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Aims Bioactive peptides are increasingly investigated as therapeutic adjuncts in plastic surgery. Despite increasing scientific, commercial, and patient interest, the current evidence base remains heterogeneous and predominantly preclinical. This review aimed to evaluate the current and emerging applications of peptides in plastic surgery, focusing on wound healing, reconstructive surgery, scar modulation, aesthetic practice, safety, regulation, and translational barriers. Methods A narrative review was performed using PubMed, EMBASE, CENTRAL, Scopus, and Google Scholar from database inception to May 2026. Evidence was synthesized narratively and graded using the Oxford Centre for Evidence-Based Medicine (OCEBM) framework alongside clinical readiness. Results Evidence was most mature in wound healing, where antimicrobial and regenerative peptides have progressed to phase II and early phase III trials, although regulatory approval for plastic surgical indications remains lacking. Scar modulation peptides have entered early clinical evaluation, and aesthetic peptides have accumulated modest human data. In contrast, reconstructive applications remain supported predominantly by preclinical evidence. Limitations included small sample sizes, heterogeneous outcome measures, short follow-up, and manufacturer-funded studies in the aesthetic literature. Translational barriers included short biological half-life, poor tissue penetration, regulatory uncertainty, and the lack of adequately powered randomized controlled trials with standardized outcome measures. Conclusions Peptides show promise but currently lack robust clinical validation across plastic surgical domains. The disparity between commercially marketed claims and current evidence is particularly pronounced in aesthetic practice. Plastic surgeons should maintain a critically informed approach when counseling patients and are uniquely positioned to lead the trials required to establish the evidence base for broader ad