Glucagon-Like Peptide-1 Receptor Agonists in Plastic Surgery: Perioperative Considerations and Safety Protocols

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prescribed among plastic surgery patients for obesity and overweight. Agents such as dulaglutide, liraglutide, semaglutide, and tirzepatide differ in pharmacology and dosing, directly influencing perioperative safety, particularly due to their effects on gastric motility and the high frequency of gastrointestinal (GI) adverse events that raise concerns about aspiration and postoperative morbidity in urgent or elective procedures. A narrative review was conducted using PubMed, Embase, and the Cochrane Library (2010-2025). Randomized controlled trials, meta-analyses, prospective studies, case reports, and perioperative guidelines were analyzed. We reviewed each agent along with the administration route, half-life, average weight loss, and recommended discontinuation prior to surgery: dulaglutide: weekly injection, half-life of approximately five days, weight loss of 3%-5%, and discontinuation at >1 week before surgery; liraglutide: daily injection, half-life of approximately 13 hours, weight loss of 5%-7%, gastrointestinal (GI) adverse events up to 40%, and discontinuation at 24-48 hours before surgery; semaglutide (weekly): Efficacy and Safety of Once-Weekly Semaglutide Versus Exenatide Extended Release (ER) in Subjects With Type 2 Diabetes (SUSTAIN-3) showing superior glycated hemoglobin (HbA1c) reduction and weight loss compared with exenatide, GI adverse events including nausea (22%), diarrhea (11%), and vomiting (7%), and discontinuation at >1 week preoperatively; semaglutide (oral): Peptide Innovation for Early Diabetes Treatment (PIONEER) trials showing 4.4 kg weight loss at 26 weeks, GI adverse events of 15%-20%, and discontinuation at 24-48 hours prior; and tirzepatide: weekly dual glucose-dependent insulinotropic polypeptide/glucagon-like peptide-1 (GIP/GLP-1) agonist, weight loss of up to 20% in SURMOUNT-1, half-life of approximately five days, and discontinuation at >1 week before surgery. Prospective ultrasound studies show a higher prevalence of residual gastric content in GLP-1 RA users, particularly during dose escalation or when GI symptoms are present. Case reports document perioperative aspiration in semaglutide users, including episodes of hypoxemia and reintubation despite guideline-concordant fasting. Perioperative risk is now supported by prospective evidence and case reports. Weekly formulations show the strongest association with delayed gastric emptying and aspiration. Pharmacovigilance data and FDA/European Medicines Agency (EMA) alerts also describe rare cases of suicidal ideation and self-harm behaviors, especially in weight-loss therapy. GLP-1 RAs are commonly used among plastic surgery patients, and their use has grown exponentially over the years. There are concerns about delayed gastric emptying and gastrointestinal intolerance that pose a perioperative challenge that demands proactive perioperative management by the plastic surgery team. Plastic surgeons must lead the development of tailored, evidence-based, risk-stratified protocols that safeguard patients while preserving the benefits of these therapies. We share the protocol that we believe can help the plastic surgery team standardize safety strategies to be considered prior to elective surgery in patients who are treated with GLP-1 RA. More prospective studies are needed to validate and concentrate all guidelines and refine best practices in the era of metabolic pharmacology.