The Impact of Herbal Products, Vitamins, and Supplements on Rhinoplasty and Cosmetic Surgery Outcomes
*This article is intended for Canadian Residents only. The content of this article is for educational purposes and not intended as medical advice, diagnosis, or treatment. Readers must consult with a qualified healthcare professional (doctor, anesthesiologist, etc.) for any medical concerns or before making any decisions related to their health. Dr Bonaparte is not liable for any risks or issues arising from using the information provided. It is possible that the information may not be entirely accurate, complete, or up-to-date, and that errors may exist.*
Case Study
Sara presents to Dr Bonaparte at the Ottawa Derm Center to discuss if she is a candidate for a Rhinoplasty. She notices that she has a large nasal tip and a hump or bump on her nose. She tells Dr Bonaparte that she does not take any medication. Sara decides to go ahead and book a Rhinoplasty surgery. After she fills out the surgery questionnaire, Dr Bonaparte and his team notice that she is taking “Herbal Supplements.”
Prior to performing a Rhinoplasty, Dr Bonaparte’s surgery nurse asks Sara to list all the supplements and vitamins she is taking.
This article will hopefully help you understand why we ask this and why it is important to tell your surgeon what supplements you are taking prior to any Rhinoplasty Surgery.
Introduction
The use of herbal products, vitamins, and supplements has become increasingly prevalent among the general population, including individuals undergoing Rhinoplasty and other surgical procedures. These substances are often perceived as natural and beneficial for health; however, they possess pharmacological properties that can significantly influence the body's physiological responses during and after surgery. Understanding the potential effects of these products is crucial for ensuring patient safety and optimizing surgical outcomes, particularly concerning the risk of bleeding and interactions with anesthesia. This report aims to provide an evidence-based overview of the impact of herbal products, vitamins, and supplements on surgery results, focusing on bleeding risk, interactions with anesthesia, and substances believed to have positive effects on surgical outcomes, including Rhinoplasty Outcomes.
Herbal Products and Bleeding Risk
Several herbal products have been identified as having the potential to increase the risk of bleeding during or after surgery due to their anticoagulant or antiplatelet properties.
Garlic
Garlic, commonly used for its cardiovascular benefits such as lowering blood pressure and cholesterol, can also increase the risk of bleeding. Studies and case reports indicate that garlic supplements can inhibit platelet aggregation, potentially leading to prolonged bleeding times and increased bleeding during and after surgical procedures This effect is attributed to compounds within garlic that prevent platelets from sticking together and forming clots. Due to its potent effect on bleeding, it is generally advised that patients disclose any garlic supplement use well in advance of surgery, with recommendations to stop at least seven days prior to the procedure.
Ginkgo Biloba
Ginkgo Biloba, often used to improve memory and circulation, has also been associated with an increased risk of bleeding. Research suggests that ginkgo can inhibit platelet-activating factor and affect the interaction between platelets and collagen, both of which are crucial for blood clotting. Case reports have linked ginkgo use to serious bleeding events, including intracranial hemorrhage. While some studies have shown no significant interaction between ginkgo and warfarin, a widely used anticoagulant, the overall evidence suggests a potential for increased bleeding, especially when combined with other blood-thinning medications or antiplatelet drugs like aspirin. Therefore, it is generally recommended that ginkgo biloba be discontinued at least two weeks prior to elective surgery.
Ginseng
Ginseng, commonly taken to boost energy and concentration, has been shown to act as an anticoagulant and increase the risk of bleeding. It may also interact with cardiac medications and those used to control blood sugar levels. The exact mechanisms by which ginseng increases bleeding risk are still being studied, but its potential to affect platelet function and prolong bleeding time has been noted. Due to these risks, it is typically recommended that ginseng supplementation be stopped at least one week before surgery.
Ginger
Ginger, often used for its anti-nausea and anti-inflammatory properties, contains salicylate, a compound similar to aspirin, which can prolong bleeding time. High doses of ginger supplements may interfere with blood clotting and could potentially interact with cardiac and anticoagulant medications. As a precaution, it is often advised to discontinue ginger supplements one to two weeks before undergoing surgery.
Other Herbal Products with Bleeding Risks
Several other herbal products have been associated with an increased risk of bleeding:
● Feverfew: May increase bleeding, especially in patients on blood-thinning medications.
● Dong Quai: Contains coumarin-like compounds that can enhance the effects of anticoagulant medications.
● Bilberry: May affect platelets and increase bleeding.
● Cayenne: May affect platelets and blood pressure.
● Red Clover: Contains coumarin derivatives that may potentiate anticoagulant medications.
● Saw Palmetto: Anecdotal evidence suggests a potential increase in bleeding risk.
● Aloe: Reported to have antiplatelet activity and linked to a case of excessive bleeding after surgery.
● Chinese Agrimony: Demonstrated to markedly suppress platelet aggregation, leading to increased bleeding time.
● Chinese Peony: Contains a glycopeptide compound similar to heparin, which can delay coagulation times.
● Hawthorn: Strongly associated with surgical bleeding, independent of anticoagulant use.
The diverse range of herbal products with potential bleeding risks underscores the importance of patients providing a complete history of supplement use to their healthcare providers prior to surgery.
Vitamins and Blood Clotting
Certain vitamins can also affect blood clotting and may increase the risk of bleeding during Rhinoplasty surgery.
Vitamin E
Vitamin E, a fat-soluble vitamin known for its antioxidant properties, has been identified as a potential risk factor for increased bleeding. High doses of vitamin E may interfere with blood clotting factors and could potentially deplete vitamin K levels in the body. Studies have shown a correlation between higher serum vitamin E levels and an increased risk of bleeding events in patients on oral anticoagulant therapy. Due to these potential risks, it is generally recommended that patients stop taking vitamin E supplements at least two weeks before undergoing surgery.
Vitamin K
Vitamin K plays an essential role in the body's blood clotting process by activating several coagulation factors in the liver. It directly interacts with warfarin (Coumadin) and other vitamin K antagonists, which are commonly prescribed as blood thinners. For patients on warfarin, maintaining a consistent intake of vitamin K-rich foods is crucial, rather than completely avoiding them, as sudden changes in vitamin K levels can affect the stability of their anticoagulation therapy. Patients should always inform their healthcare provider about any changes in their diet or vitamin K supplement intake, especially before surgery.
Other Vitamins
While Vitamin E and Vitamin K are the most commonly discussed vitamins in relation to blood clotting and surgery, it has been noted that very high doses of other vitamins, including Vitamin D3, Vitamin A, Vitamin B3, and Vitamin C, may also promote blood thinning. Patients should be cautious about taking megadoses of these vitamins, especially in the perioperative period, and should always consult with their healthcare provider regarding appropriate vitamin supplementation.
Supplements and Interactions with Anesthesia/Surgical Medications
Certain supplements can interact with anesthesia and other medications administered during surgery, potentially leading to adverse effects.
Kava
Kava, an herbal remedy often used for its anxiolytic and muscle-relaxant properties, has the potential to prolong the effects of anesthesia. It may also cause hypotension due to its inhibition of sodium and calcium channels. Kava can potentiate the central nervous system effects of various medications, including barbiturates, antidepressants, antipsychotics, and general anesthetics, potentially leading to excessive perioperative sedation. Due to these interactions, it is generally recommended to discontinue kava at least 24 hours, and preferably one to two weeks, before surgery.
St. John's Wort
St. John's Wort, a popular herbal supplement used to treat mild to moderate depression and anxiety, can interact with anesthesia and prolong its effects. It may also interfere with certain anesthesia medicines and affect blood pressure. Of significant concern is St. John's Wort's ability to induce cytochrome P450 enzymes, which can accelerate the metabolism of numerous drugs, including some anesthetics, birth control pills, antidepressants, blood thinners, and certain cancer treatments, potentially reducing their effectiveness. It is typically advised to stop St. John's Wort at least five days, and ideally two weeks, before surgery to minimize the risk of these interactions.
Valerian
Valerian, commonly used as a sleep aid and to relieve anxiety, may increase the effects of anesthesia and make it more difficult for patients to wake up after surgery. It has also been associated with potential irregular heart rhythms. Valerian can potentiate the sedative effects of various central nervous system depressants, including barbiturates and benzodiazepines. It is generally recommended to discontinue valerian at least one week before surgery to avoid these potential interactions.
Ephedra (Ma-Huang)
Ephedra, also known as Ma-Huang, is an herbal supplement that has been used for asthma and as an appetite suppressant. It can cause high blood pressure and an erratic heart rate, especially when combined with some anesthesia medicines. Due to these significant cardiovascular risks and its potential to interact dangerously with anesthesia, ephedra, which was banned by the FDA in 2003, should be avoided in the perioperative period.
Echinacea
Echinacea, often used to boost the immune system, may have adverse effects when combined with anesthesia, particularly in individuals with liver disease, potentially leading to liver damage. Long-term use of echinacea has also been suggested to suppress the immune system, which could complicate postoperative recovery. It is generally recommended to stop taking echinacea two to three weeks before surgery.
Ginseng
Beyond its effects on bleeding, ginseng can also interact with cardiac and hypoglycemic agents. It may increase heart rate and blood pressure during surgery. Patients taking ginseng should be aware of these potential interactions and discuss their supplement use with their healthcare providers before undergoing surgery.
Positive Effects on Surgical Outcomes
While some herbal products, vitamins, and supplements pose risks during surgery, others are believed to have positive effects on surgical outcomes, such as reducing inflammation and promoting healing.
Vitamin C
Vitamin C is a powerful antioxidant that plays a crucial role in collagen production, which is essential for wound healing and tissue repair after surgery. It also supports the immune system and has anti-inflammatory properties. Studies suggest that vitamin C supplementation, especially in the postoperative period, may improve the inflammatory process, reduce pain, and enhance recovery.
Vitamin A
Vitamin A is vital for wound healing, promoting new cell growth and the repair of epithelial tissue. It also plays a key role in immune function and can increase collagen cross-linking, which is important for wound strength. Adequate vitamin A intake before and after surgery can support tissue repair and help prevent infections. However, high doses of vitamin A should be avoided due to potential toxicity.
Vitamin D
Vitamin D is essential for bone health and immune function, and it may also play a role in reducing inflammation. Adequate vitamin D levels are particularly important for patients undergoing orthopedic surgeries to support bone healing and reduce the risk of fractures. Supplementation may be beneficial, especially for individuals with known deficiencies.
Bromelain
Bromelain, an enzyme found in pineapples, has been shown to have anti-inflammatory and anti-edema properties that may help reduce swelling, inflammation, and bruising after surgery. Some studies have indicated that bromelain can be effective in reducing postoperative pain and improving quality of life measures.
Arnica Montana
Arnica Montana is a homeopathic remedy traditionally used to reduce bruising, swelling, and pain after trauma or surgery. While widely used, scientific evidence supporting its efficacy is mixed, with some studies showing potential benefits in reducing edema and ecchymosis, particularly after facial procedures, while others find no significant difference compared to placebo.
Omega-3 Fatty Acids
Omega-3 fatty acids, found in fish oil and flaxseed, have potent anti-inflammatory properties and may play a role in promoting wound healing. While beneficial for postoperative recovery, the use of omega-3 supplements before surgery is controversial due to their potential to increase bleeding risk.
Zinc
Zinc is an essential mineral that plays a critical role in wound healing, immune function, and the synthesis of new tissue and collagen. Adequate zinc intake is important for supporting the body's repair processes after surgery.
Probiotics
Probiotics can help restore a healthy gut microbiome, which may be disrupted by antibiotics used during or after surgery. They can also boost the immune system and help regulate inflammation, potentially aiding in overall recovery.
Collagen
Collagen is a major protein in the body that provides structural support to tissues and plays a vital role in wound healing and tissue repair. Collagen supplements may support the body's ability to rebuild and repair tissues after surgical procedures.
Scientific Evidence Supporting Improved Outcomes
Scientific evidence supporting the use of specific supplements to improve surgical outcomes varies. Several meta-analyses and systematic reviews have examined the effects of various nutritional interventions in the perioperative period.
Vitamin C has been studied for its potential to reduce inflammation and pain after surgery, with some meta-analyses suggesting a benefit in reducing postoperative pain scores and opioid consumption, particularly when administered intravenously.
Bromelain has shown promise in reducing post-surgical swelling and pain in several studies, particularly following dental and nasal surgeries. However, findings are not consistent across all types of surgery.
Preoperative nutritional support, including oral supplements and nutrition, has demonstrated efficacy in reducing postoperative complications and the length of hospital stays, especially in malnourished patients or those at risk of malnutrition. Immunonutrition, which often includes arginine, glutamine, and omega-3 fatty acids, has been associated with decreased infectious complications and improved wound healing in some surgical settings.
The evidence for Arnica Montana remains mixed, with some studies suggesting a mitigating effect on bruising, particularly after facial procedures, while others show no significant benefit over placebo.
Overall, the scientific evidence suggests that certain supplements may offer benefits for surgical outcomes, but the effectiveness can vary depending on the specific supplement, the type of surgery, and the patient's individual nutritional status. Customized nutritional regimens based on patient demographics and surgical specifics are increasingly recognized as important for optimizing outcomes.
Recommended Guidelines for Patients
The recommended guidelines for patients regarding the use of herbal products, vitamins, and supplements before and after surgery emphasize the critical importance of open communication with Dr Bonaparte and his surgery team. Patients should disclose all supplements they are taking, including herbal remedies, vitamins, and other dietary aids, to Dr Bonaparte and anesthesiologist well in advance of the scheduled procedure.
Many organizations, such as the American Society of Anesthesiologists, recommend that patients stop taking most herbal supplements at least two weeks before surgery due to the potential for adverse interactions, including increased bleeding risk, interference with anesthesia, and cardiovascular disturbances. This timeframe allows for a sufficient "wash-out" period for the supplements to clear the system and minimize the risk of complications during the procedure.
Specific recommendations for certain supplements include:
● Vitamin E: Discontinue at least two weeks before surgery due to increased bleeding risk. Some sources recommend stopping 30 days prior.
● Garlic: Stop at least seven days before surgery due to increased bleeding risk
● Ginkgo Biloba: Discontinue at least two weeks before surgery due to increased bleeding risk. Some sources suggest stopping 36 hours to a few days prior.
● Ginseng: Stop at least one week before surgery due to increased bleeding risk and potential interaction with blood sugar levels. Some recommend two weeks.
● Kava: Discontinue at least 24 hours, and preferably one to two weeks, before surgery due to potential prolonged anesthesia effects.
● St. John's Wort: Stop at least five days, and ideally two weeks, before surgery due to potential prolonged anesthesia effects and interactions with various medications.
● Valerian: Discontinue at least one week before surgery due to potential prolonged anesthesia effects.
For vitamins, the recommendations can vary. While a balanced intake through diet is generally encouraged, high doses of certain vitamins, like Vitamin E, should be avoided before surgery due to the risk of bleeding. Vitamin K intake should be consistent for patients on warfarin, and any changes should be reported to their healthcare provider.
After surgery, patients should follow their surgeon's specific instructions regarding when to resume taking any supplements. Some supplements, like Vitamin C, Vitamin A, Zinc, and Bromelain, may be recommended to aid in wound healing and reduce inflammation. However, it is crucial to discuss any postoperative supplement use with the surgeon to ensure safety and avoid potential interactions with prescribed medications.
Typical Duration to Stop Taking Supplements Before Surgery
The typical duration a patient should stop taking specific herbal products, vitamins, or supplements before undergoing surgery to minimize risks, particularly bleeding, generally ranges from one week to one month, depending on the substance and its potential effects
● One Week Before Surgery: Garlic, Ginseng, Valerian.
● Two Weeks Before Surgery: Most herbal supplements (general recommendation by the American Society of Anesthesiologists) , Vitamin E , Ginkgo Biloba.
● Longer Durations (Specific Supplements): Echinacea (4 weeks) , Garlic (30 days) Ginger (30 days) , Ginkgo Biloba (30 days) , Ginseng (30 days) , Kava (30 days) , St John's Wort (30 days) , Turmeric (30 days) , Valerian (30 days) , Vitamin E (30 days).
These durations allow the body to clear the substances and reduce the risk of adverse events during and after surgery. However, these are general guidelines, and individual recommendations may vary based on the specific supplement, the patient's health status, and the type of surgery. Patients should always consult their surgeon or anesthesiologist for personalized advice on when to stop taking their supplements before surgery.
Conclusions
The use of herbal products, vitamins, and supplements can have a significant impact on surgical outcomes, whether it be rhinoplasty or other procedures. While some substances may offer potential benefits in terms of reducing inflammation and promoting healing, many carry risks, particularly concerning increased bleeding and interactions with anesthesia or other surgical medications. It is crucial for patients to understand these potential effects and to engage in open communication with their healthcare providers about their supplement use. Healthcare professionals, in turn, should proactively inquire about patients' supplement intake during the preoperative evaluation to identify and mitigate potential risks. Given the variability in supplement quality, regulation, and individual patient responses, a cautious and evidence-based approach is essential to ensure patient safety and optimize surgical outcomes. The general recommendation to discontinue most non-essential supplements at least two weeks before surgery is a prudent guideline, but personalized advice from the surgical team should always take precedence.
Dr James P Bonaparte, MD, MSc, FRCSC