Some herbs and vitamins are beneficial for plastic surgery patients—but many are contraindicated
The perioperative use of herbal supplements and vitamins is receiving increasing attention. Studies have shown that between 22% and 47% of patients are using herbal supplements.1–4 More importantly, a large percentage of patients do not disclose their use of herbal products. The intake of vitamins is also common, alone or in combination with herbal supplements.
Because so many of our patients self-administer supplements, we have found it beneficial to provide a perioperative nutritional-supplement package that contains known, beneficial ingredients. Certain herbal supplements can have a negative impact on surgical healing, but it is not clear whether vitamin supplementation improves healing outcomes. However, perioperative vitamin supplementation has common-sense appeal.
Our practice is limited to elective, aesthetic surgery. At the preoperative appointment 2 weeks prior to surgery, patients are instructed to discontinue their use of vitamins and herbal supplements. At this time, patients are asked to begin our structured prepackaged supplement program. Because so many patients self-administer supplements, transfer to a supplement program in which the ingredients are known eliminates the risk of potentially damaging herbs but satisfies the patient’s desire to continue to take supplements.
Replace, Don’t Modify
We find it much simpler and less time-consuming to replace patients’ supplements than to evaluate and modify them. If the regimen is too complicated, patients are often confused about which products they can continue and which they need to stop. For patients who do not generally take vitamins, supplementation can improve their nutritional status. It is unlikely that all of our patients have healthy, well-balanced diets.
The water-soluble vitamins (thiamine, riboflavin, pyroxidine, nicotinic acid, pantothenic acid, biotin, folic acid, vitamin B12, and vitamin C); the fat-soluble vitamins (A, D, E, and K); and nutrients (inositol, choline, carnitine, a-lipoic acid, and coenzyme Q) are all important for maintaining nutritional health. The trace elements zinc and magnesium are important in wound healing and collagen synthesis.
Many herbs have beneficial effects for a variety of conditions. The antiplatelet effects of some herbs may be indicated in patients with diabetes and vascular disease. And the anti-inflammatory effects of some herbs could benefit others. The importance of stopping some of these agents prior to surgery does not diminish their potential benefits in the nonsurgical setting.
This is an area of active research because of the substantial growth and amazing popularity of herbal and homeopathic products. We look forward to rigorous scientific studies to help us counsel our patients. Several excellent reviews of herbal supplements, including which ones should be discontinued prior to surgery, are available.2,5–7 Some of the more commonly used herbs that should be stopped prior to surgery, along with their effects relevant to surgery, are listed below.
• Echinacea may have immunostimulatory effects with short-term use. Long-term use (more than 8 weeks) may cause immunosuppression and may potentate barbiturate toxicity.
• Ephedra (ma huang) is a very common supplement, and it is taken by 18% of the presurgical patients surveyed by Kaye.4 Ephedra is a sympathomimetic agent with a-, b1-, and b2-effects, and causes the release of norepinephrine. Its immediate results are catecholamine effects. Its long-term use results in endogenous catecholamine depletion, tachyphylaxis, and the potential for perioperative hemo-dynamic instability.
• Ginkgo biloba may contribute to peri-operative bleeding due to the inhibition of platelet-activating factor and the inhibition of thromboxane synthetase.
• Ginseng also inhibits platelet-activating factor. It may also cause hypoglycemia.
• Garlic inhibits platelet aggregation in a dose-dependent fashion. The adverse platelet effects of garlic and ginseng are irreversible.
• St John’s wort may interfere with the metabolism of other drugs by inducing hepatic cytochromes. It is used for its ability to increase serotonin, and it may prolong sedation.
• Valerian acts on g-aminobutyric acid (GABA) receptors and potentiates the sedative effects of anesthetics.
• Kava also potentiates the sedative effects of anesthesia.
• Fish oil contains eicosapentaenoic acid and w-3 fatty acids. Eicosapentaenoic acid decreases platelet aggregation and adhesion.
• Vitamin E causes decreased platelet adherence and may impair some types of wound healing.
Bash also recommends that other less commonly used herbs, including ginger, dong quai (or angelica, used as an estrogen replacement), goldenseal, licorice, and saw palmetto be discontinued.6
What Helps Patients?
We have gained a good understanding of the supplements to avoid in the perisurgical setting, but we have had difficulty determining which supplements are actually useful. Little information is available to advise surgeons on the benefits of vitamin supplementation. Nathens et al have shown an improvement in both morbidity and length of hospital stay with early antioxidant supplementation in surgical ICU patients.8 Patel et al reviewed the importance of nutrition in chronic lower-extremity wounds.9
Little research is available to suggest improved outcomes in healthy adults, but are we aesthetic surgeons correctly assuming that all of our patients are healthy? Recent statistics indicate that the likelihood that a surgical patient will present with poor dietary habits is quite high.10–12 In addition, the trauma of surgery and the subsequent wound-healing process increase metabolic requirements by 10% to 100%.13
Many aesthetic surgery patients diet and are therefore on self-imposed caloric restrictions. This restriction during the perioperative period can reduce or eliminate vital nutrients that are necessary for optimal healing.
More relevant for the plastic surgeon are the use of arnica montana, bromelain, and vitamins. The use of arnica montana has been controversial. In the safety and efficacy report on arnica by the Plastic Surgery Educational Foundation, the arguments for and against its use are reviewed.14 However, available evidence from clinical trials indicates that arnica’s toxicity is negligible, and that it is safe for use during the perioperative period.9,14
The benefits of bromelain are clearer: It increases the resorption rate of hematomas because of its effects on plasma exudation and fibrinolysis.3 Presurgical administration of bromelain accelerates visible signs of healing.13
During the past 2–3 years, we have been using a prepackaged surgical supplement program for all patients undergoing significant procedures. The program includes arnica montana, bromelain, vitamin A, vitamin B complex, vitamin C, vitamin K, and more than 100% of the recommended dietary allowances of zinc, copper, and selenium. We have no financial interest in the company that supplies our supplement program.
Perioperative supplementation can have a significant and measurable effect on surgical outcome by favorably affecting four primary mechanisms: promoting wound healing, reducing bruising, enhancing immunity, and reducing oxidation caused by both surgery and anesthetic agents. We have observed less swelling and bruising, particularly in facial surgery, when patients use our supplement package.
We have not attempted a scientific evaluation, so our impression is purely anecdotal. Our patients’ responses have been overwhelmingly positive. Our patients are probably more health-conscious than most, and they appreciate our attempts to use all modalities to improve their outcomes. n
Goesel Anson, MD, FACS, is a plastic surgeon in private practice in Las Vegas. She has written many medical journal articles and book chapters and is certified by the American Board of Plastic Surgery and the American Board of Surgery. Terrence Higgins, MD, recently joined Anson’s practice. They can be reached at (702) 822-2100 or via the practice Web site, www.ansonmd.com.
References
1. Adusumilli PS, Ben-Porat L, Pereira M, Roesler D, Leitman IM. The prevalence and predictors of herbal medicine use in surgical patients. J Am Coll Surg. 2004;198:583–590.
2. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286: 208–216.
3. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States 1997: Results of a follow-up study. JAMA. 1998;280:1569–1575.
4. Kaye AD, Clarke RC, Sabar R, et al. Herbal medications: current trends in anesthesiology practice—A hospital survey. J Clin Anesth. 2000;12:468–471.
5. Petry, JJ. Surgically significant nutritional supplements. Plast Reconstr Surg. 1996;97: 233–240.
6. Tessier DJ, Bash DS. A surgeon’s guide to herbal supplements. J Surg Res. 2003;114:30–36.
7. Tsen LC, Segal S, Pthier M, Bader AM. Alternative medicine use in presurgical patients. Anesthesiology. 2001;93:148–151.
8. Nathens AB, Neff MJ, Jurkovich GJ, et al. Randomized, prospective trial of antioxidant supplementation in critically ill surgical patients. Ann Surg. 2002;236:814–822.
9. Patel GK. The role of nutrition in the management of lower extremity wounds. Lower Extrem Wounds. 2005;4:12–22.
10. Block G. Dietary guidelines and the results of food consumption surveys. Am J Clin Nutr. 199;53:356–357.
11. Kant AK, Schatzkin A, Block G, et al. Food group intake patterns and associated nutrient profiles of the US population. J Am Diet Assoc. 1991;91: 1532–1537.
12. Rahm D. Perioperative nutrition and nutritional supplements. Plast Surg Nurs. 2005;25:21–28.
13. White DA, Baxter M. Hormones and Metabolic Control. 2nd ed. London: Edward Arnold; 1994.
14. Lawrence WT. Arnica. Plast Reconstr Surg. 2003;112:1164–1166.
