Ehlers-Danlos syndrome, an underreported consideration in plastic surgery: A narrative review of cases

Ehlers-Danlos Syndrome (EDS) encompasses a variety of collagen disorders characterized by joint hypermobility, skin laxity, and tissue fragility. Evidence to guide plastic surgeons for both elective and reconstructive procedures is limited and consists predominantly of case reports and series. As higher-level comparative data are scarce, synthesizing case-level data remains essential to understand surgical risks, considerations, and postoperative outcomes in this patient population.

A narrative review of case reports and series was conducted using PRISMA guidelines across Scopus, PubMed/MEDLINE, Cochrane, Web of Science, and Embase. Studies from inception to September 2025 were screened for surgical management of patients with EDS. After screening 1816 abstracts with review of 230 full texts, 52 studies met inclusion criteria. Data were collected on demographics, EDS subtype, surgical indication, procedures, perioperative care, and complications. Case-level data were summarized descriptively as counts and percentages, with continuous variables reported as mean (SD) and median (range).

The 52 studies described 77 individual cases of EDS, most frequently hypermobile (36.4%), classical (27.3%), and vascular (9.1%) subtypes. The cohort was predominantly female (female-to-male ratio 1.8:1), with a mean age of 31.9 ± 16.6 years (median 28, range 3-64). Reconstruction was the primary indication (67.5%), with additional representation from aesthetic (13.0%). Across case reports and series, frequently discussed strategies included tension-free layered closure, vascular preservation, gentle tissue handling, adhesive supports, and prolonged suture retention.

Themes emerged regarding optimal practices for patients with EDS. The techniques emphasized attention to tension reduction, vascular friability, and postoperative supports to mitigate complications in this patient demographic. Heterogeneous reporting in the literature limits the generalizability of findings and underscores the need for standardized documentation. However, these cases represent a potential for developing perioperative strategies and wound-care protocols to guide best practices in this complex population.