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Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations

Temple-Oberle, Claire M.D., M.Sc.; Shea-Budgell, Melissa A. M.Sc.; Tan, Mark M.D.; Semple, John L. M.D., M.Sc.; Schrag, Christiaan M.D.; Barreto, Marcio M.D.; Blondeel, Phillip M.D., Ph.D.; Hamming, Jeremy M.D.; Dayan, Joseph M.D.; Ljungqvist, Olle M.D., Ph.D.; for the ERAS Society

Plastic and Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1056e-1071e
doi: 10.1097/PRS.0000000000003242
Breast: Original Articles

Background: Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.

Methods: A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.

Results: High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non–breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.

Conclusion: Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.


Calgary, Alberta, and Toronto, Ontario, Canada; Duarte, Calif.; Recife, Pernambuco, Brazil; Ghent, Belgium; New York, N.Y.; and Örebro, Sweden

From the Departments of Surgery, Oncology, and Anesthesiology and Pain Medicine, University of Calgary; the Tom Baker Cancer Centre; the Cancer Strategic Clinical Network, Alberta Health Services; the City of Hope National Medical Center; the Department of Surgery, University of Toronto; the Department of Plastic and Reconstructive Surgery, University Hospital of Ghent; Memorial Sloan Kettering Cancer Center; Department of Surgery, Faculty of Medicine and Health, Örebro University; and private practice.

Received for publication June 13, 2016; accepted October 17, 2016.

Presented at the 4th World Congress of the Enhanced Recovery After Surgery Society, in Lisbon, Portugal, April 27 through 30, 2016.

Disclosure:Dr. Ljungqvist is a founding member of the ERAS Study Group and ERAS Society, an executive officer of the ERAS Society, and is the founder and a shareholder in EnCARE AB, Sweden 397 (, the provider of the ERAS interactive audit system. In addition, Dr. Ljungqvist was supported by funds from Nyckelfonden, Oreboro, Sweden. No funding was provided to support the development of this article and no funding was received as a result of this article.

Claire Temple-Oberle, M.D., M.Sc., 1331 29 Street NW, Calgary, Alberta T2N 4N2, Canada,

Copyright © 2017 by the American Society of Plastic Surgeons