The Utility and Applicability of the Modified 5-Item Frailty Index in Cosmetic Surgery

Although elective cosmetic surgery is associated with relatively low complication rates, adverse outcomes may still occur, particularly in patients with preexisting vulnerabilities. The modified frailty index-5 (mFI-5) is an established predictor of adverse outcomes across multiple surgical specialties, but its relevance and applicability in cosmetic surgery have not yet been elucidated.

Data from the American College of Surgeons National Surgical Quality Improvement Program (2008-2022) were used to identify adult female patients undergoing elective cosmetic procedures. Patients were stratified by mFI-5 score (0, 1, or > 1). Demographics, perioperative characteristics, and 30-day postoperative outcomes were compared. Multivariable logistic regression assessed associations between frailty and complications. Predictive performance was evaluated using receiver operating characteristic (ROC) analysis and threshold probability assessment. To compare the predictive value of the composite frailty score with its individual components, ridge-regularized logistic regression models were analyzed using stratified five-fold cross-validation.

A total of 10,311 patients were included, of whom 88% had an mFI-5 score of 0, 11% had a score of 1, and 1% had a score greater than 1. Increasing frailty scores were associated with higher age and body mass index. Most patients underwent aesthetic breast surgery (65%), followed by abdominal contouring (29%) and combined breast-abdominal procedures (13%). Overall complication rates increased stepwise with frailty status (3% for mFI-5 = 0, 6% for mFI-5 = 1, and 12% for mFI-5 > 1; p < 0.001). Hypertension was the most prevalent frailty component, present in 87% of patients with mFI-5 = 1 and 99% of those with mFI-5 > 1, followed by diabetes. Other frailty components were uncommon. In multivariable analysis, an mFI-5 score greater than 1 independently predicted higher odds of overall complications and surgical complications, as well as increased readmission and unplanned reoperation. ROC analysis identified an mFI-5 score of 1 as a clinically relevant threshold beyond which complication risk increased. The composite mFI-5 demonstrated slightly superior discrimination and precision-recall performance compared with models based on individual comorbidities.

Frailty, as measured by the mFI-5, was relatively rare among cosmetic surgery patients. Elevated mFI-5 scores were driven primarily by hypertension and/or diabetes rather than generalized physiological decline. Although patients with mFI-5 > 1 were significantly more likely to experience postoperative complications, the mFI-5 in this context might reflect comorbidity burden rather than true frailty.

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