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Knapp et al. Plast Aesthet Res 2020;7:7 I http://dx.doi.org/10.20517/2347-9264.2019.69 Page 3 of 14

Table 1. Surgeon modifiable risks for preventing complications
Preoperative Immediate perioperative Postoperative
Glycemic control Skin prep selection Resistance exercise/early ambulation
Smoking cessation Antibiotics Glycemic control
Nutrition Glycemic control High protein intake
- Metabolic prep Hyperoxygenation Early enteral feeding
- Carbohydrate loading Drapes/wound protectors Microbiome
Clearing S. Aureus MIS surgery - Probiotics
Weight loss - Limiting antibiotics
Prehabilitation Minimize narcotics
- Cardiac/pulmonary conditioning
- Resistance exercise

MIS: Minimally Invasive Surgery

Activation of the sympathetic pathway induces a hyperglycemic state via gluconeogenesis and
glycogenolysis. Simultaneously, a surge in stress hormones including cortisol, glucagon, prolactin, and
growth hormone mediated by the hypothalamic-pituitary axis contributes to insulin resistance and
therefore an inability for the body to correct hyperglycemia. In the acute perioperative period, persistent
hyperglycemia inhibits immune function and thus surgical recovery by driving catabolic changes via
cortisol and glucagon, translating to breakdown of skeletal muscle, loss of lean body mass, and significant
deconditioning. While a patient’s preoperative physical fitness and young age may also compensate for
proteolysis, fat metabolism primarily serves to minimize protein breakdown by mobilizing glycerol
and fatty acids for energy usage. However, increased insulin levels and tissue insulin resistance present
in times of stress yield a relative decrease in adipose breakdown. Recent literature demonstrates that
immune-related nutrients such as glutamine and arginine may be depleted postoperatively and that their
[12]
replacement may improve surgical outcomes . While the effects on the modulation and attenuation of
the inflammatory response to the catabolic effects of surgery by omega-3 fatty acids [eicospentanoic acid
(EPA) and docosahexaenoic acid (DHA)] are well documented, recent data suggest that they also serve
as a substrate for production of specialized pro-resolving molecules (SPMs). SPMs not only accelerate the
resolution of inflammation, decrease post-surgical pain, and enhance the function of macrophages and
neutrophils in bacterial killing and clearance, but they do so without increasing the inflammatory state in
the process [13,14]
. Thus, micronutrient supplementation with vitamins may be warranted in patients who are
unable to resume a balanced enteral diet in the days following surgery.

PREOPERATIVE MODIFIABLE RISK FACTORS
The preoperative preparation and optimization serve to acknowledge and modify risk factors that may
negatively impact surgical outcomes. Table 1 summarizes the factors that are reviewed in this review.

Obesity
[15]
Over 60% of AWRs are performed on obese patients and obesity increases the risk of numerous
complications, including seroma, dehiscence, fistula, infections, reoperation, and thromboembolic
events. Numerous studies by bariatric surgeons confirm the high incidence of incisional hernias as well
[16]
as increased rates of wound infections in the obese patient population . The reduction of postoperative
incisional hernias and wound complications with laparoscopic gastric bypass motivated development
[17]
of the technique . However, the risk of hernia recurrence has been shown to positively correlate with
increased body mass index (BMI) regardless of the type of repair performed [18-20] . While excess weight must
be addressed with patients desiring hernia repair, it is not feasible to expect all hernia patients to achieve
ideal weight prior to an operation. We have found that hernia recurrence and surgical site occurrence rates
are prohibitively high in patients with a BMI > 50. Therefore, at our institution, elective repairs for patients
with BMI > 50 are not performed unless they present with acute concern for bowel compromise.