Prehabilitation for Breast Reconstruction Surgery: A Practical and Evidence-based Guide

Abstract

Background:

Prehabilitation, the systematic optimization of physical, nutritional, and psychosocial health before surgery, is well established in other surgical specialties but remains underused and inconsistently defined in breast reconstruction. Patients pursuing reconstruction frequently have modifiable vulnerabilities, including malnutrition, sarcopenia, impaired glycemic control, chronic pain, sleep disturbance, anxiety, and depression, which are associated with higher complication rates, delayed functional recovery, and worse quality of life.

Methods:

This review summarizes evidence-supported prehabilitation and perioperative optimization strategies from breast surgery and broader surgical populations and evaluates their relevance to breast reconstruction. We emphasize practical, multidisciplinary screening and targeted intervention across nutrition/metabolism, functional status, pain, sleep, and psychosocial health.

Results:

Multiple interventions have demonstrated benefit across surgical populations and are readily adaptable to breast reconstruction, including high-protein supplementation and micronutrient optimization, immunonutrition, carbohydrate loading with perioperative glycemic control, resistance training, multimodal pain management, stress-reduction techniques, and sleep hygiene. Implementation requires systematic assessment of nutritional, functional, psychological, and social risk factors and collaboration with dietitians, physical therapists, pain specialists, behavioral health clinicians, and social workers to deliver individualized optimization.

Conclusions:

Prehabilitation offers a feasible pathway to improve outcomes and patient experience in breast reconstruction. Prospective studies are needed to define the optimal content, timing, and intensity of multimodal programs and to tailor approaches for implant-based and autologous reconstruction.

Takeaways.

Question: How should patients prepare for breast reconstruction surgery to decrease complications and improve their recovery?

Findings: Evidence-supported interventions, including high-protein supplementation and micronutrient optimization, immunonutrition, carbohydrate loading and perioperative blood glucose control, resistance training, multimodal pain control, stress-reduction strategies, and sleep hygiene, have demonstrated benefit across surgical populations and are readily adaptable to breast reconstruction.

Meaning: Surgeons should screen for nutritional, functional, psychological, and social vulnerabilities and partner with dietitians, physical therapists, pain specialists, behavioral health clinicians, and social workers to implement targeted optimization.

PATIENT HANDOUT

This breast reconstruction prehabilitation pathway outlines practical steps patients can take before surgery to improve recovery, focusing on nutrition, strength and activity, sleep, emotional well-being, social support, and medication/pain planning. It emphasizes optimizing protein and key nutrients, building muscle, improving sleep and stress management, and addressing pain and support needs in advance to help reduce complications and support faster recovery. (See figure, Supplemental Digital Content 1, which details the Plastic Surgery Prehabilitation Pathway for breast reconstruction. Copyright © 2025 American Society of Plastic Surgeons, https://links.lww.com/PRSGO/F249.)

INTRODUCTION

Although rehabilitation refers to interventions delivered after an illness or procedure to optimize functioning and reduce disability, prehabilitation pursues these same goals but is initiated before a planned event such as surgery. Across multiple surgical specialties—including oncology and orthopedics—multimodal prehabilitation programs that integrate physical conditioning, nutrition, and psychosocial support have been associated with fewer postoperative complications and improved quality of life. Many additional patient factors in the perioperative period also influence medical and surgical outcomes and may be amenable to optimization before surgery. In breast surgery, the evidence base for prehabilitation remains comparatively limited. The most recent review of the literature regarding prehabilitation in breast cancer patients includes only 14 studies, with 6 assessing exercise and others evaluating smoking cessation, psychosocial interventions, aromatherapy, a traditional Japanese herbal medicine, comprehensive nursing, or relaxation techniques.¹ Importantly, breast reconstruction differs from many other surgical contexts studied in prehabilitation: reconstruction often involves staged procedures and/or microsurgical techniques; may occur in the setting of radiation or systemic therapy; and carries distinct functional and patient-reported priorities (eg, upper-extremity morbidity, body image, and satisfaction outcomes). Similarly, prehabilitation initiatives framed broadly around “breast cancer surgery” do not always address reconstruction-specific risks, recovery timelines, and modifiable determinants of healing that are particularly relevant to reconstructive patients. The goal of this review is to highlight how optimization of modifiable perioperative factors in women undergoing breast reconstruction can improve outcomes and the patient experience, with a focus on exercise/physical conditioning, nutritional optimization, smoking and alcohol risk reduction, and psychosocial/educational (including anxiety and expectation management) interventions, delivered as single-modality or multimodal prehabilitation programs.

Nutritional Optimization

In surgical patients, malnutrition is an independent risk factor for complications, including mortality, suboptimal wound healing, and length of hospital stay.² Prior reviews have summarized the evidence for nutritional optimization in plastic surgery patients and recommend evidence-based targeted supplementation.³ In this review, we will discuss the macro- and micronutrients that should be optimized preoperatively to encourage recovery and healing. Although most of these nutrients have not been investigated specifically in breast reconstruction, results from other surgical patient populations will be discussed. In our clinical experience, the most common potentially modifiable nutritional issue in breast reconstruction patients is inadequate protein intake. Accordingly, we frequently consider targeted screening such as serum albumin/prealbumin (when clinically appropriate) as part of preoperative risk assessment. The following recommendations apply to most patients undergoing breast reconstruction; however, select populations, such as those who have recently completed neoadjuvant chemotherapy, have experienced significant weight loss, or are using glucagon-like peptide-1 receptor agonists (GLP-1 RAs), may require additional evaluation and individualized management beyond the scope of this review.

Fats

Fats play essential roles in the human body, serving as an energy source, structural component, regulator of inflammation, and signaling molecule. They are critical for the absorption of fat-soluble vitamins (A, D, E, and K) and the synthesis of essential hormones. Omega-3 fatty acids are necessary for optimal wound healing by reducing oxidative stress and inflammation. Omega-6 fatty acids, although often considered inflammatory, are also critical for wound healing and angiogenesis. The main bioactive omega-3 fatty acids are eicosapentaenoic acid and docosahexaenoic acid, and they can be consumed through whole foods or high-quality supplements. There was historical concern that omega-3 fatty acid supplementation increased the risk of perioperative bleeding; however, this was disproven by a 2017 systematic review of 52 publications, which demonstrated that supplementation with omega-3s neither led to increased bleeding nor increased the need for perioperative blood transfusions.⁴

Protein

Protein is required for many facets of surgical recovery, including mounting an immune response, ensuring the integrity of the skin, maintaining fluid and electrolyte balance, and promoting angiogenesis. In the perioperative period, patients require at least 1.2–2.0 g of protein per kilogram of body weight per day, well above the recommended dietary allowance (RDA) of 0.8 g/kg.⁵ Clinical studies support ensuring adequate protein intake and/or protein supplementation. In plastic surgery, patients who supplemented with 80 g of protein for 4 weeks before and after body contouring surgery had decreased wound healing complications.⁶

Arginine and glutamine are conditionally essential amino acids, meaning that during times of trauma, stress, and healing, our body cannot keep up with increased demands. Studies in the perioperative period evaluating these amino acids have used between 17 and 25 g per day of supplemental arginine⁷ and up to 30 g of glutamine per day, typically using around 0.2 g/kg⁸

Vitamins and Minerals

Surgery and trauma increase the demand for micronutrients and amino acids, with deficiencies linked to impaired recovery. Although most of these nutrients have not been investigated in isolation in breast reconstruction, inferences can be made from other surgical populations.

Vitamin A is an essential micronutrient required for the production of collagen, the inflammatory response, and the reversal of steroid-induced inhibition of wound healing. The RDA for vitamin A is 700 μg for women and 900 μg for men. There is a lack of high-quality studies to determine the optimal dosing for preoperative supplementation.

Vitamin C (ascorbic acid) is a water-soluble vitamin with strong antioxidant properties that is essential for multiple enzymatic reactions, the immune response, angiogenesis, and the production of tissues such as collagen, bones, and skin. However, to optimize healing, doses ranging from 500 mg per day in noncomplicated wounds to 2 g per day in severe wounds are recommended.^9,10

Vitamin D is a fat-soluble vitamin that is important for regulating infection and the inflammatory response, modulating glycemic and lipid control, maintaining bone healing, and influencing the metabolism of other nutrients. Doses ranging from 2000 to 4000 IU are typically used in studies, but these have not been thoroughly analyzed in surgical patients.

Zinc is an essential mineral that is critical for more than 300 different enzymes. It is necessary for DNA replication, platelet function, and the regulation of inflammation, blood glucose, insulin, and the immune response. The RDA for zinc is 8 mg per day for women and 11 mg per day for men. Studies in humans suggest that supplementation with around 30 mg per day can improve wound healing.¹¹

Magnesium is a cofactor for more than 300 enzymatic reactions and is critical for modulating inflammation and the immune response, protein synthesis, collagen formation, and cellular proliferation. Its role in muscle function is also essential for postoperative recovery, as it aids in reducing muscle spasms and promoting relaxation, which can enhance patient comfort and mobility. Magnesium plays a vital role in sleep regulation, which impacts healing and recovery after surgery.¹² The RDA for magnesium is 400–420 mg for men and 320 mg for women. Studies have not been conducted to determine the best dose for the surgical patient.

Nutrients not specifically discussed but that play an important role in wound healing include selenium, quercetin, folate, and the various B vitamins. This is summarized in Table 1.

Table 1.

Key Nutrients and Their Roles in Surgical Recovery

Nutrient	Physiological Role	Suggested Dose/Range*	Evidence/Notes
Protein	Immune response, wound healing, angiogenesis	1.2–2.0 g/kg/d	Even nondeficient patients benefit from supplementation
Arginine	Collagen synthesis, vasodilation	17–25 g/d	Supports immune function
Glutamine	Fuel for immune/gut cells, antioxidant precursor	~0.2 g/kg/d (up to 30 g)	Reduces oxidative stress
Vitamin C	Collagen production, antioxidant, angiogenesis	500 mg to 2 g/d	Dose depends on wound severity
Vitamin D	Infection control, bone healing, glycemic regulation	2000–4000 IU/d	Data limited in surgical patients
Zinc	DNA synthesis, immune function, wound healing	8–11 mg RDA; ~30 mg/d for wound healing	More than 300 enzymes require zinc
Magnesium	Protein synthesis, muscle function, sleep regulation	320–420 mg/d	Supports postoperative recovery

^*Ranges are approximate; individualized care is recommended.

Importantly, many dietary supplements have not been established as safe during neoadjuvant chemotherapy and should therefore be reviewed and coordinated with the patient’s medical oncology team before initiation.

Blood Sugar Optimization

Although hyperglycemia in patients with diabetes who undergo surgery increases the rate of surgical site infection, myocardial infarction, stroke, and death, maintaining blood sugar control in the perioperative period is also crucial for reducing complications in patients without diabetes.¹³ In elective breast reconstruction patients, diabetes has been shown to be an independent risk factor for postoperative complications.¹⁴ Thus, patients’ blood sugar control should be assessed by measuring A1C before surgery and with modulation as required in the perioperative period to decrease complication risk. Current guidelines recommend a preoperative HbA1c level of less than 7.0% in low-risk patients and delaying reconstructive surgery to optimize if HbA1c exceeds 8.0%.¹⁵

Prolonged fasting, such as before surgery, can lead to hypo- and hyperglycemia, insulin resistance, suppression of the immune system, and muscle breakdown. Fasting can also be difficult to manage for patients who have glucose abnormalities, including diabetes or hypoglycemia. Carbohydrate loading the night before surgery can offset some of the negative side effects of fasting before surgery. This is accomplished with the consumption of 50 g of carbohydrates as a clear liquid 2–3 hours before surgery or by eating 100 g of carbohydrates the evening before surgery.¹⁶ Carbohydrate loading has been shown to reduce postoperative insulin resistance, hyperglycemia, muscle loss, and hospital stay while improving patient satisfaction.¹⁶ Patients with diabetes may require individualized carbohydrate-loading strategies.

Recommendations

• Discuss with patients the importance of perioperative nutrition to optimize recovery and outcomes.

• Consider evidence-based supplementation to offset nutritional deficiencies and provide increased levels of nutrients needed for healing.

• Supplementation can also be beneficial in patients who are not “deficient” in a macro- or micronutrients, as demonstrated in numerous wound healing studies.

• Ensure that high-quality, third-party-validated supplements are used in patients opting for supplementation.

Muscle Mass

Surgery results in a systemic stress response that is required to activate the immune and hormonal systems to allow for healing and recovery. These responses require protein mobilization; thus, surgery inherently leads to protein catabolism. Surgery is also often associated with required or self-imposed bed rest or activity restrictions, which quickly lead to protein breakdown and muscle atrophy, even in healthy adults. In surgical patients, inadequate preoperative protein stores have been associated with increased morbidity, delayed recovery, and worse oncological outcomes. The catabolic state of surgery combined with postoperative immobility leads to a loss of muscle mass and resultant decreased functional capacity that can negatively impact recovery and make a return to baseline difficult, especially for at-risk patient populations.¹⁷

Sarcopenia, a condition characterized by the loss of skeletal muscle and strength, can be due to aging, comorbidities, or nutritional deficiencies and is common in breast cancer patients.¹⁸ In the largest study to examine the incidence of sarcopenia in patients with stage I or II breast cancer, among 3241 women, the rate of sarcopenia was 34%.¹⁹ Although a substantial number of breast cancer patients meet criteria for a diagnosis of sarcopenia preoperatively, it is likely that even more patients have suboptimal protein stores in preparation for the surgical stress response and postoperative limited activity. In breast reconstruction, several studies have demonstrated that sarcopenia is a risk factor for mastectomy flap necrosis²⁰ and complications after deep inferior epigastric perforator (DIEP) flap reconstruction,²¹ even to a greater extent than body mass index.²²

Exercise is 1 way to optimize protein stores and prevent sarcopenia. In breast cancer survivors, exercise has been shown to positively affect quality of life, cardiorespiratory fitness, body composition,²³ and even all-cause mortality.²⁴ If aiming to increase lean muscle mass through exercise, adequate dietary protein must also be ensured, at least 1.2–2.9 g/kg as discussed earlier.

Although it is recommended that patients increase their global lean muscle mass before surgery, focus should also be given to optimizing functionality after surgery. For example, in patients undergoing DIEP flap reconstruction, the abdomen serves as the surgical donor site and lifting restrictions are imposed; therefore, increasing leg strength can enhance postoperative mobility and functionality.

The growing use of GLP-1 RAs for weight management and metabolic control has important implications for muscle preservation in surgical patients. Although highly effective at promoting weight loss, GLP-1 RAs may lead to substantial reductions in lean body mass,²⁵ which can be detrimental to healing and functional recovery.

Recommendations

• Assess preoperative protein stores in patients and emphasize the importance of lean muscle mass.

• Recommend resistance training to create a muscle reserve before the catabolic surgical experience and the postoperative period of decreased activity.

• Consider which muscle groups should be prioritized preoperatively to optimize postoperative functionality.

• If patients are on a GLP-1 agonist, emphasize a protein-dense diet and resistance training before surgery. Consider assessing albumin before surgery.

Pain

Pain is one of the most common and distressing side effects of treatment for breast cancer, with 30%–60% of patients experiencing significant disease-related pain.²⁶ The prevalence of pain actually increases after treatment, with up to 40% of women citing pain 7–36 months after treatment completion.²⁶ Pain that persists after treatment can be debilitating for patients, interfering with their daily lives and contributing to anxiety and depression. Previous studies have found that risk factors for chronic pain after mastectomy include preoperative pain, axillary lymph node dissection, anxiety, younger age, and radiation therapy.^27,28

Multimodal pain control in breast reconstruction is a cornerstone of enhanced recovery protocols, aiming to minimize opioid use while optimizing patient comfort and functional recovery. By combining different classes of analgesics and techniques that target distinct pain pathways, this approach reduces reliance on narcotics and their associated side effects, such as nausea, constipation, sedation, addiction, and delayed mobilization. Common components include preoperative acetaminophen and nonsteroidal anti-inflammatory drugs; preoperative or intraoperative regional anesthesia, such as paravertebral, serratus anterior, erector spinae plane, or pectoral blocks; use of liposomal bupivacaine; and postoperative adjuvants such as gabapentinoids, ketamine, or local anesthetic infusion catheters.^29,30 In breast reconstruction patients, multimodal analgesia has been shown to decrease opioid consumption, shorten hospital stays, improve pulmonary function through earlier mobilization, and support faster return to baseline activity, making it an essential component of perioperative care.³¹ Although ERAS (enhanced recovery after surgery) protocols involving a multimodal approach to pain control have been very successful in breast reconstruction, they do not completely eliminate pain,³² and their impact on the prevention of chronic pain remains to be elucidated.

Psychosocial factors are increasingly recognized as determinants of the pain experience. In breast cancer patients, an analysis of 47 studies demonstrated that across all postoperative time periods, there was an association between psychological factors, such as anxiety and depression, and pain.³³ Two psychosocial factors that can impact pain are pain self-efficacy (the confidence that one has in their ability to manage pain) and pain catastrophizing (the tendency to focus on pain and negatively evaluate one’s ability to deal with it). In patients with breast cancer, higher pain severity has been shown to be related to lower pain self-efficacy and higher pain catastrophizing, whereas lower pain self-efficacy and higher pain catastrophizing were significantly related to depression.³⁴ Even high pain catastrophizing scores in the preoperative period have been associated with moderate to severe postoperative pain in breast cancer patients.³⁵ These factors that impact pain outcomes can be optimized. A meta-analysis found that psychosocial interventions, such as counseling, education, relaxation, guided imagery, yoga, and meditation, were effective in the management of pain among breast cancer patients and survivors.³⁶

Recommendations

• Assess preoperative baseline pain, as this can impact postoperative pain.

• Determine whether preoperative referral to a pain management clinic or cognitive behavioral therapy is indicated.

• Use multimodal pain management strategies.

• Continue to assess pain beyond the acute postoperative period, and if chronic pain exists, refer to a pain management clinic.

Stress, Anxiety, and Depression

The prevalence of stress, anxiety, and depression in women with breast cancer is high, with depression reported in 25%–30% of women³⁷ and anxiety in more than 20%.³⁸ They are associated with numerous negative medical and surgical outcomes in this patient cohort, including persistent neuropathic pain,^39,40 increased risk of surgical complications, and prolonged hospital stay.⁴¹ A review analyzing the relationship between mood variables, such as anxiety and depression, and surgical outcomes demonstrated that 19 of 47 outcomes were predicted by a negative mood factor, even across diverse patients and procedures.⁴² Alternatively, optimistic outlooks preoperatively have been associated with improved postoperative outcomes.⁴³

Successful interventions to optimize stress, anxiety, and depression in breast cancer patients have largely used cognitive behavioral therapy. One study found that 4 sessions of preoperative stress management training were able to reduce postoperative depression and fatigue.⁴⁴ In younger women with breast cancer, mindfulness meditation and survivorship education were able to reduce depressive symptoms.⁴⁵ Other low-risk modalities that can optimize stress and anxiety include music therapy, massage, aromatherapy, flowers, and guided imagery.

Recommendations

• Assess stress, anxiety, and depression preoperatively to allow for early referral to therapy.

• Recommend low-risk, potentially beneficial approaches, such as mindfulness and meditation, to patients in the perioperative period.

Sleep

Sleep disturbances are very common in women with a breast cancer diagnosis, with increased sleep latency and decreased sleep efficiency evident well after diagnosis. Suboptimal sleep leads to numerous physiological changes (some even after just 1 night of sleep deprivation), including reduced leptin, glucose tolerance, and insulin sensitivity⁴⁶ and increased cortisol and inflammatory markers.^46–49 Sleep also impacts the microbiome and can lead to dysbiosis, which has been associated with negative medical and surgical outcomes.⁵⁰ In surgical patients, poor sleep has been associated with an increased incidence of complications and a prolonged hospital stay.⁵¹

Numerous aspects of surgery negatively impact sleep. Pain is one of the major contributors to poor sleep after surgery, and sleep quality is further diminished if narcotics are used. General anesthesia leads to decreased total sleep time, abolition of rapid eye movement sleep, and decreased slow-wave sleep postoperatively. Hospital factors negatively impacting sleep include noise pollution and light-emitting diode lights, which impair melatonin secretion. Although medications can be successful at leading to sleep onset, they do not always lead to restorative sleep. Evidence-based interventions to improve sleep in patients with breast cancer include melatonin supplementation,⁵² aerobic exercise,⁵³ yoga,⁵⁴ and acupuncture.⁵⁵

Recommendations

• Discuss the importance of sleep with patients preoperatively and assess baseline sleep quantity and quality.

• Encourage patients to establish a sleep hygiene routine preoperatively.

• Recommend that patients bring things to the hospital to aid in sleep, including pillows and blankets, a noise machine, headphones, blue light–blocking glasses, sleep eye masks, an aromatherapy machine, and so on.

CONCLUSIONS

Surgeons consider many aspects of the patient’s medical history during shared decision-making to reach the most appropriate surgical plan. However, for breast cancer patients, there are numerous evidence-based factors that are interconnected and have the potential to impact medical and surgical outcomes. Research is needed to determine which patients would benefit from prehabilitation addressing nutritional optimization, pain management, stress, anxiety, depression, sleep, body image, and the formation of social networks. Many of these topics are outside of surgeons’ area of expertise but can impact outcomes and the patient experience. Even if these factors cannot be improved perioperatively, they should be considered due to their potential impact on medical and surgical outcomes. An ideal prehabilitation program for breast reconstruction integrates exercise, dietitian-guided nutrition, stress management, smoking cessation, medical optimization, supplementation, and telehealth support beginning at diagnosis (Table 2). Nurse navigators play a key role in coordinating these services and bridging access gaps. Thus, it is critical that, while quality research addresses unanswered questions, surgeons consider these patient factors and ensure proper referrals are placed so that patients receive the help and support they need and deserve.

Table 2.

Multimodal Prehabilitation Interventions

Domain	Interventions	Evidence/Impact
Nutrition	Protein, omega-3s, arginine, glutamine, micronutrient optimization, carbohydrate loading	↓ complications, improved wound healing
Exercise	Resistance training, aerobic activity, preoperative leg strength (for DIEP flaps)	Prevents sarcopenia, ↑ functional recovery
Pain	NSAIDs, nerve blocks, liposomal bupivacaine, gabapentinoids	↓ opioids, shorter length of stay
Psychosocial	Cognitive behavioral therapy, mindfulness, guided imagery, yoga, meditation	↓ anxiety/depression, ↑ coping
Sleep	Sleep hygiene, melatonin, yoga, acupuncture	Better healing, ↓ complications
Social support	Family engagement, support groups	↑ adherence, ↓ recurrence/mortality

NSAIDs, nonsteroidal anti-inflammatory drugs.

DISCLOSURES

Dr. Knackstedt is a consultant for Abbott and uMETHOD, and a cofounder of Clara Recovery. The other authors have no financial interest to declare in relation to the content of this article.