Preoperative risk assessment in aesthetic surgery: evidence from PubMed meta-analyses

How the evidence was selected: PubMed criteria for the most recent meta-analyses

A targeted PubMed search was conducted, including only systematic reviews and meta-analyses addressing risk assessment before plastic and aesthetic surgery. Priority was given to studies reporting pooled quantitative data, analysing risk factors associated with complications, including populations undergoing plastic or aesthetic surgery, and demonstrating clear clinical relevance to the preoperative phase. The final selection comprises meta-analyses addressing obesity, smoking, diabetes, thromboembolic risk, and preventive strategies related to surgical safety.

BMI and obesity: one of the main factors in risk stratification

Body mass index (BMI) is one of the most extensively studied parameters in the preoperative assessment of aesthetic surgery. Available meta-analyses indicate that a higher BMI is associated with an increased risk of certain postoperative complications, particularly wound infections, wound dehiscence, seroma, delayed healing, and a greater likelihood of revision surgery.

This is particularly relevant in body contouring procedures, where many patients have a history of substantial weight loss and may have tissue characteristics that affect the healing process. Obesity should not automatically be considered a contraindication to aesthetic surgery, but it is an important element of individual risk assessment and may require appropriate optimisation before surgery.

Smoking and surgical risk: the main modifiable factor

Smoking is one of the most relevant and modifiable risk factors in plastic surgery. Nicotine and other components of tobacco smoke can impair tissue vascularisation and interfere with normal wound-healing processes.

Available meta-analyses have demonstrated an association between smoking and an increased risk of several postoperative complications, including:

• Wound dehiscence;
• Infections;
• Skin necrosis;
• Scar-related complications.

Identifying smoking status during the preoperative assessment is therefore an essential step, particularly for procedures involving extensive surgical incisions or significant tissue mobilisation, in which proper wound healing is especially important.

Diabetes and metabolic control before aesthetic surgery

Diabetes is an important factor in surgical risk assessment because abnormalities in glucose metabolism can negatively affect the processes involved in tissue healing.

In particular, suboptimal metabolic control can impair:

• The immune response;
• Wound healing;
• Control of infection risk.

Available evidence indicates that inadequate glycaemic control is associated with a higher likelihood of postoperative complications. For this reason, preoperative assessment should include careful consideration of the patient’s metabolic status, particularly in individuals with risk factors or a known diagnosis of diabetes.

Nutritional status and tissue-healing capacity

Assessment of nutritional status is becoming increasingly relevant in plastic surgery, particularly in patients undergoing procedures following substantial weight loss. The patient’s nutritional condition can negatively affect the ability of tissues to heal properly, interfering with fundamental processes such as collagen production, immune response, and tissue repair.

Available meta-analyses in plastic and reconstructive surgery suggest that nutritional status may contribute to the overall risk of wound complications. For this reason, preoperative assessment should consider not only body weight, but also tissue quality and the patient’s overall condition.

Thromboembolic risk: assessment before aesthetic procedures

Venous thromboembolism is a less frequent complication than local wound-related problems, but it can have potentially more serious clinical consequences. For this reason, preoperative assessment of thromboembolic risk should consider several factors, including the type and duration of surgery, the expected degree of immobilisation, personal or family history of thrombosis, and individual patient characteristics. Available evidence supports an individualised approach to risk prevention, with the aim of avoiding both underestimation of risk in patients with predisposing factors and unnecessary use of preventive strategies in low-risk individuals.

Optimisation strategies before aesthetic surgery

Available evidence indicates that reducing surgical risk begins during the preoperative phase, and the main strategies include:

• Identification of modifiable risk factors before surgery;
• Smoking cessation when indicated, to support better tissue healing;
• Optimisation of body weight in patients with increased risk;
• Control of metabolic conditions, particularly in patients with associated diseases;
• Assessment of nutritional status in selected patients;
• Individualised planning of the surgical procedure according to the patient’s characteristics.

Prevention of complications does not depend on a single strategy, but on the integration of multiple interventions aimed at reducing overall risk.

Main risk predictors identified by the meta-analyses

The available literature identifies several recurring factors that may influence the risk of complications in aesthetic surgery:

• High BMI, associated with an increased risk of wound complications and healing problems;
• Smoking, considered an important modifiable factor primarily associated with impaired tissue healing;
• Diabetes and metabolic abnormalities, associated with a higher risk of infectious complications and impaired healing;
• Individual thromboembolic risk, a key element in planning perioperative management;
• Unrealistic expectations, which may negatively influence overall patient satisfaction;
• Unfavourable tissue quality, particularly relevant in patients undergoing body contouring procedures.

Clinical implications and conclusion

Available PubMed meta-analyses show that preoperative assessment is a fundamental component of safety in aesthetic surgery. Surgical risk does not depend on a single factor, but on the interaction between several elements:

• Individual patient characteristics, including modifiable factors and associated medical conditions;
• Type of surgical procedure, with specific differences in risk profile;
• Tissue condition, which may influence healing and the final outcome;
• Perioperative management, from preoperative preparation to postoperative monitoring.

Accurate preoperative assessment makes it possible to identify higher-risk patients, address modifiable factors, and improve surgical planning. In conclusion, safety in aesthetic surgery does not begin in the operating room, but with appropriate patient selection, preoperative optimisation, and individualised risk management.

Bibliography: The 5 PubMed meta-analyses considered

• Bigarella LG, Ballardin AC, Couto LS, et al. The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis. Aesthetic Surgery Journal. 2022;42(10):NP629-NP640. PMID: 35037936.
• Niu EF, et al. Obesity as a Risk Factor in Cosmetic Abdominal Body Contouring: A Systematic Review and Meta-Analysis. Aesthetic Plastic Surgery. 2024. PMID: 37644187.
• 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. PMID: 38433792.
• Perzia BM, et al. Venous Thromboembolism and Bleeding Events With Chemoprophylaxis in Abdominoplasty: A Systematic Review and Pooled Analysis of 1596 Patients. Aesthetic Surgery Journal. 2021;41(11):1279-1289. PMID: 33599713.
• Marouf A, Mortada H, et al. Complications of Body Contouring Surgery in Postbariatric Patients: A Systematic Review and Meta-analysis. Aesthetic Plastic Surgery. 2021;45(6):2613-2625. PMID: 34018015.