Complementary and integrative medicine is particularly popular among patients undergoing facial cosmetic enhancement. This article reviews the efficacy of the most commonly practiced integrative therapies among this surgical population, with a focus on the most current literature regarding the application or potential for application of these treatments to benefit patients undergoing facial aesthetic surgery. Adverse effects of the most popular herbal and dietary supplements are also reviewed. Finally, the potential for interaction among integrative treatments as well as with conventional pharmacologic therapy is discussed.
Key points
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Complementary and integrative medicine is particularly common among patients undergoing facial cosmetic enhancement.
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Most patients undergoing facial aesthetic surgery who practice integrative therapies do so for their purported wound-healing, antimicrobial, and analgesic properties.
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Well-controlled scientific trials regarding the efficacy of integrative therapies are extremely limited.
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The existing evidence regarding the efficacy of these therapies is contradictory.
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The inherent properties of many of these products have been reported to put patients at risk of increased bleeding, excessive sedation, and dermatitis.
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Many of these products have the potential to interact with conventional pharmacologic therapies that patients may be prescribed.
Overview
Over the last decade, the US public has shown a steady and substantial use of complementary and alternative medicine (CAM), with 2007 estimates placing the overall prevalence of use at 38.3% of adults (83 million persons) and 11.8% of children (8.5 million children less than 18 years old). This CAM includes herbal remedies, massage, self-help groups, folk remedies, chiropractic manipulation, relaxation techniques, megavitamins, and others. In 2007, adults in the United States spent $33.9 billion out of pocket on visits to CAM practitioners and purchases of CAM products, classes, and materials. Annual visits to alternative practitioners have been estimated at $629 million, higher than that of primary care visits.
The use of Complementary and Integrative Medicine (CIM) is common among patients undergoing surgery. Reports have estimated its prevalence at 22% to 60% among certain adult surgical populations. In a 2000 study of patients presenting for preoperative clinic evaluation surveyed by Tsen and colleagues, 22% of presurgical patients reported the use of herbal remedies and 51% used vitamins. Another study from 2000 by Kaye and colleagues surveyed 1017 patients presenting for preanesthetic evaluation before outpatient surgery and found that 32% reported using herbal medications. In 2004, Norred surveyed 500 Denver patients about integrative medicine use in the 2 weeks before surgery and found that 67% disclosed the use of all types of CIM; 27% consumed herbs, 39% used dietary supplements, 54% took vitamins, and 1% reported the use of homeopathics. In another study, 57% of the 2186 patients undergoing elective surgery polled by Adusumilli and colleagues, in 2004, responded positively on a survey to have used herbal medicine at some point in their lives.
CIM seems to be especially popular among patients who undergo cosmetic surgery. Heller and colleagues compared the results of a survey regarding the use of herbal medication given to cosmetic surgery patients with the results of the same survey given to randomly chosen members of the general public. Fifty-five percent of the cosmetic surgery patients used herbal medications versus 24% of the general population. A 2011 UK study of 100 elective plastic surgery patients found that 44% were taking a dietary supplement, of which 17% were taking an herbal or homeopathic remedy. It has also been shown that the use of herbs, vitamins, and dietary supplements is more prevalent among white, educated, and wealthy individuals. Tsen and colleagues also reported that female patients use herbs more frequently than male patients (23.6% vs 19.2%). This description characterizes most aesthetic surgery patients.
The risk of unforeseen morbidity and mortality in the perioperative period may be increased in patients using CIM not only because of the physiologic alterations that can occur secondary to the intrinsic properties of these supplements but also because of the drug interactions made more likely by polypharmacy. The main concerns of the plastic surgeon are cardiovascular effects, alteration of coagulations, sedative effects, and interaction with other medications. Here, the authors review the most common modalities of CIM and their potential benefit to patients undergoing facial cosmetic enhancement procedures as well as the potential adverse reactions stemming from their use.
Overview
Over the last decade, the US public has shown a steady and substantial use of complementary and alternative medicine (CAM), with 2007 estimates placing the overall prevalence of use at 38.3% of adults (83 million persons) and 11.8% of children (8.5 million children less than 18 years old). This CAM includes herbal remedies, massage, self-help groups, folk remedies, chiropractic manipulation, relaxation techniques, megavitamins, and others. In 2007, adults in the United States spent $33.9 billion out of pocket on visits to CAM practitioners and purchases of CAM products, classes, and materials. Annual visits to alternative practitioners have been estimated at $629 million, higher than that of primary care visits.
The use of Complementary and Integrative Medicine (CIM) is common among patients undergoing surgery. Reports have estimated its prevalence at 22% to 60% among certain adult surgical populations. In a 2000 study of patients presenting for preoperative clinic evaluation surveyed by Tsen and colleagues, 22% of presurgical patients reported the use of herbal remedies and 51% used vitamins. Another study from 2000 by Kaye and colleagues surveyed 1017 patients presenting for preanesthetic evaluation before outpatient surgery and found that 32% reported using herbal medications. In 2004, Norred surveyed 500 Denver patients about integrative medicine use in the 2 weeks before surgery and found that 67% disclosed the use of all types of CIM; 27% consumed herbs, 39% used dietary supplements, 54% took vitamins, and 1% reported the use of homeopathics. In another study, 57% of the 2186 patients undergoing elective surgery polled by Adusumilli and colleagues, in 2004, responded positively on a survey to have used herbal medicine at some point in their lives.
CIM seems to be especially popular among patients who undergo cosmetic surgery. Heller and colleagues compared the results of a survey regarding the use of herbal medication given to cosmetic surgery patients with the results of the same survey given to randomly chosen members of the general public. Fifty-five percent of the cosmetic surgery patients used herbal medications versus 24% of the general population. A 2011 UK study of 100 elective plastic surgery patients found that 44% were taking a dietary supplement, of which 17% were taking an herbal or homeopathic remedy. It has also been shown that the use of herbs, vitamins, and dietary supplements is more prevalent among white, educated, and wealthy individuals. Tsen and colleagues also reported that female patients use herbs more frequently than male patients (23.6% vs 19.2%). This description characterizes most aesthetic surgery patients.
The risk of unforeseen morbidity and mortality in the perioperative period may be increased in patients using CIM not only because of the physiologic alterations that can occur secondary to the intrinsic properties of these supplements but also because of the drug interactions made more likely by polypharmacy. The main concerns of the plastic surgeon are cardiovascular effects, alteration of coagulations, sedative effects, and interaction with other medications. Here, the authors review the most common modalities of CIM and their potential benefit to patients undergoing facial cosmetic enhancement procedures as well as the potential adverse reactions stemming from their use.
Integrative treatment approaches and outcomes
Herbal, Homeopathic, and Dietary Supplements
The reported effects of herbal therapies and natural dietary supplements, used for generations as antiinflammatory, antimicrobial, and wound-healing treatment, have played an important role in medicine. Although a lack of standardization and paucity of well-controlled scientific trials has made it difficult to determine their efficacy, which many attribute to the lack of financial support for the study of nonpatentable natural treatments, proponents and users argue that the lack of double-blind randomized controlled trials (RCTs) does not exclude the possibility of a therapeutic effect.
Herbal
Aloe
Aloe (Aloe vera, Aloe barbadensis) is a cactuslike perennial plant belonging to the Lilaceae family that is native to southern Africa and commonly grown in tropical climates. Popular in traditional Chinese and Ayurvedic medicine, it has been used for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. More recently, aloe has been reported to
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Improve reepithelialization of surgical wounds
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Provide antiinflammatory effects
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Possibly increase dermal perfusion to decrease ischemia
Aloe leaves produce 2 substances, a gel and a juice or latex. The gel, a mucilaginous tissue from which most commercial cosmetic and medicinal products are made, is obtained from the inner part of the leaf and has been used topically to treat wounds and burns. The latex or juice refers to a bitter yellow fluid extracted from the specialized areas of the inner leaf skin and is generally sold as a powder that has very potent laxative effects. Fractionation of extracts and purification of compounds from aloe resulted in the identification of β-sitosterol, an angiogenic factor that may be beneficial to the healing process, because angiogenesis is integral to the repair mechanism. In view of the widespread use of aloe vera, the paucity of controlled clinical trials is surprising.
A 2012 systematic review of the literature summarizing the available evidence of the effectiveness of aloe vera in patients with both chronic and acute wounds, including surgical incisions, examined 7 small RCTs, with a mean sample size of 50. All had a moderate to high risk of bias caused by poor methodology. Evidence on wound healing was contradictory, and the investigators of the review concluded that there is little high-level evidence to support the use of aloe vera topical agents or aloe-derived dressings in the treatment of acute and chronic wounds. There are, however, several small studies, case reports, and animal series that have suggested that aloe vera may help with the wound-healing process. A 1995 study by Heggers and colleagues examined the role of aloe in enhancing the healing process in acute wounds in mice. Wounds treated with 10% aloe vera 3 times a day for 14 days had a significantly shorter half-life and healed faster than the control group. Additionally, the healed wound was markedly stronger than the control. A 1990 study by Fulton documented the effects of 2 different dressings for wound-healing management on full-faced dermabrasion patients. Eighteen patients suffering from acne vulgaris completed the study. Their abraded faces were divided in half. One side was treated with a standard polyethylene oxide gel wound dressing, whereas the other side was treated with a polyethylene oxide dressing saturated with aloe vera. After 48 hours with the aloe vera dressing, intense vasoconstriction and a reduction in edema was noted; less exudate and crusting were evident by the fourth day. By the fifth day, reepithelialization was complete to 90% on the aloe side compared with 40% to 50% on the control side. Overall, wound healing was approximately 72 hours faster on the aloe side. A 1995 study by Philips and colleagues compared the effect of an aloe vera derivative gel dressing with conventional treatment using hydrogen peroxide and an antibiotic with traditional dressing on 49 patients who had recently undergone shave biopsy excision for suspected skin cancers. There was no difference in the proportion of participants with a completely healed wound at 14 days; 26 out of 26 (100%) were healed in the aloe vera group compared with 23 out of 23 (100%) in the conventional therapy group, suggesting the noninferiority of aloe vera to conventional therapy.
Arnica
Arnica (Arnica montana) is an herbal remedy of European and Native American lineage used extensively in folk medicine to treat ecchymosis and pain after traumatic injuries. Arnica has frequently been cited in the herbal literature for its reported ability to promote wound healing and prevent postoperative hematomas, and it is also known as
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Leopard’s bane
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Wolf’s bane
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Mountain tobacco
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Arniflora
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Fallherb
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Fleurs d’arnica
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Guldblomme
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Monkshood
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Mountain daisy
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Mountain snuff
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Prickherb
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Smokeherb
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Sneezewort
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Snuffplant
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Spanish flower heads
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St. John’s strength flower
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Strengthwort
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Thunderwort
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Woundherb
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Wolf’s eye
The arnica that is used for medicinal purposes is an extract of dried flowers from the plant native to the meadows and mountainous regions of Europe and North America. Formulations of arnica are available as sprays for topical application, creams, gels, ointments, sublingual preparations, tablets, teas, and tinctures. It has been approved by the German Commission E as a topical agent with effective analgesic, antibacterial, and antiinflammatory properties; however, the Food and Drug Administration has classified arnica as an unsafe herb.
Marketed and sold as SinEcch by Alpine Pharmaceuticals (San Rafael, CA), arnica is used by many plastic surgeons to limit postoperative edema and ecchymosis. Anecdotal evidence is that arnica at a higher dose speeds the healing of bruises, and topical arnica is recommended to patients after soft tissue augmentation, Botox injections, fat transfer, and liposuction. Although highly diluted homeopathic preparations are considered safe and are widely used for the treatment of injuries, many clinical trials have been conducted and have not found a statistically significant efficacy for herbal or homeopathic forms of arnica over placebo. In Ernst and Pittler’s 1998 meta-analysis of 8 studies, 6 of which demonstrated no benefits for the use of arnica, the investigators concluded that this herbal agent is no more beneficial than a placebo. Likewise, a 2002 study of 19 patients with facial telangiectasias demonstrated no effect of topical arnica (concentrated at 1×) on the prevention or quickened healing of laser-induced bruising whether applied before or after laser treatment. A 2000 randomized, placebo-controlled, double-blind study performed by Ramelet and colleagues of 130 patients undergoing saphenous vein stripping demonstrated no statistically significant difference between patients receiving a sublingual dose of homeopathic arnica or indistinguishable placebo the night before and immediately after surgery with respect to postoperative hematomas. Most recently, a 2009 prospective, placebo-controlled, double-blind study of 30 male patients undergoing blepharoplasty found neither a subjective nor an objective difference in decreased ecchymosis or improved ease of recovery between the administration of homeopathic arnica and placebo.
Still, evidence of the efficacy of arnica has been reported. Although many studies have produced contradictory results, several studies suggest that arnica is at least as effective as the current treatment of select conditions. Kulick presented a randomized, prospective, double-blind, placebo-controlled trial of arnica in a series of 29 patients undergoing liposuction at the 2002 American Society for Aesthetic Plastic Surgery meeting. He demonstrated a statistically significant reduction in bruising and swelling in the arnica-treated group. The results of a 2007 study of 48 patients undergoing primary rhinoplasty with osteotomy demonstrated no differences between patients receiving arnica and those receiving corticosteroids or placebo with respect to the extent and intensity of postoperative ecchymosis. However, patients who received arnica had significantly less edema during the early postoperative period, suggesting a beneficial effect of arnica on this postrhinoplasty consequence. A 2005 randomized, double-blind, placebo-controlled study of bruising and skin color changes following rhytidectomy in 29 patients who were treated with either homeopathic arnica or placebo found no subjective differences between patients in the two treatment groups. However, patients in the arnica group did have a smaller area of ecchymosis than those receiving placebo. This difference was found to be statistically significant on postoperative day (POD) 1 and 7 but not on POD 5 and 10. Objectively, no significant difference in the degree of ecchymosis, as measured by the extent of color change, was found.
Although the subtle benefit that has occasionally been reported to be induced by arnica seems very difficult to definitively and reproducibly demonstrate in the studies involving the relatively small numbers of individuals considered in most trials to date, no serious adverse effects have been reported with the use of homeopathic arnica. Under a physician’s supervision, patients can probably safely take arnica that is available in preparations manufactured for the prevention of bruising and swelling. Patients should be discouraged from using oral arnica in amounts greater than commonly found in foods or in homeopathic formulations because of reports of severe health risks, including coma, hypertension, renal toxicity, cardiotoxicity, muscle paralysis, and death. Also, patients should be instructed not to apply arnica to abraded skin or open wounds and advised against prolonged topical use because of the potential for irritant or allergic contact dermatitis.
Bromelain
Bromelain (Ananas comosus , Ananas sativus) is a protease enzyme mixture derived from the pineapple plant that has been used by native cultures as a digestive aid and as a remedy for skin disorders. It is also known as
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Ananase
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Anansase100
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Ananase Forte
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Bromelain-POS
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Traumanase
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Wobenzym
It has been reported to have antiinflammatory, antiedematous, anticoagulant, and antimetastatic properties and has also been shown to enhance antibiotic activity. Bromelain may be of particular interest in plastic surgery because of its apparent antiedematous, antiinflammatory, and anticoagulation properties, which may be beneficial in postoperative healing. There is also some evidence that suggests that it may be beneficial in pain reduction, wound healing, burn debridement, and ischemia reperfusion. It seems to be most effective when taken orally.
An early double-blind, controlled clinical trial in obstetric patients reported faster rates of reduction of edema and bruising after episiotomy in patients who received bromelain treatment compared with those who received placebo. None of the results were statistically significant, however. In another double-blind, placebo-controlled study, bromelain was shown to reduce edema and ecchymoses by one-half to one-third fewer days in patients who experienced surgical (eg, rhinoplasty) or nonsurgical trauma to the face. More recently, a 2003 study of wound healing in healthy adults found that an oral nutritional supplement containing bromelain, as well as other vitamins and minerals, including other proteases, decreased the soft tissue wound healing time when administered during the early phase of wound healing, although the extent to which bromelain was responsible more than the other components was not elucidated.
Grape seed extract
Grape seed extract ( Vitis vinifera , Vitis coignetiae ) has been used to treat venous insufficiency, inflammatory conditions, and promote wound healing in Europe. It is also known as
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Pine bark
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Pinus maritima
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Grape complex
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Grape seed
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Grape seed oil
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Grape skin extract
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Muskat
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ActiVin
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Endotelon
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Grape seed standardized extract
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Leucoselect-phytosome
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Masquelier’s Original OPCs
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Pycnogenol
It has been established as a potent antioxidant because of its constituent oligomeric proanthocyanidins and thought to exhibit a wide range of biologic, pharmacologic, chemoprotective, and antioxidant activity. Additionally, proanthocyanidins are thought to have the capacity to stabilize collagen and elastin, thereby improving the elasticity, flexibility, and appearance of the skin.
Motivated by encouraging results in vitro and in animal models, grape seed, its oil, and its extract have been increasingly used for strengthening vessels and preventing bruising. The extract has been reported to increase wound contraction and closure speed in mice, vascular endothelial growth factor (VEGF) and tenascin levels in the wound edge, and connective tissue deposition. A 2001 in vitro study by Khanna and colleagues reported evidence showing that grape seed proanthocyanidin extract (containing resveratrol) facilitates oxidant-induced VEGF expression in keratinocytes. VEGF induces the migration and proliferation of endothelial cells and enhances vascular permeability consistent with the purported ability to promote angiogenesis. Angiogenesis plays a central role in wound healing.
A 2002 study by Khanna and colleagues examined the effect of topical grape seed proanthocyanidin extract (GSPE) on the healing of full-thickness excisional wounds in the mouse model. GSPE treatment was associated with a more well-defined hyperproliferative epithelial region, higher cell density, enhanced deposition of connective tissue, and improved histologic architecture in treated wounds compared with control wounds in the same animal. GSPE treatment also increased VEGF and tenascin expression in the wound edge tissue, which are markers in granulation tissue often used as indicators of cutaneous wound repair.
A 2010 study by Nayak and colleagues of the wound-healing activity in mice of a finely ground grape-skin powder derived from the Cabernet Sauvignon variety demonstrated that animals in the treatment group exhibited significant increases in the rate of wound contraction (100% by day 13 when compared with control [82.1%] and standard treatment with mupirocin [93.0%]) and an increased rate of epithelialization. Similarly, a 2004 study by Blazsó and colleagues demonstrated that regular topical application of Pycnogenol, a patented nutrient supplement extracted from the bark of European coastal pine Pinus maritime that consists of flavonoids, catechins, procyanidins, and phenolic acids (which are the same constituents found in grape seed, although it is not the same supplement), accelerated wound healing and reduced scar formation in rats. Gels of increasing concentration (1%, 2%, and 5%) were applied to wounds inflicted on the backs of the animals with a 100°C branding iron. The 1% gel significantly shortened the wound healing time by 1.6 days, the 2% gel reduced the time by 2.7 days, and the 5% gel by 5.3 days. Pycnogenol also reduced the diameter of the scars remaining following complete scab loss in a concentration-dependent manner.
Ginkgo
Ginkgo (Ginkgo biloba) is one of the top 10 best-selling herbs in the United States and the most widely sold phytomedicine in Europe. It is also known as
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Maidenhair tree
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Duckfoot tree
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Fossil tree
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Yin xing
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Ich, ginnan
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Japanese silver apricot
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ArginMax
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BioGinkgo
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Gincosan
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Ginexin Remind
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Gingopret
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Ginkai
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Ginkgo Go
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Ginkgo Phytosome
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Ginkgo Powder
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Herbal vX
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Seredrin
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Tanakan
Ginkgo is widely used to treat a variety of conditions:
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Dementia
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Memory impairment
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Peripheral vascular disease
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Erectile dysfunction
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Premenstrual syndrome
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Macular degeneration
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Tinnitus
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Vertigo
The known physiologic effects of ginkgo are congruent with a vascular mechanism of action. Gingko has been researched among methods being devised to reduce tissue damage caused by ischemia in major surgical reconstructions that require extensive flap use. The effects of ginkgo biloba extract on cellular membranes are scavenging oxygenated free radicals produced during arachidonic acid metabolism. Free oxygen radicals have been accused of causing cellular injury both during the course of ischemia and at the time when these total ischemic tissues are reperfused.
A 1997 study of the effects of oral ginkgo biloba extract on flap viability in rats reported significantly lower rates of skin necrosis and levels of free radical scavenging biochemical enzymes malonyldialdehyde (MDA), superoxide dismutaste, and glutathione peroxidase, measures of free radical activity, in biopsy specimens. On electron microscope investigation, the treated group had more normal tissue structures compared with high levels of degeneration and loss of the dermal-epidermal junction in the control group. These results suggest that ginkgo biloba extract may be beneficial in modulating the no-reflow phenomena and subsequent tissue injury and may help to improve tissue salvage. Another 1997 study of the effects of oral Ginkgo biloba on skin flaps in the rat model reported that biopsies of the flap site in ginkgo-treated groups had significantly lower MDA levels than control samples after 120 minutes of ischemia, indicating that ginkgo may decrease free radical activity and a possible benefit in modulating the no-reflow phenomenon and subsequent reperfusion injury, and may help to improve tissue salvage. A 1998 study by Bekerecioğlu and colleagues examined the effect of Ginkgo biloba on caudal-based dorsal rat flaps. The investigators reported that the group that was administered ginkgo intraperitoneally for 6 days beginning 24 hours after surgery demonstrated a significantly reduced area of flap necrosis after 10 days compared with the control. A 2010 study by Sambuy and colleagues analyzed the effect of Ginkgo biloba on the survival of fasciocutaneous flaps in rats. They reported a statistically significant reduction in the area of necrosis of the total surface flap in the group administered ginkgo for 7 days starting 24 hours postoperatively and a reduction approaching statistical significance ( P = .053) in the group administered ginkgo for 7 days beginning immediately after surgery. These results suggest that the reduction in necrotic areas of the flaps by free radical scavengers, such as Ginkgo biloba , indicates that the extract may have an indirect role in the survival of these flaps and may be useful in salvaging some parts of distally necrotic flaps. Further research is warranted to determine if ginkgo might be advantageous in human patients.
Other herbs
There are several less widely used herbs that have been associated with effects that may be beneficial to patients undergoing cosmetic enhancement procedures, including the following:
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Chamomile
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Marigold
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Honey
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Turmeric
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Cocoa
The wound-healing properties of these herbs have been explored in limited studies. Animal studies demonstrated that aqueous chamomile ( Matricaria recutita ) increased the rate of wound contraction and wound strength in addition to its antioxidant activity. Marigold ( Calendula officinalis ) is recommended as a topical preparation for the treatment of wounds, ulcers, burns, boils, rashes, chapped hands, herpes zoster, and varicose veins. In animals, surgical wounds displayed faster reepithelialization and fibroblasts increased proliferation and migration. In vitro and in vivo studies of honey have demonstrated not only its effectiveness against many human pathogens, including methicillin-resistant Staphylococcus aureus but also its ability to retain a proper amount of moisture in the wound and aid in the formulation of granulation tissue and reepithelialization, significant deodorization, and angiogenic activity. Several in vitro studies of curcumin, the yellow-colored primary active constituent derived from the spice turmeric, have shown protective effects on keratinocytes and fibroblasts, cells involved in wound healing. One human study also reported significantly reduced pain, fatigue, and the use of supplementary analgesics in postoperative patients. External application of cocoa has been reported to have a variety of benefits, including soothing burns, disinfecting wounds, and acting as a moisturizer for the skin. Additionally, one study showed that consumption of flavanol-rich cocoa increased microcirculation in the skin, which may be important to the wound-healing process.
Dietary supplements
Like herbal therapy, dietary supplements and topical applications containing one or more ingredients purported to exert a pharmaceutical therapeutic benefit but not necessarily a biologic therapeutic benefit, defined as cosmeceuticals , are used and promoted as improving outcomes in cosmetic surgery.
Retinoids
Derivatives of vitamin A, collectively known as retinoids, are used in topical preparations and have been studied extensively for the treatment of photodamage and acne. Within cosmeceutical formulations, various derivatives of vitamin A can be found, including the following:
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Retinol
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Retinaldehyde
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Retinyl esters
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The oxoretinoids
Retinoids are also known to have positive effects on wound healing. They have been shown to increase epidermal water content, epidermal hyperplasia, and cell renewal while enhancing collagen synthesis. In a small 1995 study of 4 elderly men with extensively photodamaged skin, Popp and colleagues reported that treatment with a topical retinoid significantly and dramatically accelerated wound healing. Examination of wounds inflicted with a punch biopsy revealed that the wound areas treated with the retinoid were 35% to 37% smaller on days 1 and 4 and 47% to 50% smaller on days 6, 8, and 11 compared with the controls. Also, reepithelialization occurred more rapidly both clinically and histologically.
The use of topical retinoids is often recommended before laser resurfacing procedures because of the beneficial effects in accelerating wound healing, enhancing collagen production, and activating fibroblasts. A 2004 study of 16 women undergoing nonablative laser remodeling treatment of the neckline and forehead reported that patients treated with a daily topical application of 0.05% retinaldehyde immediately after the first laser treatment and up to 3 months after the fifth treatment showed a statistically significant increase in dermal thickness compared with controls. A survey of 339 dermatologists and plastic surgeons revealed that 80% of respondents recommended preoperative treatment with topical retinoids before laser resurfacing procedures.
Vitamin C
Vitamin C ( l -ascorbic acid) is a naturally occurring antioxidant normally found in human skin that functions as a free radical scavenger. Vitamin C–containing cosmeceuticals have been shown to promote collagen synthesis, improve fine rhytides, and decrease hyperpigmentation. Vitamin C is often recommended to improve wound healing. Two intervention studies from the same research group aimed to evaluate the effect of vitamins (ascorbic acid and pantothenic acid) supplementation before and after tattoo resection on the healing of surgical wounds. In both studies, hydroxyproline in skin and scars decreased from day 8 to day 21, which was associated with an increase in fibroblasts. Also, rigidity and breaking energy of the scars were higher in a dose-dependent fashion, suggesting supplementation of ascorbic acid in combination with pantothenic acid before and after a planned surgery of the skin may partly improve the mechanical properties of scars. Theoretical benefits to the use of topical vitamin C with laser resurfacing procedures include minimizing postprocedural inflammation and erythema and increasing new collagen formation. A 1998 study by Alster and West examined the effects of vitamin C in 21 patients who underwent carbon dioxide laser resurfacing followed by treatment of half of the face with topical ascorbic acid and half with petrolatum-based cream. Significantly reduced erythema was observed in skin treated with 10% l -ascorbic acid in aqueous formulation compared with placebo.
Vitamin E
Vitamin E (α-tocopherol) is a lipophilic antioxidant that occurs naturally in the skin and scavenges free radicals. Topical vitamin E preparations have been marketed to assist in wound healing and in minimizing postsurgical scarring. Data supporting these claims have been contradictory, however. Several studies have examined the effects of topical vitamin E on wound healing after laser resurfacing with conflicting results. In a 1993 study by Simon and colleagues, porcine skin was irradiated with various doses of argon and copper-vapor laser and evaluated for effects on healing time of pretreatment with topical or intramuscular vitamin E. Skin treated with vitamin E demonstrated significantly decreased wound healing time by approximately 1 week after exposures of intermediate duration. A split-face study compared the effects of a topical formulation containing 4% tocopherol acetate among several other ingredients with petrolatum alone on wound healing after resurfacing with YAG laser. The investigators reported decreased time to reepithelialization, as well as decreased pain, erythema, and edema in the skin treated with the vitamin E–containing compound. As noted in a subsequent review article, however, the contribution of vitamin E is questionable because its effect was not isolated from the potential actions of the additional ingredients.
Zinc
Zinc is an essential trace element in the human body that plays key roles in each phase of wound healing and has antiinflammatory effects. In the rat model, supplemental zinc administered orally to zinc-deficient patients in a 1970 study was found to increase the progression of wound healing, and in a 1985 study, zinc applied topically for 12 days was beneficial in the treatment of full-thickness excisional wounds, regardless of the nutritional status of the rats. A 1991 porcine study by Agren and colleagues reported that topical zinc oxide enhanced reepithelialization of partial-thickness wounds in nutritionally balanced pigs. In human studies, a 1984 study of 37 geriatric patients with either venous or arterial leg ulcers showed statistically significant improvement in healing in nearly twice as many patients in the groups administered topical zinc, suggesting that healing of leg ulcers is improved after the addition of zinc oxide to the local regimen. Whether zinc enhances wound healing in human beings is unclear for nondeficient individuals.
Acupuncture
Acupuncture is part of an age-old paradigm within traditional Chinese medicine (TIM), a holistic approach that addresses the entire body when treating a localized condition or anatomy. Based on the concept of energy flow, or Qi, which is separated into yin and yang, the goal of TIM is to manipulate the balance of yin and yang along 12 basic channels that flow throughout the body to maximize health. Stimulation of special acupuncture points on the body surface with needles, heat, or pressure has been done in China for more than 2500 years to treat diseases and relieve pain. Within aesthetic plastic surgery, the use of acupuncture has been explored as a compliment or alternative to various procedures and also as an adjunct to conventional pharmacologic control of postoperative pain, nausea, and vomiting.
Facial rejuvenation
The goal of TIM in facial rejuvenation is to enhance facial muscle and skin tone to its optimum level without injections or surgery. Acupuncture has also been described as a compliment to improve results as a component of aesthetic surgery that is similar to physical therapy for orthopedic surgery. Practitioners insert acupuncture needles into the face at different points along designated channels to attain tonification or sedation effects. According to one California-based acupuncturist, many younger patients and established patients needing maintenance do not require major surgery and can benefit from a noninvasive approach. In a 2005 article, Barrett outlined the major channels used in facial rejuvenation and the aspects of those channels that most strongly affect the face: tonification techniques are used in patients with flabby skin and poor muscle tone and to promote blood circulation, and sedation techniques are used to relax tense muscles and to reduce inflammation and acne. A single case of a 26-year-old woman seeking reduction in nasolabial fold prominence, facial edema, and poor muscle tone in her eyes and cheeks was presented. Over a 1-month period, the patient received 10 treatments with 2-Hz electroacupuncture needles inserted 1 to 2 mm at 0.5-in intervals for 20 minutes at approximately 5 mA “to strengthen local Qi and blood circulation while promoting collagen formation.” In the results, evaluated through the assessment of pretreatment and posttreatment photographs, the investigator reported a 50% shortening and 20% reduction in depth of the nasolabial fold, complete bilateral elimination of the lines above the eyes, and a 50% reduction of the depth and 20% reduction of the length of the lines under the eyes.
Acupuncture analgesia
Acupuncture analgesia is a technique directed toward the relief of pain and regulation of the physiologic function of the human body by needling. Relief of pain during surgery is conventionally provided by the administration of opioid drugs. Risks of undesirable side effects, such as nausea, vomiting, and decreased genitourinary and alimentary tract motility, can lead to delayed postoperative recovery. Therefore, the use of adjunct analgesics that provide opioid-sparing effects and decrease the incidence of opioid-related side effects has been explored.
There are increasing numbers of clinical trials evaluating the efficacy of acupuncture and related techniques as an adjuvant method for postoperative analgesia. Physiologically, acupuncture may inhibit gastric acid secretion and stimulate the release of endogenous endorphins, offering a potential explanation for therapeutic effects on nausea, vomiting, and pain. The P6, or Neiguan acupuncture point over the median nerve on the volar aspect of the wrist, is thought to regulate these symptoms. A 2008 meta-analysis evaluating the efficacy of acupuncture and related techniques as adjunct analgesics for acute postoperative pain management included 15 studies encompassing a wide range of interventions and types of surgery (not cosmetic). The investigators found that acupuncture and related techniques are effective adjuncts for postoperative pain management as demonstrated by a significant reduction of postoperative pain scores and opioid consumption. A 2009 RCT by Larson and colleagues targeted patients undergoing cosmetic and reconstructive face, breast, and body-contouring cosmetic procedures and examined the effect of electro-acustimulation versus placebo on postoperative nausea, vomiting, and pain. Statistically significant findings included that patients in the electro-acustimulation group reported lower nausea scores at 30 minutes and 120 minutes postoperatively. There was no difference in emetic events. A shorter time to discharge was noted in treated patients undergoing abdominal procedures and a decreased need for intravenous (IV) fentanyl in treated patients undergoing breast procedures. However, these differences were not demonstrated in patients undergoing facial procedures.
A 2005 randomized, double-blind, sham-controlled study of 105 adults undergoing elective plastic surgery by White and colleagues examined the effect of timing of acustimulation when administered in combination with ondansetron for preventing postoperative emetic symptoms. Results demonstrated that acustimulation at the P6 acupoint for 30 minutes before and up to 72 hours after surgery resulted in 25% less postoperative nausea and vomiting (PONV) than with preoperative treatment alone and 13% less PONV than with only postoperative treatment. A 2010 study of 90 patients by Sahmeddini and colleagues to test whether electroacupuncture (EA) of specific points is superior to sham acupuncture for complementary analgesia after nasal septoplasty reported that perioperative EA is a suitable alternative to intravenous morphine (0.1 mg/kg) in reducing postoperative pain scores. The results suggested that the use of both EA and 0.1 mg/kg IV morphine given intraoperatively resulted in a similar postoperative pain score and postoperative analgesic requirement, which meant EA had a similar analgesic effect to morphine in this study.
Mind-Body Medicine
Numerous prospective randomized studies have investigated the effectiveness of mind-body techniques used before and after surgery in improving surgery outcomes as measured by
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Decreased anxiety
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Decreased pain
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Reduced need for pain medication
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Shortened hospital stays
Published pain management guidelines also recognize the role of the mind-body technique in the management of postoperative pain. Facial neuromuscular training with electromyogram (EMG) biofeedback is a mind-body medicine technique that has been well described. The process of monitoring and feeding back information to patients is used to aid in training patients to alter some characteristic of that activity. Biofeedback EMG instruments are essentially general-purpose physiologic monitoring devices that are designed to provide ongoing information about a physiologic function that normally occurs involuntarily, such as heart rate, blood pressure, or, in this case, muscle tension levels as measured by EMG. A 2004 study by Vaiman and colleagues described the outcome of biofeedback training of nasal muscles in cases of nasal valve stenosis and collapse. Fifteen nonrandomized patients with clinically evident nasal valve collapse were treated with 9 to 12 months of surface and intranasal EMG biofeedback-assisted specific strategies for nasal muscle education and a home exercise program of specific nasal movements. Although all patients improved subjectively, 86.66% (13 out of 15) showed objective improvement obviating endonasal surgery.
Hypnosis
Hypnosis involves the intentional induction, deepening, maintenance, and termination of a natural trance state for a specific purpose, usually to reduce suffering or promote the healing of patients. The hypnotic phenomenon has been used since antiquity to assist healing. It may be induced using relaxation, meditation techniques, guided imagery, deep breathing, or self-induced focus. Hildebrand and Anderson described techniques that can be used in the practice setting of the plastic surgery including
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Mindful focus
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Focused breathing
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Body scan
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Progressive muscle relaxation
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Guided imagery
The use of hypnosis techniques has been promoted for a variety of situations in the plastic surgery setting. They have been used to assist with the use of Botox, the use of dermal fillers, and the removal of sutures or staples. Hypnosis has also been used to lessen the severity of pain associated with surgery when used in combination with a local anesthetic. A 2002 study of 20 women randomized to standard care versus preoperative hypnosis for excisional breast biopsy by Montgomery and colleagues found that brief (10 minute) hypnosis was effective in reducing postsurgery pain and distress both before and after surgery. Patients in the hypnosis group required less propofol, and reported less pain intensity, nausea and discomfort than the control group. Hypnosis has also been reported to be as helpful as complementary or integrative therapy for treating warts. In a controlled study by Surman and colleagues, 53% of the experimental group consisting of 17 experimental patients with bilateral common or flat warts had improvement of their warts 3 months after the first of 5 hypnotherapy sessions, whereas none of the control group had improvement.
Adverse Effects
Many patients have the misconception that because integrative treatments are natural there are no adverse effects. Although there is no clear evidence that the preoperative use of herbal supplements will cause harmful effects, there are many potential complications that the surgeon should know. A 2002 survey of surgical patients revealed that patients admitted to taking herbal medication that had coagulation effects (40.5%), blood pressure effects (32.7%), cardiovascular effects (20%), sedative effects (16.7%), and effects on electrolytes or diuresis (8.9%); 22.8% of patients reported using herbs that are known to cause adverse effects when combined with prescription medications. Of the direct pharmacologic effects, the putative risk of bleeding imparted by the use of various herbal medicines is of particular concern. Certain remedies can increase the risk of intrinsic bleeding, which can result in serious problems for plastic surgeons and their patients. Some herbals inherently possess significant pharmacologic activity to antagonize normal platelet aggregation and coagulation mechanisms; others contain coumarins, and their plants are similar in structure to warfarin.
Garlic
There is substantial evidence to implicate garlic as a potential cause of bleeding, and studies indicate it may inhibit platelet aggregation in a dose-dependent fashion. In vitro studies have shown reduction in adenosine diphosphate (ADP)–induced platelet aggregation, thromboxane reduction, CA+ mobilization, and inhibition of the synthesis of thromboxane B2. In vivo human studies have documented garlic’s effect on hemostatic parameters, such as ADP-induced platelet aggregation, thromboxane reduction, and clotting time. Garlic has also been implicated as a cause of spontaneous bleeding in several case reports, including a spontaneous epidural hematoma in an elderly man, a hematoma after breast augmentation that required evacuation, and a hemorrhage after a transurethral prostate resection in a 72-year-old patient taking no medications other than garlic that required transfusion of 4 units of blood. The potential for irreversible inhibition of platelet function may warrant patients to discontinue garlic use at least 7 days before surgery, especially if postoperative bleeding is a particular concern or other platelet inhibitors are given.
Ginkgo
Ginkgo also inhibits thromboxane synthetase, which may increase surgical bleeding. These antiplatelet effects are dose dependent, long lasting, and rapidly established after oral intake. Several anecdotal reports of bleeding complications attributed to Ginkgo biloba use illustrate ginkgo’s potential inhibitory effect on platelet activating factor and consequently on platelet aggregation, including
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Spontaneous bilateral subdural hematomas
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Fatal intracerebral mass bleeding
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Spontaneous hyphema
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Postoperative bleeding following laparoscopic cholecystectomy
Attempts to scientifically demonstrate an in vivo effect of ginkgo on platelet or coagulation function have fallen short, however. Clinical trials with small numbers of patients have not demonstrated complications from bleeding. In 44 clinical studies with a total of 9772 patients, the incidence of adverse effects was 0.5%. Recently, a 2003 prospective, double-blind, randomized, and placebo-controlled study was carried out in 32 young, male, healthy volunteers. No significant effect on hemostasis, coagulation, platelet function, and fibrinolysis was observed. Likewise, in a 2004 study of 50 healthy male volunteers taking ginkgo, none of 29 platelet and coagulation parameters was abnormal. A 2007 study of 10 healthy adult volunteers taking ginkgo at the manufacturer’s recommended dose for 2 weeks also showed no significant changes in platelet count, prothrombin time (PT), partial thromboplastin time (PTT), or bleeding time.
Asian ginseng
Asian ginseng (Panax ginseng) , the most expensive and probably the most popular herb sold worldwide, has been valued in Chinese medicine for more than 2000 years for its invigorating, adaptogenic, and tonic properties. Presently marketed in the United States to increase alertness and energy, Asian ginseng has also been shown to exhibit irreversible antiplatelet effects. In rats, ginseng has been shown to inhibit platelet aggregation induced by thrombin or collagen; a 1989 study suggested that it may exhibit irreversible antiplatelet activity in humans by the inhibition of thromboxane formation. However, a 2007 study of the effects of ginseng administered at the manufacturer’s recommended dose showed no significant alteration in platelet count, PT, PTT, or bleeding time. Case reports implicating ginseng as a cause of bleeding are limited to 2 reports from the 1980s of vaginal bleeding in postmenopausal women after using ginseng either topically or orally and menometrorrhagia in a 39-year-old woman using oral and topical ginseng, which abated 10 days after she stopped taking the ginseng. Although the elimination half-life of ginseng is relatively short, its irreversible platelet inhibition suggests that use should be discontinued at least 7 days before surgery.
Ginger
Ginger, a popular remedy for nausea, gastrointestinal bloating, dyspepsia, and arthritic inflammation, has been shown to decrease platelet aggregation in randomized controlled studies; concern has been raised that ginger may prolong bleeding time because of its inhibition of thromboxane synthetase. A 2003 Australian study showed that compounds in ginger and their derivatives are more potent antiplatelet agents than aspirin in vitro. Several trials have found evidence contradicting these reports, including 2 trials that failed to demonstrate any association of ginger with platelet aggregation, fibrinolytic activity, or fibrinogen levels. Still, most recommendations are that ginger should not be taken in the perioperative period because of the increased risk of hematoma and prolonged bleeding, and patients should be advised to discontinue the use of ginger 2 to 3 weeks before surgery.
Feverfew
Feverfew is an herb that has been used traditionally as an antipyretic but is most commonly used for migraine prevention. No cases of bleeding problems in patients using feverfew have been reported; however, an in vitro study showed that feverfew extract inhibited the deposition of platelets on collagen in a dose-dependent way. Caution dictates that patients should be advised to discontinue feverfew use before surgery. Plastic surgeons should advise patients to taper, then discontinue feverfew completely no later than 2 to 3 weeks before surgery because abrupt cessation of feverfew therapy may result in a syndrome characterized by nervousness, tension headaches, insomnia, stiffness, joint pain, and tiredness.
Kava and valerian
Kava and valerian, 2 popular herbal medications often taken as anxiolytics or sleep aids, have been associated with excessive sedative effects. It has been suggested that kava, a pepper plant derivative, has a therapeutic potential in the symptomatic treatment of anxiety. Its active constituents, kavalactones, have a dose-dependent potentiating effect on gamma-aminobutyric acid (GABA) inhibitory neurotransmission. Although most Western countries suspended kava sales in 2002 following reports of liver toxicity, it may still be obtained through traditional herbalists and online distributors. Potential for abuse exists; however, investigations into addiction, tolerance, and acute withdrawal are lacking. Additionally, heavy users of kava have experienced a characteristic reversible kava dermopathy after several months at high doses. Symptoms include reddened eyes, scaly skin eruptions, and a yellowish discoloration of the skin and hair. The potential for interaction with anesthetic agents warrants its discontinuation at least 24 hours before surgery.
Valerian, widely available as an herbal sleep aid, also acts by mediating GABA neurotransmission. Valerian produces dose-dependent sedation and hypnosis. There is a 1998 case report in which valerian withdrawal seemed to mimic acute benzodiazepine withdrawal syndrome in a patient who presented with symptoms of delirium and cardiac complications following surgery that were relieved with the administration of benzodiazepines. Because of this unknown incidence of withdrawal effects, patients should be advised to taper the dose over several weeks before surgery or continue taking valerian up until the day of surgery. St. John’s wort, an herb with clinically proven antidepressant effects that is also used as an integrative treatment of anxiety and sleep disorders, may also potentially prolong postoperative sedation in some patients. However, no controlled studies support these observations.
Cutaneous reactions
Many cutaneous reactions to herbal preparations have been reported. Numerous herbal medicines may profoundly affect the skin and thereby adversely interact with the facial plastic surgeon’s efforts to improve skin quality through resurfacing techiniques. Kava dermopathy has previously been mentioned. St. John’s wort poses a risk of photosensitivity reaction. Animal studies have noted the development of blisters similar to burns on exposure to bright sunlight with heavy consumption, and 2 case reports detail photosensitivity reactions in humans associated with the ingestion of the herb.
A young woman has been described with leukemia-related Sweet syndrome elicited by pathergy to topical arnica; however, the most common cutaneous adverse effect of herbal preparations is allergic contact dermatitis. Certain medicinal plants of the carrot family ( Apiaceae ) contain furanocoumarins and can also cause a photodermatitis in humans from sensitization of the skin to UV light. Use of herbal medicines containing furanocoumarins should be avoided while undergoing cosmetic surgery, UV exposure, or in conjunction with other photosensitizing agents or dermal irritants.
Phytoestrogens
Many facial plastic surgery patients who are perimenopausal or postmenopausal have turned to herbal remedies following adverse outcomes of hormone replacement therapy reported by the Women’s Health Initiative. More than 500 plant species contain phytoestrogens, naturally occurring substances functionally similar to estradiol, which may potentiate or antagonize estrogen effects. Among the more commonly used phytoestrogen-containing herbs are
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Dong quai ( Angelica sinensis )
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Red clover ( Trifolium pratense )
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Alfalfa ( Medicago sativa var italica )
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Licorice ( Glycyrrhiza glabra )
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Black cohosh ( Cimicifuga racemosa )
These compounds may contribute to changes in skin pigmentation following plastic surgery procedures such as dermabrasion, laser skin resurfacing, microdermabrasion, and scar revisions. In one case, postmenopausal bleeding was attribute to the estrogenlike effect of topical ginseng. Moreover, use of some phytoestrogens in conjunction with estrogen replacement therapies may result in symptoms, such as nausea, bloating, hypotension, breast fullness or tenderness, migraine headaches, and edema.
Pharmacokinetic and Pharmacodynamic Interactions
The interaction of herbal medications with allopathic medicines is complex. A growing body of scientific literature has highlighted the pharmacokinetic and pharmacodynamic interactions between herbal and prescription medicines. Many of the harmful interactions stem from the cytochrome P450 (CYP) pathway used by many medications. St. John’s wort induces the CYP isoform 3A4 as well as the drug efflux transporter P-glycoprotein. Documented St. John’s wort interactions include a diverse group of drugs including
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The immunosuppressants cyclosporine and tacrolimus
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The protease inhibitor indinavir
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The non-nucleoside reverse transcriptase inhibitor nevirapine
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The tricyclic antidepressant amitriptyline
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The 5- hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor simvastatin
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Calcium channel blockers
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Serotonin receptor agonists
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Oral contraceptives
The CYP isoform C is also induced by St. John’s wort and can decrease levels of warfarin and nonsteroidal antiinflammatory drugs (NSAIDs). Steady use may, on the other hand, lower digoxin levels. Both aloe vera (taken internally) and cascara ( Rhamnus purshiana ) may potentiate cardiac glycosides as well as antiarrhythmic drugs.
Several studies support the avoidance of garlic usage with coagulation inhibitors, including heparin, warfarin, aspirin, and NSAIDs. In particular, garlic has been reported to increase the international normalized ratio when used in combination with warfarin and may potentiate bleeding postoperatively. Concomitant use of Ginkgo biloba with antiplatelets, anticoagulants, and NSAIDs should also be avoided. Case reports of a spontaneous hyphema when a patient who had been on aspirin therapy commenced taking ginkgo and another who experienced cerebral hemorrhage when he added ginkgo to a regimen that included warfarin highlight the dangers of these combinations. Ginseng has been reported to interact with monoamine oxidase inhibitors, resulting in tremulousness and mania; concomitant use should be avoided. Caution should also be used when ginseng is taken along with anticoagulation and antiinflammatory pharmaceuticals because the platelet inhibition is irreversible. Because valerian and kava can cause sedation, patients should be advised to avoid combining with benzodiazepines, barbiturates, and alcohol. Furthermore, kava interacts with levodopa to potentiate Parkinsonian symptoms.
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