Journal Logo

Ideas and Innovations

Nutrition and the Plastic Surgeon: Possible Interventions and Practice Considerations

Roy, Mélissa MDCM*; Perry, Julie A. MSc, PhD*; Cross, Karen M. MD, PhD, FRCSC*,†

Author Information
Plastic and Reconstructive Surgery - Global Open: August 2018 - Volume 6 - Issue 8 - p e1704
doi: 10.1097/GOX.0000000000001704
  • Open
  • Canada
  • Keynotes or Deep Cuts Podcast



Surgical outcomes are largely influenced by patients’ preoperative health, including their nutritional status.1,2 Up to 45% of hospital inpatients are malnourished upon admission,3 and our own experience suggests that up to 25% of plastic surgery outpatients are at risk for malnutrition.4 Alarmed by the magnitude of this problem, we developed a universal nutritional screening platform based on the Integrated Nutrition Pathway for Acute Care5 and recommendations from the American Society for Parenteral and Enteral Nutrition.6 This screening platform involves 2 stages: universal triage with the 2-question Canadian Nutritional Screening Tool (CNST), and further screening and classification of those deemed “at risk” with the more in-depth Subjective Global Assessment.7 Our nutritional screening strategy was easy to implement in a busy tertiary care center, feasible in an outpatient context, and accurate.8 However, the question remains as to how to address malnourishment in our patients. The objective of this editorial was to highlight the importance of nutrition in plastic surgery, to offer possible outpatient nutritional interventions within the surgical care setting, and to guide plastic surgeons in integrating nutrition as a key practice enhancement strategy for the care of their patients.


Adequate nutrition is important in surgical patients. Macronutrients are essential for all phases of wound healing. For example, protein depletion leads to a prolonged inflammatory phase by decreasing fibroblast proliferation, proteoglycan synthesis and neoangiogenesis.9 Not only does wound healing require adequate nutritional input, but wounds increase baseline caloric and protein demands.9 Micronutrients also play significant roles in the process of wound healing. Vitamin A stimulates fibroblasts,10 vitamin C promotes collagen synthesis and fibroblast proliferation,11 and zinc is essential for protein and collagen synthesis.12 Arginine and glutamine have been extensively studied.13 Although there exist no current guidelines with regard to their use in clinical practice, arginine supplementation has been shown to enhance wound tensile strength and glutamine to improve nitrogen balance and immune function post major surgery, trauma, or sepsis.13 Malnourished patients are overall at higher risk for wound infection due to their impaired immune system following a decreased in T-cell function, phagocytic activity, and complement and antibody levels.10 Delayed wound healing and increased risk of postoperative wound complications and infections due to a reversible nutritional cause should be of concern to the plastic surgeon.

The recognized importance of nutrition in holistic patient care has started a nutritional revolution over the past decades.14 Pivotal innovations have included the advent and implementation of total parenteral nutrition in the late 1960s.15 The need to establish a nutritional care plan was emphasized by the recognition of the high incidence of protein-calorie malnutrition in hospitalized and surgical patients.16,17 Various nutritional assessments and quantification of nutritional deficits have been subsequently developed to identify patients at risk.18,19 Nutrition is particularly relevant to the plastic surgeon in relation to head and neck reconstructions, burns, patients receiving chemo or radiotherapy such as breast oncologic reconstructions, and wounds.14


The vast majority of lower income adults do not consume the recommended amounts of fruits, vegetables, and whole grains and instead have high intake of processed meat, sweets, and sugar-sweetened beverages.20 Economic barriers can partly explain such a phenomenon,21 but lower diet quality has also been associated with limited access to fruits and vegetables.21–23 Interventions should focus on improving access to healthier food options and promoting their affordability.24 Exposure interventions encourage familiarity with and acceptance of nutrition products25 and include activities such as tastings or educational sessions.26 Incentive interventions facilitate access to adequate nutrition options25 such as programs increasing the purchasing power of low-income consumers to buy healthy foods,26–28 or placement of markets in underserved neighbourhoods.24,29–31 Although implementing these interventions requires large-scale policy changes, governments are increasingly aware of the need for access to affordable and healthy food. On a smaller scale, dieticians can be your allies to direct your patients toward local programs that can benefit their long-term nutritional, surgical, or wound healing status.


Importantly, malnutrition is a reversible diagnosis once it is recognized. Upon clinical assessment, we would encourage plastic surgeons to promote the recognition and screening of malnutrition risk by implementing a rapid nutritional screening tool like the CNST (Fig. 1) in addition to recording patients’ body mass index. Nursing staffs can perform these measurements as routine brief clinical assessments preceding clinical encounters. If limitations or shortage in personnel occur, patients’ self-report of the CNST’s 2 questions upon presentation to the clinic could be an acceptable alternative. If clinical suspicion for risk of malnutrition is present, as indicated with 2 “Yes” answers on the CNST, blood work including albumin/prealbumin levels can be ordered by the plastic surgeon as a first-line investigation. Prompt referral to a dietician for perioperative nutritional optimization should also be reinforced as part of the “prehabilitation” framework.32,34,35 After appropriate nutritional expertise consultation, further investigations like blood work to review patients’ macro- (eg, albumin) and micronutrient status (eg, vitamins A, B12, C, D, E, iron, folate) are also highly valuable to identify specific reversible deficiencies. Prehabilitation represents the metabolic enhancement of patients’ preoperative status to increase physiologic reserves and encompasses physical activities, psychological assessment, and nutrition care.32 Preoperative interventions include guidance to improve glycemic control, access to weight loss programs, or support in individually adapted exercises. System, practice, and patient limitations may influence one’s ability to screen or intervene on patients’ nutritional status. There is a definite discrepancy between evidence of nutritional support’s benefits and clinical applications of this knowledge.33 In this era of patient-centered care, the provision of quality care should allow nutritional optimization especially in perioperative patients at risk for malnutrition.

Fig. 1.:
Screening for the risk of malnutrition using the CNST. Used with the permission of the Canadian Malnutrition Task Force. The Canadian Nutrition Screening Tool form can be accessed from


This work is connected to Nourish, a collaborative initiative about the future of food in health care. See Resources section of for more information. The authors wish to acknowledge the Canadian Malnutrition Task Force for the use of the Canadian Nutrition Screening Tool in this study and for use of the graphic in this article (Fig. 1).


1. Hill GL, Blackett RL, Pickford I, et al. Malnutrition in surgical patients. An unrecognised problem. Lancet. 1977;1:689–692.
2. Ho JW, Wu AH, Lee MW, et al. Malnutrition risk predicts surgical outcomes in patients undergoing gastrointestinal operations: results of a prospective study. Clin Nutr. 2015;34:679–684.
3. Allard JP, Keller H, Jeejeebhoy KN, et al. Malnutrition at hospital admission—contributors and effect on length of stay: a prospective cohort study from the Canadian Malnutrition Task Force. JPEN J Parenter Enteral Nutr. 2016;40:487–497.
4. Yu J, Hunter PJ, Perry JA, et al. Plastic surgery patients are malnourished: utilizing the Canadian Malnutrition Screening Tool. Plast Reconstr Surg Glob Open. 2016;4:e1058.
5. Keller HH, McCullough J, Davidson B, et al. The Integrated Nutrition Pathway for Acute Care (INPAC): building consensus with a modified Delphi. Nutr J. 2015;14:63.
6. Mueller C, Compher C, Ellen DM; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr. 2011;35:16–24.
7. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11:8–13.
8. Roy M, Hunter P, Perry JA, et al. Development of a universal nutritional screening platform for plastic surgery patients. Plast Reconstr Surg Glob Open. 2017;5:e1342.
9. Gruen D. Wound healing and nutrition: going beyond dressings with a balanced care plan. J Am Col Certif Wound Spec. 2010;2:46–49.
10. Campos AC, Groth AK, Branco AB. Assessment and nutritional aspects of wound healing. Curr Opin Clin Nutr Metab Care. 2008;11:281–288.
11. Boyera N, Galey I, Bernard BA. Effect of vitamin C and its derivatives on collagen synthesis and cross-linking by normal human fibroblasts. Int J Cosmet Sci. 1998;20:151–158.
12. Posthauer ME. The role of nutrition in wound care. Adv Skin Wound Care. 2012;25:62–63.
13. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25:61–68.
14. Ruberg RL. The role of nutrition in plastic surgical practice: a review. Plast Reconstr Surg. 1980;65:363–370.
15. Dudrick SJ, Wilmore DW, Vars HM, et al. Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery. 1968;64:134–142.
16. Butterworth CE Jr.. The skeleton in the hospital closet. Nutrition. 1994;10:442.
17. Bistrian BR, Blackburn GL, Hallowell E, et al. Protein status of general surgical patients. JAMA. 1974;230:858–860.
18. Copeland EM 3rd, Daly JM, Dudrick SJ. Nutrition as an adjunct to cancer treatment in the adult. Cancer Res. 1977;37:2451–2456.
19. Blackburn GL, Thornton PA. Nutritional assessment of the hospitalized patient. Med Clin North Am. 1979;63:11103–11115.
20. Leung CW, Ding EL, Catalano PJ, et al. Dietary intake and dietary quality of low-income adults in the Supplemental Nutrition Assistance Program. Am J Clin Nutr. 2012;96:977–988.
21. Walker RE, Keane CR, Burke JG. Disparities and access to healthy food in the United States: a review of food deserts literature. Health Place. 2010;16:876–884.
22. Moore LV, Diez Roux AV, Nettleton JA, et al. Associations of the local food environment with diet quality—a comparison of assessments based on surveys and geographic information systems: the multi-ethnic study of atherosclerosis. Am J Epidemiol. 2008;167:917–924.
23. Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36:74–81.
24. Young CR, Aquilante JL, Solomon S, et al. Improving fruit and vegetable consumption among low-income customers at farmers markets: Philly Food Bucks, Philadelphia, Pennsylvania, 2011. Prev Chronic Dis. 2013:10:E166.
25. Bowling AB, Moretti M, Ringelheim K, et al. Healthy Foods, Healthy Families: combining incentives and exposure interventions at urban farmers’ markets to improve nutrition among recipients of US federal food assistance. Health Promot Perspect. 2016;6:10–16.
26. Anderson JV, Bybee DI, Brown RM, et al. 5 a day fruit and vegetable intervention improves consumption in a low income population. J Am Diet Assoc. 2001;101:195–202.
27. Freedman DA, Bell BA, Collins LV. The veggie project: a case study of a multi-component farmers’ market intervention. J Prim Prev. 2011;32:213–224.
28. Herman DR, Harrison GG, Jenks E. Choices made by low-income women provided with an economic supplement for fresh fruit and vegetable purchase. J Am Diet Assoc. 2006;106:740–744.
29. Freedman DA, Flocke S, Shon EJ, et al. Farmers’ market use patterns among Supplemental Nutrition Assistance Program recipients with high access to farmers’ markets. J Nutr Educ Behav. 2017;49:397–404.e1.
30. Evans AE, Jennings R, Smiley AW, et al. Introduction of farm stands in low-income communities increases fruit and vegetable among community residents. Health Place. 2012;18:1137–1143.
31. Lindsay S, Lambert J, Penn T, et al. Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities. Prev Chronic Dis. 2013;10:E188.
32. Gillis C, Loiselle SE, Fiore JF Jr, et al. Prehabilitation with whey protein supplementation on perioperative functional exercise capacity in patients undergoing colorectal resection for cancer: a pilot double-blinded randomized placebo-controlled trial. J Acad Nutr Diet. 2016;116:802–812.
33. Martindale RG, McClave SA, Taylor B, et al. Perioperative nutrition: what is the current landscape? JPEN J Parenter Enteral Nutr. 2013;37:5S–20S.
34. Minnella EM, Bousquet-Dion G, Awasthi R, et al. Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience. Acta Oncol. 2017;56:295–300.
35. Brown K, Topp R, Brosky JA, et al. Prehabilitation and quality of life three months after total knee arthroplasty: a pilot study. Percept Mot Skills. 2012;115:765–774.
Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.