Re: Assessing patient frailty in plastic surgery: A systematic review.

Dear Sir,

I read with interest the above article by Gallo and colleagues. The COVID pandemic has caused major disruption to elective plastic surgery procedures, resulting in backlog of patients waiting for surgery. In accordance with the ‘Coronavirus action plan’ published by the UK government, supporting early discharge from hospital is high on the agenda, as part of the ‘mitigation phase’. It has become increasing important to stratify patients according to their pre-morbid functional status, in the hope of alleviating the risk of prolonged hospital stay post-operatively. A growing backlog of care requires a paradigm shift in service planning and reconfiguration of patient pathways. I would like to congratulate the authors on their work, which adds much-needed clarity on the role of pre-operative frailty assessments on peri‑operative morbidity and mortality in plastic surgery.

Factoring in the effect of age on plastic surgery outcomes is imperative given the rapidly aging population. There is a general decline in wound healing potential with age, with decreased cellular turnover, skin collagen content and compromised immune functions. Although the plastic surgeon community is familiar with the physiological changes with age, many of us fail to acknowledge the effect of general frailty that could lead to adverse surgical outcomes, due to our limited understanding on how best to conceptualize and assess it objectively. The available evidence suggests that pre-operative frailty is associated with worse outcomes across all levels of operative stress. This systematic review provides a useful summary of standardised tools available for evaluating frailty, while critically evaluated the strength, validity, and reliability of each tool in clinical practice. Gallo and colleagues highlighted the relevance of incorporating frailty assessment in a few key areas, namely predicting postoperative recovery in elective procedures such as melanoma excision, risk stratification to aid in postsurgical arrangements in the context of breast reduction surgery, and decision making in emergency surgery such as replantation.

Although the term ‘frailty’ could encompass a broad spectrum of definitions, the use of a valid and reliable index could provide an objective and reproducible assessment across several key domains such as physical, psychological, and social. Prehabilitation before major surgery could be an integral part of patient pathway, taking into consideration of frailty scores, and aids in patient quicker return to functional baseline. Multimodal interventions, such as improving a patients’ physical reserve via nutritional supplement, altering mental status through psychological support and lifestyle interventions such as smoking cessation could help in reducing complications and improve outcomes. Although the concept of frailty assessment is in its relative infancy in plastic surgery, we must continue to learn and adapt to provide the best care for our patients, as we approach the ‘new normal’ in the post-lockdown period.

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