Implications of Rheumatic Disease and Biological Response-modifying Agents in Plastic Surgery

David M. Tsai, B.A.; Gregory L. Borah, M.D.


Plast Reconstr Surg. 2015;136(6):1327-1336. 

In This Article

Abstract and Introduction


The preoperative evaluation for any reconstructive or aesthetic procedure requires a detailed history of existing medical conditions and current home medications. The prevalence of rheumatic diseases such as rheumatoid arthritis, gout, and psoriasis is high, but the impact of these chronic illnesses on surgical outcome and the side effects of the powerful medications used for treatment are often underappreciated. In this review, the authors highlight key perioperative considerations specific to rheumatologic diseases and their associated pharmacologic therapies. In particular, the authors discuss the perioperative management of biological response-modifying agents, which have largely become the new standard of therapy for many rheumatic diseases. The literature reveals three key perioperative concerns with biological therapy for rheumatic disease: infection, wound healing delays, and disease flare. However, data on specific perioperative complications are lacking, and it remains controversial whether withholding biological therapy before surgery is of benefit. The risk of these adverse events is influenced by several factors: age, sex, class of biological agent, duration of exposure, dosage, onset and severity of disease, and type of surgical procedure. Overall, it remains best to develop an individualized plan. In younger patients with recent onset of biological therapy, it is reasonable to withhold therapy based on 3 to 5 half-lives of the specific agent. In older patients with a substantial history of rheumatic disease, the decision to discontinue therapy must be weighed and decided carefully in conjunction with the rheumatologist.


The burden of rheumatic disease is great, yet its implications for reconstructive and aesthetic surgery are underappreciated. These chronic illnesses are complex and involve medical management that can be difficult to navigate in today's era, where newer biological agents have largely become the standard. The conscientious plastic surgeon must be mindful of these conditions and understand the potential impacts on surgical outcome and patient safety.

In this article, we review common rheumatic conditions and discuss important perioperative considerations and associated pharmacologic therapies. Furthermore, we review the literature regarding perioperative complications of biological agents, and address the challenging question of whether patients benefit from discontinuation before surgery.