Top-10 List of Herbal and Supplemental Medicines Used by Cosmetic Patients: What the Plastic Surgeon Needs to Know

COSMETIC

Justin Heller, B.S. Background: Widespread use of herbal medications/supplements among the Joubin S. Gabbay, M.D. presurgical population may have a negative effect on perioperative patient care. Kiu Ghadjar Thus, the authors’ goal was to identify the prevalence of such use in a cosmetic Mickel Jourabchi surgery patient population compared with use among the general public; to Catherine O’Hara, B.A. assess physician awareness of proper management of these herbal medications/ Misha Heller, B.S. supplements; and to review the literature to provide rational strategies for James P. Bradley, M.D. managing perioperative patients taking these remedies. Los Angeles, Calif. Methods: To assess patient (n ϭ 100) and general public (n ϭ 100) usage rates, open-ended lists of (1) the most common herbal medications/supplements and (2) homeopathic treatments were compiled. Board-certified plastic surgeons (n ϭ 20) were then given the same list of herbs/supplements and surveyed on their awareness of these treatments and perioperative side effects. Results: The usage rate for cosmetic versus public surveys for herbal medicines/ supplements was 55 percent versus 24 percent (p Ͻ 0.001), with 35 percent versus 8 percent (p Ͻ 0.001) engaging in homeopathic practices, respectively. Cosmetic patients’ top four herbal/supplements of usage were chondroitin (18 percent), ephedra (18 percent), echinacea (14 percent), and glucosamine (10 percent). The top four used by the general public were echinacea (8 percent), garlic (6 percent), ginseng (4 percent), and ginger (4 percent). The physician survey demonstrated awareness of 54 percent of the listed supplements/herbal medicines, 85 percent of which were not suggested to be discontinued preoperatively, with only ephedra achieving 100 percent physician discontinuation preoperatively. Conclusions: Herbal medicines and supplements displayed greater prevalence in the cosmetic surgery population than in the population at large. Further- more, side effects and potential complications warrant addressing these remedies as pharmaceuticals rather than as safe and “natural.” Thus, a descriptive “top-10” list with perioperative recommendations was compiled for the plastic surgeon. (Plast. Reconstr. Surg. 117: 436, 2006.)

n the past decade, the vast increase in the use considered harmless by the lay public because of of alternative medicine, defined as healing their association with the word “natural” and Imethods “not generally taught in medical remain virtually unregulated by the Food and schools or typically practiced in hospitals,” has Drug Administration. However, the word “drug” called for the reassessment of safety precautions is derived from a Middle English word meaning by health care professionals.1–5 In particular, the “root.” As such, many drugs are derived from use of herbal supplements should be carefully leaves, roots, bark, or other parts of plants. For monitored for both the physiologic effects and example, white willow bark and meadowsweet interactions with other prescription or over-the- plant are the basis for salicylic acid (a precursor counter medications. Herbal supplements are to aspirin); foxglove plant is the basis for digitalis; cinchona bark is the precursor to quinine From the Division of Plastic and Reconstructive Surgery, compounds; and periwinkle provides the chemo- University of California, Los Angeles. therapeutic agent vincristine. Thirty percent of Received for publication November 4, 2004; revised January all modern conventional medicines are derived 26, 2005. from plants.6 Copyright ©2006 by the American Society of Plastic Surgeons In cosmetic patients, the degree to which DOI: 10.1097/01.prs.0000197217.46219.a7 herbal medicines and supplements are used is

436 www.plasreconsurg.org Volume 117, Number 2 • Herbal and Supplemental Medicine not known. It is feared that many cosmetic pa- supplements could be written in the blank space tients may not reveal their use of these agents provided. In addition, homeopathic medicinal because more than 70 percent of all medical practices (e.g., acupuncture, chiropractic manip- patients do not reveal their usage to treating ulation, hypnosis, massage, meditation, yoga) physicians.7,8 To study this, we compared surveys were also listed in a similar open-ended manner. on the use of herbal medicine and supplements Both sections also listed choices corresponding to by the cosmetic surgery population to that by the how often subjects engaged in the practice (once general population. In addition, plastic sur- per day; twice per day; once per week; twice per geons’ knowledge on these homeopathic reme- week) or again a blank space labeled “other” for dies was tested. We also detailed the contraindi- the patient to fill in. Finally, open-ended questions cations for the most commonly used herbs and were asked at the end of each section for the supplements and provided perioperative recom- patient to include any additional information. mendations for the cosmetic surgeon. We in- The data from the surveys were collected into clude, for easy office reference, a “top-10 list” of a database (MS Access; Microsoft Corp., Red- the most prevalent herbal medicines and supple- mond, Wash.) and the following information was ments with potentially dangerous side effects gathered: usage rates for herbal medicines/sup- and appropriate perioperative recommenda- plements and for homeopathic practices among tions. cosmetic surgery patients and among the public, Use of alternative medicines is widespread and patterns between the two. A Fisher’s exact test among the general public and not an integral was used for comparison. part of the hospital or medical education. Thus, the following should bring to the forefront Physician Survey awareness of purpose, side effects, and compli- An additional survey for plastic surgeons, cer- cations that are associated with some frequently tified by the American Board of Plastic Surgeons, used herbs and supplements. was conducted (n ϭ 20). This survey contained three sections. The sections were designed to as- PATIENTS AND METHODS sess (1) physician awareness of herbal medicines and supplements (as listed in the patient’s survey); Patient and General Population Surveys (2) knowledge of the perioperative complications Cosmetic surgery patients encountered con- associated with these treatments; and (3) appro- secutively at the Division of Plastic and Recon- priate recommendations for patient discontinua- structive Surgery at the University of California ϭ tion preoperatively. Again, the data from the sur- were surveyed (n 100). In addition, adults aged veys were collected into a database (MS Access) 40 years or older with equal distribution of sex and analysis was performed. from the general population of five cities within Los Angeles were randomly surveyed with the RESULTS same questionnaire (n ϭ 100). The five cities selected were those most commonly encountered in Cosmetic Patient Usage our cosmetic clinic. Our surveyed cosmetic patient population In the survey, a list of the 13 carefully selected consisted of five men and 95 women with a mean herbal medicines and dietary supplements was in- age of 46.7 Ϯ 11.2 years. Procedures performed cluded. The herbal medicines were echinacea included 42 abdominoplasties, 25 breast augmen- (Echinacea augustfolia), ephedra (Ma-huang), gar- tations, 11 mastopexies, two ear reconstructions, lic (Allium sativum), ginger, ginseng (Eutherococcus 17 liposuctions, 30 face lifts, three chin augmen- senticosus), gingko (Gingko biloba), goldenseal (Hy- tations, three rhinoplasties, and two corrections drastasis canadenis), kava (Piper methysticum rhi- for pectus excavatum. Forty-seven percent of pa- zoma), milk thistle (Silybum marianus), St. John’s tients underwent more than one cosmetic proce- wort (Hypericum perforatum), and valerian (Valeri- dure at the time of operation. ana officinalis). The dietary supplements were A 55 percent rate of usage of herbal medicines chondroitin and glucosamine. Herbs and supple- was observed among these cosmetic patients. Of ments in this list were chosen either based on the 55 percent taking herbal remedies/supple- national sales according to Information Re- ments, 100 percent took at least two remedies and sources, Inc., or for their high potential for peri- at least one on a daily basis. Chondroitin (18 per- operative complications. This list was left open cent), ephedra (18 percent), glucosamine (10 per- ended such that additional herbal medicines or cent), milk thistle (4 percent), and garlic (2 per-

437 Plastic and Reconstructive Surgery • February 2006 cent) were all taken on a daily basis. Echinacea (10 valerian, St. John’s wort, milk thistle, kava, or percent) was taken once or twice a week, with 4 ephedra (Fig. 1). percent who took it “occasionally” or “when feel- Homeopathic treatment [acupuncture (2 per- ing sick.” Goldenseal (4 percent), milk thistle (4 cent), hypnosis (2 percent), meditation (2 per- percent), and kava (2 percent) were also taken cent), yoga (2 percent), and Pilates (2 percent)] twice each week. Valerian, St. John’s wort, and was practiced by 6 percent of the population. Four ginger were not reported taken by our cosmetic percent of the general population practiced ho- patients (Fig. 1). meopathics at least on a weekly basis and only two Thirty-five percent of cosmetic patients en- percent practiced homeopathics of at least two gaged in homeopathic practices [acupuncture (7 forms. percent), chiropractic manipulation (3 percent), hypnosis (5 percent), massage (3 percent), med- Comparison: Cosmetic Patient versus General itation (5 percent), yoga (3 percent), and Pilates Population (2 percent)]. Seventeen percent of cosmetic pa- The usage rate for cosmetic versus public sur- tients practiced homeopathics at least on a weekly veys for herbal medicines/supplements was 55 basis, with 12 percent practicing homeopathics of percent versus 24 percent (p Ͻ 0.001), with 35 at least two forms. percent versus 8 percent (p Ͻ 0.001) engaging in homeopathic practices, respectively. For the cos- General Population Usage metic patients, the top four herbal medicines of Our general population survey consisted of 46 usage in descending order were chondroitin (18 men and 54 women with a mean age of 42.6 Ϯ 13.1 percent), ephedra (18 percent), echinacea (14 years. Twenty-four percent of the population re- percent), and glucosamine (10 percent). For the ported usage of herbal medicines. Of those taking generalized population, the top four herbal med- herbal remedies/supplements (24 percent), only icines of usage in descending order were echina- 33 percent took at least two and 50 percent took cea (8 percent), garlic (6 percent), ginseng (4 at least one on a daily basis. Echinacea (8 percent) percent), and ginger (4 percent). Thus, only echi- and chondroitin (4 percent) were taken once a nacea was common among the two groups, with 6 day. Garlic was taken either once a day (2 percent) percent greater usage by the cosmetic patients. or once a week (4 percent). Ginger (4 percent), This correlates with the observed difference in ginseng (4 percent), gingko (2 percent), gold- usage rates for the cosmetic patients versus the enseal (2 percent), and glucosamine (2 percent) public, respectively. were all taken once a week. There was no usage of Physician Survey The physician survey demonstrated that physicians were aware, by name, of 54 percent of the listed supplements/herbal medicines. However, all physicians correctly knew the side effects of only one herbal medicine (ephedra). Chondroitin was identified properly in 30 percent to be associated with bleeding. No other of these herbal medications/supplements was properly identified with their corresponding side-effect profiles. Thus, for 90 percent of the herbal remedies listed, side-effect profiles were not known, yet physicians admitted that they did not recommend stopping 85 percent of herbal medications preoperatively or in the perioperative period. All (100 percent) Fig. 1. Daily medicinal supplement usage by cosmetic patients recommended stopping ephedra for its associa- (nϭ100)versusthegeneralpopulation(nϭ100).Medicinalsup- tion with elevated blood pressure and stroke. plementsarerepresentedalongtheverticalaxis,withusagerates representedaspercentagesofthe100patientssurveyedforeach DISCUSSION group along the horizontal axis. Filled bars, cosmetic patients; Interest in alternative medicine has grown rap- shaded bars, public patients. Numerical percentage usages are idly over the past decade and usage among the listed to the right of each respective bar. public has become widespread.1–5 However, de-

438 Volume 117, Number 2 • Herbal and Supplemental Medicine spite the usage and documented physiologic side blood-thinning medications. Glucosamine con- effects, complementary medicine is not widely tains polypeptide-p, known to be plant insulin that taught as a part of medical education; nor, by may thus mimic human insulin, artificially elevat- definition, is it a part of regular patient care in the ing levels and causing hypoglycemia. This effect is hospital. This was exemplified by our surgeon sur- enhanced by glucosamine’s known inhibition of vey in which surgeons on average were unable to glucose transport and glycolysis. Thus, to avoid identify side-effect profiles for 90 percent of the perioperative risk of bleeding and hypoglycemia, medicinal supplements listed. it is recommended that usage of these supple- Previous studies throughout the United States ments be discontinued. Exact time is unknown, have shown a 22 percent rate of usage of herbal and thus recommendations are based on guide- medicines and supplements.9 Similarly, our gen- lines from the American Society of Anesthesiolo- eral population survey with similar sex and age gists, which advises that all herbal medicines with- distribution as the national survey, although lim- out formal study be discontinued at 2 to 3 weeks ited to Southern California, showed a 24 percent before an elective surgical procedure.10 rate of usage of herbal medicines and supplements. This comparable usage implies that usage Ma-huang (Ephedra sinica) in Los Angeles roughly parallels national averages. Ephedra has been known to promote weight As such, the cosmetic patients’ much greater us- loss, increase energy, and treat respiratory tract age of 55 percent with a female predominance conditions, such as asthma and bronchitis. Ephed- may also correlate with national averages. This was rine, a chemical contained in ephedra, has med- recognized in the physician survey, wherein plastic ical uses, mostly in operating rooms and intensive surgeons perceived an increased usage of herbal care units. It is sympathomimetic agent and thus medicines and supplements among their cosmetic causes positive inotropic and chronotropic re- patients. Most surgeons wished to learn more sponses to raise blood pressure and heart rate, about the side effects of these remedies commonly respectively; dilates bronchioles; and increases used by their patients to prevent avoidable com- metabolic rate. As such, it is contained in many plications. In fact, one plastic surgeon, albeit an- over-the-counter “slimming preparations.” Side ef- ecdotal, noted a postoperative hematoma after fects such as psychiatric disturbances, heart attack, performing a face lift. On questioning of the cardiac dysrhythmias associated with volatile gen- woman, the only medicine noted was garlic. eral anesthetic agents (e.g., halothane) and car- A top-10 list of herbal medicines and supple- diac glycosides (e.g., digitalis), stroke, and even ments commonly used by the cosmetic patient is death. As such, it has been outlawed.11–16 Of note, an easy guide for practitioners (Table 1). What patients taking ephedra under general anesthesia follows details (1) the reason people take these can have severe hypotension that can be con- herbal medicines or supplements, (2) the side trolled with phenylephrine instead of ephedrine. effect from them, and (3) the perioperative rec- If a patient is still using ephedra, health care per- ommendations. To be thorough, a brief commen- sonnel should inform the person of the drug’s tary is also made on four herbs (saw palmetto, St. adverse effects and discontinue usage at least 24 John’s wort, valerian, and ginger), one supple- hours before perioperative care.17 ment (eicosapentaenoic acid), and one vitamin (vitamin E) that did not make our top-10 list but that do have perioperative issues (Table 2). Echinacea (Echinacea augustfolia) Echinacea is often used for the prevention and treatment of viral, bacterial, and fungal infections, Chondroitin and Glucosamine chronic wounds and ulcers, and chronic Chondroitin and glucosamine are supple- arthritis.18,19 Unlike over-the-counter deconges- ments that are often administered together. They tants or antihistamines, alkylamine and polysac- are both components of the normal cartilaginous charide constituents of echinacea posses signifi- matrix and as such are used to treat osteoarthritis. cant in vitro and in vivo immunostimulation Potential complications from these supplements properties because of enhanced phagocytosis and arise from there structure. Chondroitin and hep- nonspecific T-cell stimulation. It is for this reason arin are similar in chemical composition and thus that it is contraindicated in systemic and autoim- researchers speculate that people may suffer mune disorders.20 In fact, the immunostimulatory bleeding complications from chondroitin, partic- effects can offset immunosuppressive actions of cor- ularly when it is used in combination with other ticosteroids and cyclosporine. Side effects include

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Table 1. Top-10 List of Medicinal Herbs/Supplements Perioperative Rank* Common Name and Dose Common Uses (Marketing) Surgical Caution Recommendations 1 Chondroitin (400–800 mg Osteoarthritis Perioperative bleeding D/C 2–3 weeks before BID) surgery§ 2 Ephedra‡ (2.7–3.0 g QD) Energy, weight loss, asthma Hypertensive, cardiac instability D/C Ն 1 day before with anesthetics surgery 3 Echinacea (2.7–3.0 g QD) Infections, ulcers, arthritis, to Potentiate barbiturate and D/C 2–3 wk before prevent bruising halothane toxicity, allergic surgery§ reaction, immunosuppression 4 Glucosamine (1500 mg Osteoarthritis Hypoglycemia D/C 2–3 weeks before QD) surgery§ 5 Ginkgo biloba (120–240 Cognition (dementia), vascular Postoperative sedation, D/C Ն 1.5 days before mg QD) disease, tinnitus, asthma, perioperative bleeding surgery colds, anti-inflammatory Surgery Reconstructive and Plastic 6 Goldenseal (125–500 mg Laxative, anti-inflammatory, Volume depletion, postoperative D/C 2–3 wk before BID) infection sedation, photosensitization surgery§ 7 Milk thistle (100–300 mg Hepatoprotective, anti- Volume depletion (choleretic D/C 2–3 weeks before TID) inflammatory activity) surgery§ 8 Ginseng (0.5–2.0 g QD Antioxidant, energy, lowers Perioperative bleeding; avoid D/C Ն 1 week before root) (200–600 mg QD blood glucose use in children and pregnant surgery extract) women 9 Kava (2.7–3.0 g QD) Anxiolytic, muscle relaxant Postoperative sedation D/C Ն 1 day before surgery 10 Garlic (600–900 mg QD) Infection, hypertension, Perioperative bleeding D/C Ն 1 wk before (8 mg QD oil) hypercholesterolemia, cancer surgery (4 g QD cloves) prevention D/C, discontinue; MAOIs, monoamine oxidase inhibitors; BID, two times per day; TID, three times per day; QD, every day. This table may be cut out or copied for quick office reference. *Ranked order of supplements from cosmetic patient survey information (1 ϭ most, 10 ϭ least prevalent usage). †Gram values for powder unless otherwise specified. ‡As of April 12, 2004, the U.S. Food and Drug Administration has banned the use ofephedra.

§According to recommendations from the American Society of Anesthesiologists. • eray2006 February Volume 117, Number 2 • Herbal and Supplemental Medicine

unpleasant taste, gastrointestinal upset, headache, dizziness, and potential allergic reactions.20,21 Pro- longed use of this drug (Ͼ8 weeks) has been documented to cause tachyphylaxis through an unknown mechanism. Echinacea is also an inhibitor of cytochrome P450 3A4 and sulfotransferase and as such can potentiate toxicity of drugs that are metabolized by means of these pathways. Thus, the theoretical risk of both poor wound healing and

5 days before surgery; do not 1 week before surgery infection from nonspecific immunostimulation and

Ն Ն excess sedation from toxicity of benzodiazepines population dependent combine with MAOIs and barbiturates warrant discontinuation 2 to 3 D/C 2–3 week before surgery†; D/C weeks before surgery according to American Society of Anesthesiologists guidelines.10

Gingko (Gingko biloba) A standardized extract of ginkgo (Egb 761) has become widely used for its efficacy in treating pe- ripheral and cerebral circulatory disturbances, in- cluding claudication and memory impairment (e.g., Alzheimer’s disease).22 The herb has the ability to inhibit platelet-activation factor and modulate nitric oxide and possesses an anti-inflammatory effect. With these effects come a few disturbing case wound healing collapse, photosensitization, swelling reports. Gingko biloba–induced spontaneous hy-

Perioperative bleeding D/C 2–3 weeks before surgery† phema (bleeding from the iris in the anterior chamber of the eye), subarachnoid hemorrhage, and spontaneous bilateral subdural hematomas have all been described.23–26 Thus, concomitant use with anticoagulants should be avoided. Other side effects include headache, nausea, gastric symptoms, diarrhea, and allergic skin reactions.27,28 Discontin- uation is recommended at least 36 hours before surgery.17

Goldenseal (Hydrastasis canadenis) Goldenseal is used as a mild laxative and anti- inflammatory and to treat infection. It may be taken internally or applied externally. Active ingredients are thought to be alkaloid compounds called hy-

hypertrophy, aphrodisiac drastine and berberine. Its usage for intestinal prob- lems may increase blood pressure or cause electro- lyte imbalance from diarrhea.29 This is important during the perioperative period, when volume depletion is already common. Furthermore, inhibition of cytochrome P450 3A4 metabolism has also been demonstrated in vitro and, as such, concern is raised about potentiation of drugs metabolized by it. Sur- gically, this correlates with possible barbiturate and benzodiazepine toxicity, leading to excess postoperative sedation. In addition, photosensitivity reactions have been documented. Exposure to ultraviolet A or laser light is thus contraindicated.30,31 Other side Ginger (1–4 g QD)Eicosapentaenoic acid (1–2 gVitamin QD) E (200–800 IU QD) Cardioprotective, skin disorders, asthma Cardioprotective, cancer (antioxidant) Perioperative bleeding Antiemetic, sore throat, anti-inflammatory Perioperative bleeding, Perioperative prolonged bleeding D/C 2–3 week before surgery† D/C 2–3 week before surgery† St. John’s wort (2.7–3.0 g QD)Valerian (400–900 mg QD) Depression, anxiety, pain, insomnia, infection Postoperative Insomnia, sedation, anxiolytic cardiovascular Postoperative sedation D/C Table 2. Additional Remedies with Perioperative Concerns Common Name and Dose*Saw palmetto (2.7–3.0 g QD) Sedative, anti-inflammatory, benign prostatic Common Uses (Marketing)D/C, discontinue; MAOIs, monoamineThis oxidase table inhibitors; may QD, be*Gram every cut values day. out for or powder†According copied unless to for otherwise recommendations quick specified. from office the reference. American Society of Anesthesiologists. Surgicaleffects Caution include Perioperativeirritation Recommendations of skin, mouth, throat, and

441 Plastic and Reconstructive Surgery • February 2006 vagina from high-dose exposure.21,29 Thus, with no to interact with warfarin with clinical coagulation formal bioavailability studies suggested, time of dis- modulation, suggesting an antiplatelet effect. Be- continuation before surgery is 2 to 3 weeks accord- cause platelet inhibition caused by ginseng may be ing to the American Society of Anesthesiologists.10 irreversible,36 it is recommended that patients discontinue ginseng use at least 7 days before surgery.17 Milk Thistle (Silybum marianum) Milk thistle has emerged for its hepatoprotec- Kava (Piper methysticum rhizoma) tive, anti-inflammatory, and regenerative proper- Kava is popular for its sedative and anxiolytic ties. The extracted substance “silymarin” is the properties.17 Kava lactones are the active com- most widely studied. Silymarin mediates two pri- pounds contained in the herb. They act by poten- mary sites of action that affect the liver: the outer tiating gamma-aminobutyric acid inhibitory neu- surface of the hepatocyte cell membrane and the rotransmission. This correlated with an increased ribosomal proteins (glutathione produced). Sily- barbiturate-induced sleep time in laboratory ani- marin also has anti-inflammatory properties as a mals and may explain the mechanism underlying result of inhibiting leukotriene production; helps the report of a case of coma attributed to an al- stabilize mast cells; and is a mild iron chelator. It prazolam-kava interaction.37 Thus, surgical cau- may also inhibit lipid peroxidation with butyro- tion must be advised because of the increased phenones and phenothiazines and may antago- effects of barbiturates and benzodiazepines caus- nize other herbs such as yohimbine and phentol- ing excessive sedation when used with kava.17 Fur- amine. Side effects are rare but include severe thermore, with long-term use, kava may lead to sweating, headache, irritability, allergic reaction, abuse (addiction, tolerance, and withdrawal) and abdominal cramping, nausea, vomiting, weakness, kava dermopathy (reversible, scaly cutaneous and diarrhea.32 Loose stools are dosage depen- eruptions) and was even withdrawn in Canada for dent and are secondary to choleretic activity with causing fulminant hepatitis.38 Thus, because of increased bile flow. This may potentiate volume kava’s half-life, recommended time of discontin- depletion in the perioperative patient and thus uation before surgery is at least 24 hours.17 caution is advised. Until further studies are conducted, suggested time of discontinuation before Garlic (Allium sativum) surgery is 2 to 3 weeks according to American Garlic is known to aid in the reduction of athero- Society of Anesthesiologists guidelines.10 sclerosis and hypercholesterolemia.17 It is also taken as an antioxidant, an antibiotic, a diuretic, an antitussive, Ginseng (Panax ginseng) to remove “evil” spirits, strengthen the stomach and 39 Ginseng has been used for its ability to protect spleen, and relieve diarrhea. The active ingredient is the body from stress and restore homeostasis. The allicin, which has been reported to inhibit platelet ag- herb has been labeled adaptogenic, augmenting ad- gregation. There is a case of spontaneous spinal/epi- renal steroidogenesis by means of a centrally medi- dural hematoma in an 87-year-old man, with associated platelet dysfunction related to excessive garlic ated mechanism and causing a ginseng-induced hy- 40 poglycemia. This hypoglycemic effect has been ingestion. Therefore, garlic should not be taken with attributed to the constituent ginsenoside Rb2 and other coagulation inhibitors (e.g., warfarin, heparin, panaxans I, J, K, and L. A possible therapeutic use is nonsteroidal anti-inflammatory inhibitors, and aspi- lowering postprandial blood glucose in patients with rin). Other side effects include halitosis, nausea, hypo- type 2 diabetes mellitus. In people without diabetes, tension, headache, bloating, and possible allergic reaction.23,41,42 It is suggested that garlic be discontin- this effect may create unintended hypoglycemia, es- 17 pecially in patients who have fasted before surgery. ued at least 1 week before surgery. Side effects include insomnia, headache, vomiting, epistaxis, Stevens-Johnson syndrome, postmeno- Additional Remedies with Perioperative pausal vaginal bleeding, mastalgia, diffuse breast Concerns nodularity, and hypertension.9,21,33–35 Because gin- Saw Palmetto (Serenoa repens or Sabal seng can cause hypertension, attention should focus serrulata) on perioperative hemodynamic variation, as these Saw palmetto has been advocated for the patients are often volume depleted, and anesthetic symptomatic treatment of mild to moderate be- agents can cause generalized vasodilation. An addi- nign prostatic hyperplasia (Table 2). Side effects tional perioperative concern for ginseng involves its are typically mild and include gastrointestinal effect on coagulation pathways. It has been reported symptoms (nausea, vomiting, diarrhea), rhinitis,

442 Volume 117, Number 2 • Herbal and Supplemental Medicine and headache.21 Of interest is the fact that in the ommended that usage be discontinued 2 to 3 weeks perioperative period intraoperative hemorrhage before surgery, according to American Society of has been associated with saw palmetto.43 Thus, Anesthesiologists guidelines.10 discontinuation is advised at 2 to 3 weeks before Eicosapentaenoic Acid (fish oil) surgery.10 Eicosapentaenoic acid is rapidly growing in pop- St. John’s Wort (Hypercum perforatum) ularity and is commonly taken to reduce the inci- An herb typically used to treat depression and dence of thrombotic cardiovascular disease.56,57 Its anxiety, St. John’s wort is also used for aches and mechanism of action is believed to be by means of pains, asthma, and sleep-related disorders.17,44 Ex- inhibition of adenosine diphosphate–induced plate- tracts from this herb inhibit isoforms of mono- let aggregation. Thus, to avoid perioperative risk of amine oxidase in vitro. Thus, concomitant use bleeding, it is prudent that usage be discontinued 2 with selective serotonin reuptake inhibitors may to 3 weeks before surgery, according to American cause serotonergic syndrome.45,46 Associated side Society of Anesthesiologists guidelines.12 effects may include dry mouth, dizziness, fatigue, constipation, nausea, gastrointestinal upset, swell- Vitamin E ing and, rarely, photosensitization.17,47,48 Photo- The average American adult has stores of sensitization has been reported most prevalently vitamin E to last for 4 years. Supplementation for those undergoing ultraviolet A or laser beyond stores has been used for its antioxidant treatment.49–51 Surgeons should be cautioned that effects and potential to slow progression of ath- long-term use of the herb has been associated with erosclerosis. Reported effects have been popu- cardiovascular collapse on induction of anesthe- lation dependent. For patients with normal sia. The herb may also prolong postoperative platelets taking vitamin E, platelet aggregation sedation.52 It is recommended that the herb be remains unaffected, but platelet adherence is discontinued at least 5 days before surgery to avoid inhibited, whereas with patients who have ab- these complications.17 normal platelets, such as diabetics, both aggregation and adhesion are inhibited. Further- Valerian (Valeriana officinalis) more, vitamin E has also been shown to be Typically used as a relaxant and anxiolytic, inhibitory to collagen synthesis and thus wound valerian is known to be taken as a sedative and is healing.57,58 As such, the following perioperative 17 found in almost all sleeping aids. Valerian has recommendations are made. For patients with been shown to increase activity at gamma-ami- normal platelets or those undergoing tendon nobutyric acid receptors and to be an inhibitor of repairs, vitamin E should be discontinued be- cytochrome P450 3A4. As such, it should not be fore surgery and withheld until after the healing taken in conjunction with anesthetics, because it 17 phase is complete. Patients with abnormal plate- may cause excessive sedation. Other side effects lets such as diabetics may benefit from stopping may include gastric distress, blurred vision, excit- vitamin E before surgery, but resuming it after- ability, restlessness, acute hepatitis, possible ward may be beneficial to avoid increased plate- tremor, headache, and cardiac disturbances, and 21,53,54 let aggregation. This latter decision should con- long-term use is associated with withdrawal. sider this need with the need for a strong For these reasons, it is suggested that use of the 59 8 collagen-mediated wound closure. Finally, pa- herb be discontinued 1 week before surgery. tients requiring other antiplatelet agents should Ginger (Zingiber officinale) not take vitamin E. Discontinuation at 2 to 3 Ginger has been used as a digestive aid, stimu- weeks before surgery is recommended accord- lant, diuretic, and antiemetic.55 Reported effects in- ing to American Society of Anesthesiologists clude potent inhibition of thromboxane synthetase guidelines.12 enzyme, leading to prolongation of bleeding time. Thus, use of ginger should be avoided in the perioperative period and should not be combined with CONCLUSIONS other anticoagulants (e.g., warfarin and heparin, or Herbal medicines and supplements dis- drugs such as nonsteroidal anti-inflammatory inhib- played greater prevalence in the cosmetic sur- itors and aspirin). Other side effects include heart- gery population than in the population at large. burn or stomach distress, diarrhea, and burning or As such, it is of great import for the cosmetic tingling of the mouth. Thus, to avoid perioperative surgeon to understand these remedies and treat risk of bleeding and other complications, it is rec- them as pharmaceuticals rather than as safe and

443 Plastic and Reconstructive Surgery • February 2006 natural. The side effects and potential compli- 18. Braunig, B. Echinacea purpurea radix for strengthening the cations warrant such caution. immune response in flu-like infections. Z. Phytother. 13: 7, 1992. James P. Bradley, M.D. 19. Schoneberger, D. The influence of the immune stimulating Division of Plastic and Reconstructive Surgery effects of pressed juices from echinacea purpurea on the David Geffen School of Medicine course and intensity of the common cold: Results of a double- University of California, Los Angeles blind-clinical trial. Forum Immunol. 2: 18, 1992. 200 Medical Plaza, Suite 565 20. Melchart, D., Walther, E., Linde, K., et al. Echinacea root Los Angeles, Calif. 90069 extracts for the prevention of upper respiratory tract infec- [email protected] tions: A double-blind, placebo-controlled, randomized trial. Arch. Fam. Med. 7: 541, 1998. 21. Kaweski, S. Medicines. . .Allergies. . .Herbs? 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40. Rose, K. D., Croissant, P. D., and Parliament, C. F. Sponta- 49. Golsch, S., Vocks, E., Rakoski, J., et al. Reversible Erhohung neous spinal epidural hematoma with associated platelet der Photosensitivitat im UV-B-Bereich durch Johannisk- dysfunction from excessive garlic ingestion: A case report. rautextrakt-Praparate. Hautarzt 48: 249, 1997. Neurosurgery 26: 880, 1990. 50. Bove, G. M. Acute neuropathy after exposure to sun in a 41. Jappe, U., Bonnekoh, B., Hausen, B. M., et al. Garlic-related patient treated with St John’s wort. Lancet 352: 1121, 1998. dermatoses: Case report and review of the literature. Am. J. 51. Lane-Brown, M. M. Photosensitivity associated with herbal Contact Dermat. 10: 37, 1999. preparations of St John’s wort (Hypericum perforatum). Med. J. 42. Perez-Pimiento, A. J., Moneo, I., Santaolalla, M., et al. Ana- Aust. 172: 302, 2000. phylactic reaction to young garlic. Allergy 54: 626, 1999. 52. Crowe, S., and McKeating, K. Delayed emergence and St. 43. Cheema, P., El-Mefty, O., and Jazieh, A. R. Intraoperative haem- John’s wort. Anesthesiology 96: 1025, 2002. orrhage associated with the use of extract of saw palmetto herb: 53. O’Hara, M., Kiefer, D., Farrel, K., et al. A review of 12 com- A case report and review of literature. J. Intern. Med. 250: 167, monly used medicinal herbs. Arch. Fam. Med. 7: 523, 1998. 2001. 54. Ciocon, J. O., Ciocon, D. G., and Galindo, D. J. Dietary 44. Ernst, E. Herbal medicines: Where is the evidence? Growing supplements in primary care: Botanicals can affect surgical evidence of effectiveness is counterbalanced by inadequate outcomes and follow-up. Geriatrics 59: 20, 2004. regulation. B.M.J. 321: 395, 2000. 55. Newall, C. A., Anderson, L. A., and Phillipson, J. D. Herbal 45. Ness, J., Sherman, F. T., and Pan, C. X. Alternative medicine: What the data say about common herbal therapies. Geriatrics 54: Medicines: A Guide for Healthcare Professionals. London: Phar- 33, 1999. maceutical Press, 1996. 46. Czekalla, J., Gastpar, M., Hubner, W. D., et al. The effect of 56. Awang, D. V. C. Ginger. Can. Pharm. J. 309, 1992. hypericum extract on cardiac conduction as seen in the 57. Petry, J. Surgically significant nutritional supplements. Plast. electrocardiogram compared to that of imipramine. Phar- Reconstr. Surg. 97: 223, 1996. macopsychiatry 30 (Suppl. 2): 86, 1997. 58. Havlik, R. Vitamin E and wound healing: Plastic Surgery 47. Ernst, E., Rand, J. I., Barnes, J., and Stevinson, C. Adverse Educational Foundation DATA Committee. Plast. Reconstr. effects profile of the herbal antidepressant St. John’s wort Surg. 100: 1901, 1997. (Hypericum perforatum L.). Eur. J. Clin. Pharmacol. 54: 589, 59. Brown, S. A., Coimbra, M., Coberly, D. M., Chao, J. J., and 1998. Rohrich, R. J. Oral nutritional supplementation acceler- 48. Hypericum Depression Trial Study Group. Effect of Hyperi- ates skin wound healing: A randomized, placebo-con- cum perforatum (St John’s wort) in major depressive disorder: trolled, double-arm, crossover study. Plast. Reconstr. Surg. A randomized controlled trial. J.A.M.A. 287: 1807, 2002. 114: 237, 2004.

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