Prehabilitation in Plastic Surgery: Review-Based Framework and Research Priorities

A narrative review of prehabilitation in plastic and reconstructive surgery describes a proposed, multimodal pathway that could be tailored to common reconstructive and esthetic settings, while drawing heavily on prehabilitation evidence synthesized from other surgical specialties.

The authors organize the framework around four pillars—physical conditioning, nutritional optimization, risk-factor modification, and psychological preparation—and present these as interdependent rather than standalone inputs. They also note that direct, specialty-specific interventional evidence remains sparse in plastic surgery, so much of the rationale is extrapolated. Overall, the review offers a structured lens for how preoperative preparation might be bundled and adapted across plastic surgery contexts.

The review outlines a risk-stratified approach to program structure and discusses practical considerations for preoperative timelines. Within risk-factor modification, it highlights smoking as a key modifiable risk in plastic surgery populations. Rather than presenting a single protocol, the authors describe tiered intensity based on baseline vulnerability—often framed through frailty and nutrition screening—and adapted to procedure urgency. In this framing, timing functions as a practical constraint on what can be delivered and monitored, rather than a fixed calendar applied uniformly.

For physical conditioning, the review describes exercise training as a core component of prehabilitation. For nutrition, it frames nutritional optimization as a central pillar and highlights modifiable risks such as malnutrition and obesity. The authors also position prehabilitation as building on the success of Enhanced Recovery After Surgery (ERAS) pathways. Across these pillars, they repeatedly link plastic-surgery planning back to indirect data and implementation lessons reported in other surgical fields.

Implementation is presented as a coordinated workflow anchored by a multidisciplinary team, with roles spanning surgeon, nurse coordinator, physiotherapist, dietitian, psychologist, anesthesiologist, and pharmacist. In the review’s description, these contributors support screening, coaching, monitoring, and perioperative coordination. The authors also describe digital and hybrid prehabilitation delivery models—including apps, telehealth check-ins, and wearables—as a way to extend preoperative support beyond in-person visits while standardizing tracking of adherence and patient-reported measures. They note implementation considerations for digital tools alongside operational barriers such as variable digital literacy, platform/privacy infrastructure needs, and sustaining engagement; hybrid approaches are described as one way to balance access with oversight.

Within plastic surgery domains, the review proposes a risk-stratified framework tailored to breast reconstruction, head-and-neck microsurgery, post-bariatric body contouring, and major aesthetic procedures. For head-and-neck oncologic free-flap reconstruction, the authors emphasize the high prevalence of nutrition-related vulnerability and the practical challenge of compressed preoperative timelines, describing more intensive or tightly coordinated approaches when surgical lead time is limited. In post-bariatric body contouring, the review foregrounds the overlap of weight stability, micronutrient deficiency risk, and reduced lean mass as factors shaping how nutrition and conditioning may need to be integrated. For esthetic procedures, the authors frame prehabilitation as potentially aligned with patient motivation and expectation management, with psychological preparation and behavior change described as particularly salient in that setting.

Evidence gaps are a central theme, with the authors explicitly noting that plastic-surgery-specific randomized controlled trials evaluating multimodal prehabilitation have not yet been performed. They add that current specialty evidence more often reflects isolated optimization steps or ERAS components rather than standardized prehabilitation bundles. Research priorities described in the review include defining which plastic surgery populations to target first (for example, higher-risk and more complex reconstructive cohorts), comparing component combinations and delivery models, and incorporating stratification approaches such as frailty or nutrition risk in study design.

The authors also propose outcome domains for future trials that extend beyond complications alone, including flap- and wound-specific endpoints, functional recovery measures, patient-reported outcomes, physiologic/nutrition markers, and economic metrics. Overall, the agenda is presented as hypothesis-generating, oriented toward building shared outcome definitions that can support consistent evaluation across studies.

Key Takeaways:

• The narrative review organizes plastic-surgery prehabilitation into four pillars and describes a coordinated multimodal framework largely adapted from other surgical fields.
• The review outlines risk-stratified timing and team-based implementation, and it describes digital/hybrid delivery options and related implementation considerations.
• The review discusses domain-specific considerations across multiple plastic surgery contexts and maps evidence gaps, including proposed outcome domains for future trials.