient area.

Taking a break can help make these problems less likely, but it does not rule them out completely; healing varies from person to person, even in people who do not smoke.

Do e-cigarettes, hookah and nicotine patches have an effect too?

The answer depends on the product. Two questions help to tell the products apart: Does the product contain nicotine? Is tobacco or charcoal burned? Nicotine narrows blood vessels; burning produces carbon monoxide and the other substances in smoke.

Although e-cigarettes produce very little carbon monoxide, products that contain nicotine still have nicotine’s vessel-narrowing effect, and nicotine-free products have not been shown to be safe for healing either. That is why switching to e-cigarettes is no substitute for taking a break during the healing period.

Nicotine patches, gum and lozenges (nicotine replacement therapy) are used to help people quit smoking. These products involve no smoke and none of the substances produced by burning; however, the effect of nicotine on its own on wound healing is still being debated. Do not decide by yourself whether to use these products around the time of your procedure; make this decision based on your doctor’s assessment.

What is not yet known?

• How much does it affect whether the grafts take hold? It is not possible to put a number on this effect. It is also unclear how much difference it makes to smoke only a little, or to take a break only for a short time around the procedure.
• How long should the break be? Research on other surgical procedures reports that the longer the break, the greater the benefit. Even a short break lowers the nicotine and carbon monoxide in the blood; the benefit for wound healing and infection, however, becomes clearer with a longer break. The best length of time for a hair transplant has not been established by studies specific to hair transplants; this is one reason why you see different timings in different sources.
• What about newer products? The effects of e-cigarettes and heated tobacco products on wound healing and on long-term health are still being studied.
• Does smoking also affect hair loss? Some observational studies have reported a link between smoking and male pattern hair loss. However, studies of this kind cannot show cause and effect on their own; it has not been proven that smoking causes hair loss.

How do we address smoking in the examination and in your written instructions?

During the examination, we ask whether you use cigarettes, e-cigarettes, hookah or any other nicotine product, and how often. Our aim is not to judge you but to base your plan and your instructions on your real habits. Conditions that can affect blood circulation, such as diabetes, are part of the same assessment; we cover them in our article on chronic conditions and hair transplants.

Smoking is generally not considered a reason on its own to rule out a hair transplant, but it is a factor we take into account in planning. We determine whether you are suitable for a hair transplant during the examination, by looking at your health as a whole.

We state in your written preparation and aftercare instructions how long you need to take a break from smoking and other nicotine products before and after the procedure. You may read different timings elsewhere; follow your own instructions. You can find other preparation topics in our article on preparing for a hair transplant, and general aftercare advice on the hair transplant aftercare page.

If you find it hard to take a break, or have not been able to, let us know before the procedure; we will talk through together what you need to watch out for in your situation. If you are thinking about quitting smoking altogether, you can get support from your family doctor or a smoking cessation clinic.

If you notice increasing pain, redness or swelling, discharge or a fever while you heal, contact us without waiting for your follow-up appointment; if you cannot reach us, go to the nearest healthcare facility. We explain how to tell normal signs of healing from signs of infection in our article on itching, redness and pimples after a hair transplant. The course of healing and results vary from person to person.