Most smoke-related diseases point toward effects on the microcirculation. For one, the development of pulmonary emphysema occurs at the microcirculatory level of the delicate alveolar membranes, presumably due to a dysbalance between aggressive factors such as tissue degrading mediators and reactive oxygen species released from smoke-activated neutrophils (i.e., elastase, hydrolytic enzymes) and protective factors such as a-1 antiprotease, which are inactivated by cigarette smoke. Also, the association of cigarette smoking and chronic inflammatory conditions such as periodontal disease is a largely microcirculatory phenomenon that involves phagocyte dysfunction and other pathomech-anisms. Another important problem related to cigarette smoking-induced microcirculatory dysfunction is of major concern to plastic surgeons. There is an impressive literature on the adverse effects of cigarette smoking on the outcome after surgical interventions, such as (i) a significantly higher incidence of skin necrosis after face lifts, (ii) reduced viability of transplanted skin flaps, (iii) increased graft failure after microvascular toe or finger replantation, (iv) deleterious effects on bone grafting for fracture stabilization, and (v) an increased incidence of anastomotic dehiscence after colonic resection. The authors even suggested that surgeons should have a lower threshold for using a proximal diversion in smokers in order to lessen mortality and morbidity after colonic surgery. The fact that smoking has been linked to erectile dysfunction may appear of secondary impor-tance—at least to those who are not affected by this micro-circulatory dysfunction.
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