Table 1.

ERAS Society Enhanced Recovery after Surgery Recommendations for Perioperative Care in Breast Reconstruction

Item	Recommendation	Evidence Level	Recommendation Grade
1. Preadmission information, education, and counseling	Patients should receive detailed preoperative counseling.	Moderate	Strong
2. Preadmission optimization	For daily smokers, 1 mo of abstinence before surgery is beneficial. For patients who are obese, weight reduction to achieve a BMI ≤30 kg/m2 before surgery is beneficial. For alcohol abusers, 1 mo of abstinence before surgery is beneficial. For appropriate groups, referral should be made to resources for these behavior changes.	Moderate (smoking) High (obesity) Low (alcohol)	Strong Strong Strong
3. Perforator flap planning	If preoperative perforator mapping is required, CTA is recommended.	Moderate	Strong
4. Perioperative fasting	Preoperative fasting should be minimized and patients should be allowed to drink clear fluids up to 2 hr before surgery.	Moderate	Strong
5. Preoperative carbohydrate loading	Preoperative maltodextrin-based drinks should be given to patients 2 hr before surgery.	Low	Strong
6. Venous thromboembolism prophylaxis	Patients should be assessed for venous thromboembolism risk, Unless contraindicated, and balanced by the risk of bleeding, patients at a higher risk should receive low-molecular-weight heparin or unfractionated heparin until ambulatory or discharged. Mechanical methods should be added.	Moderate	Strong
7. Antimicrobial prophylaxis	Chlorhexidine skin preparation should be performed and intravenous antibiotics covering common skin organisms should be given within 1 hr of incision.	Moderate	Strong
8. Postoperative nausea and vomiting prophylaxis	Women should receive preoperative and intraoperative medications to mitigate postoperative nausea and vomiting.	Moderate	Strong
9. Preoperative and intraoperative analgesia	Women should receive multimodal analgesia to mitigate pain.	Moderate	Strong
10. Standard anesthetic protocol	General anesthesia with TIVA is recommended.	Moderate	Strong
11. Preventing intraoperative hypothermia	Preoperative and intraoperative measures, such as forced air, to prevent hypothermia should be instituted. Temperature monitoring is required to ensure the patient’s body temperature is maintained above 36°C.	Moderate	Strong
12. Perioperative intravenous fluid management	Overresuscitation or underresuscitation of fluids should be avoided and water and electrolyte balance should be maintained. Goal-directed therapy is a useful method of achieving these goals. Balanced crystalloid solutions, rather than saline, is recommended. Vasopressors are recommended to support fluid management and do not negatively affect free flaps.	Moderate	Strong
13. Postoperative analgesia	Multimodal postoperative pain management regimens are opioid-sparing and should be used.	High	Strong
14. Early feeding	Patients should be encouraged to take fluids and food orally as soon as possible, preferably within 24 hr after surgery.	Moderate	Strong
15. Postoperative flap monitoring	Flap monitoring within the first 72 hr should occur frequently. Clinical evaluation is sufficient for monitoring, with implantable Doppler devices recommended in cases of buried flaps.	Moderate	Strong
16. Postoperative wound management	For incisional closure, conventional sutures are recommended. Complex wounds following skin necrosis are treatable with debridement and negative-pressure wound therapy.	High (sutures) Moderate (NPWT)	Strong
17. Early mobilization	Patients should be mobilized within the first 24 hr after surgery.	Moderate	Strong
18. Postdischarge home support and physiotherapy	Early physiotherapy, supervised exercise programs, and other supportive care initiatives should be instituted after discharge.	Moderate	Strong

BMI, body mass index; CTA, computed tomographic angiography; TIVA, total intravenous anesthesia; NPWT, negative-pressure wound therapy.