Anthony Youn, M.D., is a plastic surgeon in Metro Detroit. He is the author of “In Stitches,” a humorous memoir about growing up Asian American and becoming a doctor.

I cringe every time I see a patient for a breast lift who is a smoker. I’m deathly afraid that despite my warnings, she will smoke before or after surgery and cause her nipples to turn black and fall off.

Yes. Smokers who undergo breast lifts are at great risk of losing their nipples.

I’ve seen it before.

The nicotine in cigarettes and the carbon monoxide contained in cigarette smoke can diminish blood flow to various parts of the body. These toxins act as a virtual tourniquet. If the blood flow to a particular body part becomes greatly reduced or halted, that body part dies.



In my memoir “In Stitches,” I told the story of a smoker whose nipples turned purple while undergoing a breast lift surgery. Purple is the precursor to black. Black is the precursor to falling off. To save the patient—and her nipples - we turned to the only treatment available.

We went medieval.

We used leeches.

Because of the mechanics of blood flow, when the blood supply is inadequate, which occurs with smoking, the tiniest veins often fail. This insufficiency results in a backup of old (venous) blood in the body part, causing it to turn purple. If the backup of old blood is serious enough, the purple color may eventually turn black. That’s when we know the body part - toe, finger, or nipple - is dead.

We use leeches to literally suck out the excess venous blood from the body part, acting as an attachable vein. The leech drains the old blood, causing it to turn from unhealthy purple back to healthy pink. We place leeches intermittently until the body part grows new blood vessels to do the leeches’ work. This can take several days.

Not long ago, during a consultation for a breast lift, a patient, Susan, admitted to being a pack-a-day smoker. I informed her that smoking can cause difficulty in healing and instructed her to quit smoking at least one month before surgery and to stay off cigarettes for at least a month afterward. Several months later, when she arrived at the hospital for her breast lift, she smelled like an ashtray.

“Susan, I thought you quit smoking.”

“I did. OK. For a while. It’s really hard to quit, Dr. Youn.”

“I know,” I said. “But this is a big deal. There could be major healing problems if you smoke before or after surgery.”

“I understand. But I want to go ahead with the surgery anyway. It’ll be fine.”

She wasn’t hearing me. I needed to get through to her. “Susan, listen to me. If I operate on you, your nipples could turn black and fall off.”

Her eyes widened. “You mean… I’d have no nipples?”

“No nipples. That’s what smoking can do.”

Susan flushed. She raised her voice. “Dr. Youn, I took a week off work for this surgery. I had to put my whole life on hold for an entire week. If you told me I’d lose my nipples from smoking, I would’ve quit for good. This is your fault.”

Yes. Seriously. Susan blamed me for the inconvenience.

Thanks to her, I’ve changed my policy. In addition to the Surgeon General’s Warning that appears on cigarette packages, I now offer the Plastic Surgeon’s Warning to all my patients who smoke: If you are having a breast lift or reduction and you smoke, your nipples could turn black and fall off. If you are having a tummy tuck and you smoke, you may get an infection resulting in a big gross open wound that will take three months to heal. If you are having a facelift and you smoke, the skin of your cheek could turn black and slough off, leaving exposed fat.

Imagine yourself looking like “Two-Face” from “Batman: The Dark Knight.”

And do you really want me to reach for the jar of leeches?

Smokers, you have been warned.