Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift

Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift Abstract Background With a focus on providing high quality care and reducing facility based expenses there has been an evolution in perioperative care by way of enhanced recovery after surgery (ERAS). ERAS allows for a multidisciplinary and multimodal approach to perioperative care which not only expedites recovery but maximizes patient outcomes. This paradigm shift has been generally accepted by most surgical specialties, including plastic surgery. Objectives The goal of this study was to evaluate the impact of ERAS on outcomes in cosmetic plastic surgery. Methods A prospective study consisting of phone call questionnaires was designed where patients from two senior plastic surgeons (N.H.R. and J.D.F.) were followed. The treatment group (n = 10) followed an ERAS protocol while the control group (n = 12) followed the traditional recovery after surgery which included narcotic usage. Patients were contacted on postoperative days (POD) 0 through 7+ and surveyed about a number of outcomes measures. Results The ERAS group demonstrated a significant reduction in postoperative pain on POD 0, 1, 2, and 3 (all P < 0.01). There was also statistically less nausea/vomiting, fatigue/drowsiness, constipation, and hindrance on ambulation compared to the control group (all P < 0.05). Significance was achieved for reduction in fatigue/drowsiness on POD 0 and 1 (P < 0.01), as well as ability to ambulate on POD 0 and 3 (P = 0.044). Lastly, opioid use (P < 0.001) and constipation (P = 0.003) were decreased. Conclusions ERAS protocols have demonstrated their importance within multiple surgical fields, including cosmetic plastic surgery. The utility lies in the ability to expedite patient’s recovery while still providing quality care. This study showed a reduction in postoperative complaints by avoiding narcotics without an increase in complications. Our findings signify the importance of ERAS protocols within cosmetic plastic surgery. Level of Evidence: 4 The concept of enhanced recovery after surgery (ERAS) was developed in 1997, by a colorectal surgeon in Denmark, in order to expedite a patient’s recovery by reducing the profound physiologic stress response of surgery.1 It incorporates a multimodal and multidisciplinary approach to perioperative care.2 Its utility within multiple surgical fields has been established in the literature and has since been published in a broad array of subspecialties such as colorectal, vascular, hepatobiliary, thoracic, as well as urology and gynecology3-8 ERAS protocols began to emerge in the plastic surgery literature in 2014 as a tool for abdominal wall reconstruction.9 It has since been studied within microvascular and implant based breast reconstructions.10,11 Unfortunately, there remains very little in the literature for their use in cosmetic plastic surgery. A variety of such protocols exists, but the main elements include preoperative counseling, maximization of nutrition, standardized anesthetic and analgesia regimens, and early mobilization.2 Successful implementation of these protocols has translated into a decrease in hospital stay, complications, and high patient satisfaction.11,12 With healthcare costs rising, there has been pressure to reduce the length of hospital stays while improving the patient experience concomitantly.13 Additionally, the ongoing “opioid epidemic” has urged the political environment, medical associations, and healthcare providers across the nation to focus on minimizing narcotic consumption in order to prevent any of their detrimental adverse events.14,15 ERAS protocols have demonstrated reduction of healthcare expenditures while improving overall patient satisfaction.16 Multimodal pain management protocols can also decrease narcotic consumption with some protocols avoiding narcotic use completely.16,17 This can reduce the potential for postoperative complications from narcotics, specifically sedation or addiction. At our institution, the senior author (N.H.R.) has formulated a narcotic-sparing ERAS protocol within his cosmetic plastic surgery practice, which has been in use for over 7 years. In order to determine its utility and impact within cosmetic patients, a comparative prospective study was designed to evaluate outcomes at sequential postoperative days. Results were analyzed and compared to a cohort who followed the “traditional recovery after surgery” which utilized postoperative narcotics. In addition, our multimodal protocol will be assessed with a review of pharmacology and their side effect profiles. METHODS Patients Consecutive cosmetic plastic surgery patients from two board certified plastic surgeons (N.H.R. and J.D.F.) at our institution were prospectively followed from May to August of 2016. One surgeon (N.H.R.) exclusively applied the ERAS protocol on all his patients while the other one (J.D.F.) managed his patients using traditional recovery, which included postoperative narcotic consumption. Any patient undergoing cosmetic surgery with N.H.R. was assigned to the ERAS study arm while all of J.D.F.’s patients were part of the control arm. Ultimately, a total of 22 patients were enrolled: 10 in the ERAS protocol, 12 within the control group. Protocol Our ERAS protocol follows the general guidelines laid out by the ERAS Society.18 These include preoperative counseling, optimization of nutrition, standardized analgesic, and anesthetic regimens and early mobilization. Every patient is seen for an initial consultation and a preoperative visit. The surgical procedures, medications to be utilized, and the expected postoperative course is discussed in detail. Patient expectations are inquired and set appropriately by the surgeon, in person. The control group underwent an initial consultation which was routine care per that author (J.D.F). There were no changes in surgical care or counseling of any patients with inclusion in this observational study. The night before and on the morning of surgery, celecoxib, gabapentin, and ondasetron are preloaded. Intravenous (IV) dexamethasone and a promethazine suppository are given after the induction of anesthesia with weight-adjusted fentanyl and propofol. Intraoperative single-dose antibiotics and sequential compression devices are applied. Liposomal Bupivacaine is injected beneath the fascia over the rectus sheath in abdominoplasty procedures. Regular Bupivicaine is used as a local block or placed into the surgical pocket for all other procedures including breast surgery. IV acetaminophen is administered at the end of the case, prior to extubation. Gabapentin is given in the postanesthesia care unit (PACU) prior to discharge home or the end of the 23 hour hospital stay. Postoperatively, celecoxib and gabapentin are given on a scheduled basis for 3 to 5 days. A methylprednisolone dose pack is also given. The patients are furthermore instructed to utilize acetaminophen for any postoperative breakthrough discomfort. The pharmacological components of the study protocol are delineated in Tables 1 and 2.19 Price estimates for the administered and prescribed drugs are listed in Table 3. In contrast, the control group had no standardized medication protocol other than narcotics as needed for postoperative pain control. Table 1. Pharmacological Review (alphabetically)* Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. i.v., intravenously; p.o., per os; q, “every”. *Data Source: Truven Health Analytics. MICROMEDEX Solutions (Pharmacological Library). http://www.micromedexsolutions.com/micromedex2/librarian/. Accessed June 15, 2017. **Most common ones selected View Large Table 1. Pharmacological Review (alphabetically)* Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. i.v., intravenously; p.o., per os; q, “every”. *Data Source: Truven Health Analytics. MICROMEDEX Solutions (Pharmacological Library). http://www.micromedexsolutions.com/micromedex2/librarian/. Accessed June 15, 2017. **Most common ones selected View Large Table 2. Medication Timing in ERAS Group Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) ERAS, enhanced recovery after surgery; PACU, postanesthesia care unit; POD, postoperative days; q = “every”. View Large Table 2. Medication Timing in ERAS Group Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) ERAS, enhanced recovery after surgery; PACU, postanesthesia care unit; POD, postoperative days; q = “every”. View Large Table 3. Cost Estimates Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) *All estimates are made conservatively, do not include coupons, and are likely on the higher end of the price spectrum. View Large Table 3. Cost Estimates Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) *All estimates are made conservatively, do not include coupons, and are likely on the higher end of the price spectrum. View Large Study Design and Follow-Up The study was approved by the Institutional Review Board of the Houston Methodist Research Institute (IRB, protocol number 00014845). All patients signed informed consent at their preoperative visit. There were no changes in perioperative management in the control group from the surgeon’s typical routine. Perioperative nursing as well as anesthesia staff were all counseled on the ERAS study in order to ensure adherence to the protocol. A one night stay was included in the cosmetic surgery package, which is standardized at our institution, regardless of what procedure is performed. The decision to discharge or stay was not necessarily related to the surgical procedure. Patients were contacted on postoperative days (POD) 0, 1, 2, 3, 5, 7+, and asked a short series of 5 to 7 questions about their recovery (Appendix A, available online as Supplementary Material at www.aestheticsurgeryjournal.com) by the study coordinator (E.L.B.). POD 0 was defined as within 24 hours of the surgical procedure, POD 1 was defined as 24 to 48 hours after the surgical procedure, and so on. Timing of calls were standardized to the afternoon with the exception of POD 0 which was in the evening. Questions included level of discomfort on the visual analogue scale (VAS), nausea/vomiting, ability to ambulate, patient concern about discharge home, fatigue/drowsiness, and constipation. Results were given as a 0 to 10 Likert scale for VAS, and closed yes/no questions for the remaining variables. Statistics Demographic and surgical details were evaluated for all patients enrolled in this study. Next, univariate analysis compared the two cohorts for their preoperative characteristics and postoperative patient-reported outcomes. The statistical level of significance was set at 5% (P < 0.05) for all analyses using the unpaired sample t test for continuous and the chi-square test for categorical variables. All calculations were conducted using SPSS version 24.0 (IBM Corp., Armonk, NY). RESULTS Demographics and Surgical Management Ten patients were enrolled in the ERAS and twelve in the control arm of our clinical trial. All patients were of female gender due to the nature of this cosmetic population and the procedures performed. Mean age and body mass index (BMI) were 43.1 ± 12.1 years (range, 26-59 years) and 25.3 ± 3.0 kg/m2 (range, 22.0-29.4 kg/m2), respectively, in the study group. On average, control patients were 48.3 ± 19.1 years old (range, 17-75 years) and had a BMI of 24.9 ± 4.9 kg/m2 (range, 19.7-36.3 kg/m2). Overall, there were no significant differences between both groups in terms of their demographic characteristics (Table 4). Table 4. Demographic Characteristics Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 BMI, body mass index; ERAS, enhanced recovery after surgery; SD, standard deviation. View Large Table 4. Demographic Characteristics Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 BMI, body mass index; ERAS, enhanced recovery after surgery; SD, standard deviation. View Large With regards to the surgical management of the patients participating in this study, no statistical differences were observed between both cohorts. The patients underwent a multitude of cosmetic operations, all under general anesthesia, ranging from breast surgeries to trunk and facial procedures. A large proportion received two or more procedures concomitantly. Anesthesia induction was performed following the same protocol with fentanyl as analgesic and propofol as hypnotic agent - both drugs were administered weight-adjusted by our anesthesiology colleagues. No significant differences were observed in their dosing. In the control group, 1/12 patients received Bupivicaine, compared with 7/10 patients in the ERAS group. The remaining 3/10 patients in the ERAS group received Liposomal Bupivicaine (P < 0.001*). When Liposomal Bupivicaine was used it was mixed with saline. All long acting anesthetics were infiltrated locally. No regional blocks were performed. Operative time, too, was similar for both study groups: 227 ± 102 minutes (range, 63-355 minutes) for ERAS and 260 ± 95 minutes (range, 82-413 minutes) for control patients. All patients in the ERAS group (100.0%) were operated on in the outpatient setting defined as a stay of up to 23 h while 91.7% of patients in the reference group were treated on inpatient basis (P < 0.001). Duration of stay was significantly shorter in the former group with 0.6 ± 0.5 days (range, 0-1 days) compared to control patients averaging 1.2 ± 0.6 days (range, 0-2 days) (P = 0.026, Table 5). Table 5. Surgical Details Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* ERAS, enhanced recovery after surgery; SD, standard deviation. *Procedure count higher than patient count due to multiple simultaneous procedures **P < 0.05 View Large Table 5. Surgical Details Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* ERAS, enhanced recovery after surgery; SD, standard deviation. *Procedure count higher than patient count due to multiple simultaneous procedures **P < 0.05 View Large No complications, either in terms of surgical events or medication side effects, occurred within our standard follow-up period of 2 weeks when patients would be seen in clinic for their postoperative visit (Table 6). Table 6. Follow Up and Adverse Events Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — ERAS, enhanced recovery after surgery. Standardized follow-up period of 2 weeks View Large Table 6. Follow Up and Adverse Events Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — ERAS, enhanced recovery after surgery. Standardized follow-up period of 2 weeks View Large Questionnaire Survey Following the cosmetic procedure, patients in the ERAS protocol reported significantly lower pain levels on a 0 to 10 visual pain scale for POD 0 through 3 (P < 0.01). Only on POD 5 of our study, both groups had similarly low levels of pain (Figure 1A). Additionally, patients in the ERAS group indicated a significantly more favorable pain experience to our study physician; 90% had less pain as they originally expected before surgery compared to only 25% in the control group (P = 0.009, Figure 1B). Nausea and/or vomiting were significantly less common on POD 1 and POD 2 in the ERAS cohort. These patients only experienced such discomfort immediately after their operation (POD 0) in 20% of cases and were completely free of symptoms afterwards. Due to the power of our study, the formidable differences did not read statistical significance on POD 0, POD 3, and POD 5 (Figure 2). Feeling of fatigue or drowsiness were reported by 83% of control patients on POD 0 and 50% on POD 1. No patient in our ERAS group experienced such symptoms (0%) leading to a significantly better outcome for both days (P < 0.01, Figure 3). In the same vein, no patient (0%) in the ERAS group reported inability to ambulate due to pain on any of the postoperative days. In contrast, 17% to 33% of control patients reported such discomfort depending on the day of follow up. These disparities reached significance for POD 0 and POD 3 (P < 0.05, Figure 4). Furthermore, patients undergoing cosmetic surgery and following the ERAS protocol required significantly less narcotics in the PACU (P < 0.001), were less likely to show reluctance to be discharged (P = 0.009), and to experience constipation (P = 0.003). Reluctance to be discharged was based on the level of concern regarding the transition to home on POD 0, regardless to whether patients were staying in house or not. Postoperative narcotic use was not compared to the experimental group as one dose of tramadol was given to one patient in the ERAS group and none further. No statistical disparities were found in terms of whether or not our patients would like to undergo the same surgery again; 90% of our ERAS cohort agreed that the additional costs of medication were worth the benefit (Table 7). Table 7. Additional Outcome Measures from Questionnaires Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — ERAS, enhanced recovery after surgery. *P < 0.05 **Administered in PACU for breakthrough pain; no further opioids needed after gabapentin initiation View Large Table 7. Additional Outcome Measures from Questionnaires Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — ERAS, enhanced recovery after surgery. *P < 0.05 **Administered in PACU for breakthrough pain; no further opioids needed after gabapentin initiation View Large Figure 1. View largeDownload slide (A) Postoperative pain scores on visual 0-10 scale. POD 0: P = 0.001*; POD 1: P < 0.001*; POD 2: P < 0.001*; POD 3: P = 0.002*; POD 5: P = 0.093; POD 7+: P = 0.156. (B) Response to the question, “Was the postoperative pain more than, less than, or just as expected?” P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 1. View largeDownload slide (A) Postoperative pain scores on visual 0-10 scale. POD 0: P = 0.001*; POD 1: P < 0.001*; POD 2: P < 0.001*; POD 3: P = 0.002*; POD 5: P = 0.093; POD 7+: P = 0.156. (B) Response to the question, “Was the postoperative pain more than, less than, or just as expected?” P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 2. View largeDownload slide Nausea/vomiting. POD 0: P = 0.069; POD 1: P = 0.044*; POD 2: P = 0.044*; POD 3: P = 0.105; POD 5: P = 0.198. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 2. View largeDownload slide Nausea/vomiting. POD 0: P = 0.069; POD 1: P = 0.044*; POD 2: P = 0.044*; POD 3: P = 0.105; POD 5: P = 0.198. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 3. View largeDownload slide Fatigue/drowsiness. POD 0: P < 0.001*; POD 1: P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 3. View largeDownload slide Fatigue/drowsiness. POD 0: P < 0.001*; POD 1: P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 4. View largeDownload slide Inhibition of ambulation. POD 0: P = 0.044*; POD 1: P = 0.176; POD 2: P = 0.089; POD 3: P = 0.044*; POD 5: P = N/A. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 4. View largeDownload slide Inhibition of ambulation. POD 0: P = 0.044*; POD 1: P = 0.176; POD 2: P = 0.089; POD 3: P = 0.044*; POD 5: P = N/A. All P values marked with an asterisk show statistical significance with P < 0.05. DISCUSSION Since its introduction into the colorectal literature in 1997, ERAS protocols have been expanding to multiple surgical specialties.3-8 Superior outcomes have been demonstrated including shorter length of hospital stay, decreased healthcare expenditure, and high overall patient satisfaction without affecting overall complication rates.13 Since its introduction within the plastic surgery specialty in 2013, a series of articles have been published in abdominal wall reconstruction, microvascular breast reconstruction, and, most recently, implant based reconstruction. Davidge et al were the first to publish a series of patients undergoing autologous breast reconstruction with pedicle transverse rectus abdominus myocutaneous (TRAM) flaps. Although the article does not describe their protocol in relation to ERAS, but rather “processes of care,” they follow the principles described by the ERAS Society and showed a progressive reduction in hospital stay with improved protocol compliance.20 Fayezizadeh et al were the first within the plastic surgery literature, in 2014, to describe their ERAS protocol and the rationale behind each of the elements.9 This article did not follow any cohort of patients thus no measureable outcome could be studied. In 2015, Batdorf et al then described their ERAS protocol with a retrospective cohort analysis of patients undergoing microvascular breast reconstruction. Hospital length of stay was shorter, morphine requirements were decreased, and time to ambulation was reduced in the ERAS cohort without any effect on complication profile.10 Then in 2017, Dumestre’s research team published their ERAS protocol as a partial prospective series evaluating patients undergoing implant based breast reconstruction. ERAS patients were discharged home on POD 0. They had less pain, nausea, felt better rested without any effect on complications or number of emergency room visits.11 Also in 2017, Afonso et al published an article describing their ERAS protocol within microvascular breast reconstruction. Their study showed a decrease in opioid requirement and hospital length of stay.21 These articles demonstrate the utility of ERAS protocols in the field of plastic surgery. However, there remains a void in the literature for their use in cosmetic plastic surgery. With rising healthcare costs, there is pressure to transition to outpatient type procedures to reduce hospital costs. Cash paying cosmetic patients also demand competitive fee for service procedures which require appropriate allocation of resources. In addition, in this current era of online physician reviews and social media, patient satisfaction is paramount to having a successful cosmetic practice. All in all, cosmetic plastic surgery patients make an ideal target population for ERAS protocols. ERAS protocols have been slow to be embraced within plastic surgery, especially at our institution. The protocol has been formulated by the senior author (N.H.R.) with good success in his clinical practice. It is hard to initiate change in any well-established practice thus this pioneer study was designed to show the utility of our ERAS protocol in a cosmetic surgery patient population. In this small prospective study of 22 patients, the application of our ERAS protocol translated to a decrease in postoperative pain, nausea and vomiting, decrease fatigue/drowsiness, less inhibition of ambulation, less concern over discharge, and less constipation. Although the sample size is small, there is promising data for use of ERAS protocols within this population. A number of outcome measures demonstrated statistically significant differences between the cohorts, which can be further substantiated when larger studies will be conducted. This ERAS protocol has been designed and improved based on the needs of our patients. The first and most important factor in any ERAS protocol is adequate counseling. The patients need to understand what the surgery entails and what the medications are used for. Expectations should be set and clear from the beginning. We do not use the word pain, but rather, discomfort as pain has a rather negative connotation. Patients are optimized in terms of nutrition in our practice by encouraging a healthy weight and eating habits. It is known that obese patients have a higher complication profile thus these patients are encouraged to be within their goal weight range prior to undergoing any elective procedure.22 Patients understand the nature of an outpatient surgery and are anticipated to ambulate on POD 0. When this expectation is set forth preoperatively and its significance explained, our experience has shown that patients are more likely to comply. The medication protocol has been in use for 7 years and has evolved based on our patient needs. This protocol is narcotic sparing, which is beneficial given the social, medical, and economic impact of narcotic abuse in the United States. Published in the Wall Street Journal, middle-aged Americans accounted for 44% of overdoses - an age bracket similar to that of our study participants. These medications have been overused and have led to chronic dependence and accidental death.14 This national epidemic has caught the attention of the nonmedical mainstream media which has translated to a heightened public awareness. The thought of avoiding narcotics altogether initially may sound unreasonable in the setting of cosmetic surgery, however, based on the results of this study it is clear that narcotics are not absolutely necessary.15 Many different medications protocols have been published but, in our opinion, the protocol presented in this report is advantageous due to the preloading effect and combination of multimodal therapy. Two doses of celecoxib and gabapentin are given prior to surgery: one the day prior to the surgical date and the second the morning of. This preloading is known as preemptive analgesia and is thought to prevent sensitization of central nervous system.23 The same applies to nausea with the antiemetic, ondansetron. If the patient has a history of motion sickness or is undergoing a forehead surgery, a scopolamine patch is used to act synergistically with ondansetron. After the induction of anesthesia, dexamethasone, and a promethazine suppository are given. Steroids decrease inflammation and contribute to pain reduction as well as nausea. They again act synergistically with other antiemetics and may even augment their efficacy.24 Promethazine acts, again synergistically, with ondansetron. A long-acting local anesthetic is always used during a surgical procedure. The senior author (N.H.R.) uses a long acting local anesthetic for each of his surgical procedures. All breast and upper extremity cases receive Bupivicaine and abdominal cases receive Liposomal Bupivicaine. Liposomal Bupivacaine (Exparel) has been shown to decrease postoperative narcotic requirements by many studies.25 These are injected at the end of the procedure as a local block in this study, however, a regional block could be performed as well for more complete coverage. IV acetaminophen is given prior to the cessation of the procedure because of its quick onset of action and also has been shown to decrease narcotic requirements.26,27 Gabapentin is given in the PACU prior to discharge home or one night stay. We found that after the initiation of gabapentin in the PACU, postoperative pain was significantly decreased. One patient in the study group required one dose of tramadol for breakthrough pain but once gabapentin was administered in the PACU, no additional breakthrough tramadol was needed. The mechanism of action of gabapentin is unknown however there is no question that it is efficacious as it has been shown to decrease the amount to narcotics needed to control postoperative pain.28 Celecoxib and gabapentin are given on a scheduled basis for 3 to 5 days postoperatively. Celecoxib is another powerful adjunct for controlling postoperative pain and it has not been shown to increase postoperative bleeding in this cohort or other patient populations studied in the literature.29 A methylprednisolone dose pack is given for patients without significant medical comorbidities, such as uncontrolled diabetes, as, in our experience, it contributes to pain reduction and may protect against sensitivity to medications.30 Steroids have known side effects such as glucose intolerance and insulin resistance; however, our patient population had a normal BMI without significant comorbidities. Short-term steroid31 use did not show any adverse effects on this patient population. Oral acetaminophen is used for intermittent discomfort but is not scheduled. Many of the medications used have mechanisms of action that are not well understood. Tables 1 and 2 list the theorized mechanism of action for the medications in the protocol and their side effect profiles.19 Despite the multitude of potential adverse reactions known in medical literature, none of our patients experienced any side effects. We contribute this to limited short-term use and safe dosing schedule. There is an additional cost related to the use of medications in the ERAS protocol. Although 90% of patients reported that the additional cost of medications was “worth it,” cost reduction is an important factor in cosmetic plastic surgery. With larger sample sizes, it may be more evident that the maximal efficacy is reached at a shorter time frame, thus limiting the amount to medications required. Reviewing the data in this study, it appears that maximum benefit is received for pain reduction by POD 3. Further treatment beyond this period may not be necessary as statistical significance was not reached after this time. This would drive down costs of medications as a result which is a drawback of the protocol. Additionally, less costly medications or generics could be evaluated as substitutions for some of the more expensive pharmaceuticals such as celecoxib. Ibuprofen is another anti-inflammatory medication commonly used for pain control. It is a nonselective cyclooxygenase (COX) inhibitor which has potential risk of gastrointestinal upset and platelet inhibition. The more selective COX-2 inhibitor, celecoxib, was chosen to mitigate these side effects, however, the utility of this medication in the protocol should be investigated. Being a pilot project in plastic surgery with initially unknown findings, this observational study was limited to the small sample size mandated by the IRB. In order to gain a better understanding of clinically significant outcomes, larger sample sizes are indeed needed. Therefore, we merely compared two cohorts of two different surgeons and did not modify routine care whatsoever. Detailed cost analysis of the ERAS medications (Table 3) were not performed since pricing may vary between institutions, geographical regions in the United States, or even between pharmacies. Completely matching procedures, surgical techniques, and only evaluating a single surgeon’s procedures would naturally allow for a better comparison between the groups as the results would be more likely related to medication effects. Blinding the individual contacting the patients could also limit any potential bias that was introduced by knowing which arm of the study patients are in. For these reasons, the study patients were aware about their enrollment in the ERAS group and thus, prone to the Hawthorne effect.32 Knowing that they were to receive additional treatment and enhanced recovery may have influenced their responses. Lastly, using a validated ERAS questionnaire instead of our self-designed one would strengthen our positive findings. Patients in the ERAS group experienced significantly less postoperative pain, nausea, and vomiting when compared with the control group without any effect on complication rates. Although the sample size is small, we can show that this is related to the multimodal approach and effects of preloading medications, given the prospective comparative study design. A similar clinical trial evaluating the impact of ERAS in a plastic surgery cohort undergoing cosmetic procedures has not been published to date and our report therefore has a pioneer function. CONCLUSION The results of our prospective study demonstrate that performing elective cosmetic procedures following the ERAS protocol leads to numerous improvements for our patients. Significantly decreased duration to discharge, lower postoperative pain, less nausea, vomiting, fatigue, and drowsiness were shown in addition to statistically lower opioid use and constipation without creating complications. This equates to enhanced safety and obviates narcotic use. We are hopeful that our perioperative management will be beneficial to others and that randomized controlled trials will validate our protocol. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. 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Is enhanced recovery the new standard of care in microsurgical breast reconstruction ? Plast Reconstr Surg . 2017 ; 139 ( 5 ): 1053 - 1061 . Google Scholar CrossRef Search ADS PubMed 22. Agha-Mohammadi S , Hurwitz DJ . Enhanced recovery after body-contouring surgery: reducing surgical complication rates by optimizing nutrition . Aesthetic Plast Surg . 2010 ; 34 ( 5 ): 617 - 625 . Google Scholar CrossRef Search ADS PubMed 23. Arsalani-Zadeh R , ElFadl D , Yassin N , MacFie J . Evidence-based review of enhancing postoperative recovery after breast surgery . Br J Surg . 2011 ; 98 ( 2 ): 181 - 196 . Google Scholar CrossRef Search ADS PubMed 24. Gupta P , Jain S . Postoperative nausea and vomiting prophylaxis: A comparative study of ondansetron, granisetron and granisetron and dexamethasone combination after modified radical mastectomy . Saudi J Anaesth . 2014 ; 8 ( Suppl 1 ): S67 - S71 . Google Scholar PubMed 25. Wick EC , Grant MC , Wu CL . Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review . JAMA Surg . 2017 ; 152 ( 7 ): 691 - 697 . Google Scholar CrossRef Search ADS PubMed 26. Singla NK , Hale ME , Davis JC et al. IV acetaminophen: Efficacy of a single dose for postoperative pain after hip arthroplasty: subset data analysis of 2 unpublished randomized clinical trials . Am J Ther . 2015 ; 22 ( 1 ): 2 - 10 . Google Scholar CrossRef Search ADS PubMed 27. Hansen RN , Pham AT , Böing EA , Lovelace B , Wan GJ , Miller TE . Comparative analysis of length of stay, hospitalization costs, opioid use, and discharge status among spine surgery patients with postoperative pain management including intravenous versus oral acetaminophen . Curr Med Res Opin . 2017 ; 33 ( 5 ): 943 - 948 . Google Scholar CrossRef Search ADS PubMed 28. Peng C , Li C , Qu J , Wu D . Gabapentin can decrease acute pain and morphine consumption in spinal surgery patients: A meta-analysis of randomized controlled trials . Medicine (Baltimore) . 2017 ; 96 ( 15 ): e6463 . Google Scholar CrossRef Search ADS PubMed 29. Hokuto D , Nomi T , Kawaguchi C et al. The administration of celecoxib as an analgesic after liver resection is safe . Dig Surg . 2017 ; 34 ( 2 ): 108 - 113 . Google Scholar CrossRef Search ADS PubMed 30. Delaney A , Carter A , Fisher M . The prevention of anaphylactoid reactions to iodinated radiological contrast media: a systematic review . BMC Med Imaging . 2006 ; 6 : 2 . Google Scholar CrossRef Search ADS PubMed 31. Buchman AL . Side effects of corticosteroid therapy . J Clin Gastroenterol . 2001 ; 33 ( 4 ): 289 - 294 . Google Scholar CrossRef Search ADS PubMed 32. McCambridge J , Witton J , Elbourne DR . Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects . J Clin Epidemiol . 2014 ; 67 ( 3 ): 267 - 277 . Google Scholar CrossRef Search ADS PubMed © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift

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Oxford University Press
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© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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1090-820X
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1527-330X
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10.1093/asj/sjx217
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Abstract

Abstract Background With a focus on providing high quality care and reducing facility based expenses there has been an evolution in perioperative care by way of enhanced recovery after surgery (ERAS). ERAS allows for a multidisciplinary and multimodal approach to perioperative care which not only expedites recovery but maximizes patient outcomes. This paradigm shift has been generally accepted by most surgical specialties, including plastic surgery. Objectives The goal of this study was to evaluate the impact of ERAS on outcomes in cosmetic plastic surgery. Methods A prospective study consisting of phone call questionnaires was designed where patients from two senior plastic surgeons (N.H.R. and J.D.F.) were followed. The treatment group (n = 10) followed an ERAS protocol while the control group (n = 12) followed the traditional recovery after surgery which included narcotic usage. Patients were contacted on postoperative days (POD) 0 through 7+ and surveyed about a number of outcomes measures. Results The ERAS group demonstrated a significant reduction in postoperative pain on POD 0, 1, 2, and 3 (all P < 0.01). There was also statistically less nausea/vomiting, fatigue/drowsiness, constipation, and hindrance on ambulation compared to the control group (all P < 0.05). Significance was achieved for reduction in fatigue/drowsiness on POD 0 and 1 (P < 0.01), as well as ability to ambulate on POD 0 and 3 (P = 0.044). Lastly, opioid use (P < 0.001) and constipation (P = 0.003) were decreased. Conclusions ERAS protocols have demonstrated their importance within multiple surgical fields, including cosmetic plastic surgery. The utility lies in the ability to expedite patient’s recovery while still providing quality care. This study showed a reduction in postoperative complaints by avoiding narcotics without an increase in complications. Our findings signify the importance of ERAS protocols within cosmetic plastic surgery. Level of Evidence: 4 The concept of enhanced recovery after surgery (ERAS) was developed in 1997, by a colorectal surgeon in Denmark, in order to expedite a patient’s recovery by reducing the profound physiologic stress response of surgery.1 It incorporates a multimodal and multidisciplinary approach to perioperative care.2 Its utility within multiple surgical fields has been established in the literature and has since been published in a broad array of subspecialties such as colorectal, vascular, hepatobiliary, thoracic, as well as urology and gynecology3-8 ERAS protocols began to emerge in the plastic surgery literature in 2014 as a tool for abdominal wall reconstruction.9 It has since been studied within microvascular and implant based breast reconstructions.10,11 Unfortunately, there remains very little in the literature for their use in cosmetic plastic surgery. A variety of such protocols exists, but the main elements include preoperative counseling, maximization of nutrition, standardized anesthetic and analgesia regimens, and early mobilization.2 Successful implementation of these protocols has translated into a decrease in hospital stay, complications, and high patient satisfaction.11,12 With healthcare costs rising, there has been pressure to reduce the length of hospital stays while improving the patient experience concomitantly.13 Additionally, the ongoing “opioid epidemic” has urged the political environment, medical associations, and healthcare providers across the nation to focus on minimizing narcotic consumption in order to prevent any of their detrimental adverse events.14,15 ERAS protocols have demonstrated reduction of healthcare expenditures while improving overall patient satisfaction.16 Multimodal pain management protocols can also decrease narcotic consumption with some protocols avoiding narcotic use completely.16,17 This can reduce the potential for postoperative complications from narcotics, specifically sedation or addiction. At our institution, the senior author (N.H.R.) has formulated a narcotic-sparing ERAS protocol within his cosmetic plastic surgery practice, which has been in use for over 7 years. In order to determine its utility and impact within cosmetic patients, a comparative prospective study was designed to evaluate outcomes at sequential postoperative days. Results were analyzed and compared to a cohort who followed the “traditional recovery after surgery” which utilized postoperative narcotics. In addition, our multimodal protocol will be assessed with a review of pharmacology and their side effect profiles. METHODS Patients Consecutive cosmetic plastic surgery patients from two board certified plastic surgeons (N.H.R. and J.D.F.) at our institution were prospectively followed from May to August of 2016. One surgeon (N.H.R.) exclusively applied the ERAS protocol on all his patients while the other one (J.D.F.) managed his patients using traditional recovery, which included postoperative narcotic consumption. Any patient undergoing cosmetic surgery with N.H.R. was assigned to the ERAS study arm while all of J.D.F.’s patients were part of the control arm. Ultimately, a total of 22 patients were enrolled: 10 in the ERAS protocol, 12 within the control group. Protocol Our ERAS protocol follows the general guidelines laid out by the ERAS Society.18 These include preoperative counseling, optimization of nutrition, standardized analgesic, and anesthetic regimens and early mobilization. Every patient is seen for an initial consultation and a preoperative visit. The surgical procedures, medications to be utilized, and the expected postoperative course is discussed in detail. Patient expectations are inquired and set appropriately by the surgeon, in person. The control group underwent an initial consultation which was routine care per that author (J.D.F). There were no changes in surgical care or counseling of any patients with inclusion in this observational study. The night before and on the morning of surgery, celecoxib, gabapentin, and ondasetron are preloaded. Intravenous (IV) dexamethasone and a promethazine suppository are given after the induction of anesthesia with weight-adjusted fentanyl and propofol. Intraoperative single-dose antibiotics and sequential compression devices are applied. Liposomal Bupivacaine is injected beneath the fascia over the rectus sheath in abdominoplasty procedures. Regular Bupivicaine is used as a local block or placed into the surgical pocket for all other procedures including breast surgery. IV acetaminophen is administered at the end of the case, prior to extubation. Gabapentin is given in the postanesthesia care unit (PACU) prior to discharge home or the end of the 23 hour hospital stay. Postoperatively, celecoxib and gabapentin are given on a scheduled basis for 3 to 5 days. A methylprednisolone dose pack is also given. The patients are furthermore instructed to utilize acetaminophen for any postoperative breakthrough discomfort. The pharmacological components of the study protocol are delineated in Tables 1 and 2.19 Price estimates for the administered and prescribed drugs are listed in Table 3. In contrast, the control group had no standardized medication protocol other than narcotics as needed for postoperative pain control. Table 1. Pharmacological Review (alphabetically)* Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. i.v., intravenously; p.o., per os; q, “every”. *Data Source: Truven Health Analytics. MICROMEDEX Solutions (Pharmacological Library). http://www.micromedexsolutions.com/micromedex2/librarian/. Accessed June 15, 2017. **Most common ones selected View Large Table 1. Pharmacological Review (alphabetically)* Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. Drug Brand name and manufacturer Drug category Mechanism of action Primary indication Potential adverse reactions** Dosing in study Acetaminophen Tylenol (Johnson & Johnson, New Brunswick, NJ) Analgesic Antipyretic Unclear Fever or pain Nausea, vomiting, skin reactions, liver failure 1000 mg i.v. 500 mg p.o. q 4 h Bupivacaine Marcaine (Pfizer, New York City, NY) Local/regional anesthetic Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Bupivacaine, liposome Exparel (Pacira Pharmaceuticals, San Diego, CA) Local/regional anesthetic, longer acting Na-channel antagonist Local infiltration Nerve blocks Epidural anesthesia Allergies, neurologic, cardiotoxic (intravascular injection) 0.25% or 0.5% solution for injection Celecoxib Celebrex (Pfizer, New York City, NY) NSAID Inhibition of Cyclooxygenase-2 Pain of various etiology Hypertension, diarrhea, nausea, headaches 200 to 400 mg p.o. Dexamethasone Decadron (Merck & Co, Kenilworth, NJ) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 8 mg p.o. Gabapentin Neurontin (Pfizer, New York City, NY) Gamma aminobutyric acid Anticonvulsant Unclear Various, predominantly neurologic disorders Dizziness, fatigue, drowsiness, ataxia, nystagmus, tremor 300 to 600 mg p.o. Methylprednisolone Medrol (Pfizer, New York City, NY) Glucocorticoid Intracellular glucocorticoid receptor agonist Various Hypertension, impaired wound healing, Cushing’s syndrome, osteoporosis 4 to 48 mg p.o. Ondansetron Zofran (GlaxoSmithKline, Brentford, UK) Antiemetic Selective serotonin5-HT3-receptor antagonist Nausea and vomiting due to chemotherapy or surgery Constipation, diarrhea, increased LFTs, headaches 8 mg p.o. Promethazine Phenergan (Baxter International, Deerfield, IL) Phenothiazine Antihistamine H1 receptor antagonist Pain, nausea, vomiting Sedation, tardive dyskinesia, confusion, xerostomia 25 mg suppository Scopolamine Transderm Scop (Novartis, Basel, Switzerland) Anticholinergic Muscarinic receptor antagonist Nausea and vomiting Mydriasis, glaucoma, somnolence, xerostomia One standard patch per 72 h Tramadol Ultram (Janssen Pharmaceutica, Beerse, Belgium) Centrally acting opioid μ-Opioid receptor agonist Pain Constipation, nausea, somnolence, dizziness, miosis 50 mg p.o. i.v., intravenously; p.o., per os; q, “every”. *Data Source: Truven Health Analytics. MICROMEDEX Solutions (Pharmacological Library). http://www.micromedexsolutions.com/micromedex2/librarian/. Accessed June 15, 2017. **Most common ones selected View Large Table 2. Medication Timing in ERAS Group Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) ERAS, enhanced recovery after surgery; PACU, postanesthesia care unit; POD, postoperative days; q = “every”. View Large Table 2. Medication Timing in ERAS Group Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) Time Medication Comments POD −1 Night before surgery Celecoxib — Gabapentin — Ondansetron — POD 0 Morning of surgery Celecoxib — Gabapentin — Ondansetron — Scopolamine Forehead surgery or history of motion sickness Induction of anesthesia Dexamethasone — Promethazine — Intraoperatively Acetaminophen At the end of the case Bupivacaine Into pocket or injected at surgical site PACU Gabapentin — POD 1 through POD 7+ Postoperatively Acetaminophen Q 4 h depending on pain Celecoxib 5-7 days Gabapentin 5-7 days Methylprednisolone 6 days Tramadol Backup for breakthrough pain, not required after starting gabapentin in PACU (ERAS cohort) ERAS, enhanced recovery after surgery; PACU, postanesthesia care unit; POD, postoperative days; q = “every”. View Large Table 3. Cost Estimates Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) *All estimates are made conservatively, do not include coupons, and are likely on the higher end of the price spectrum. View Large Table 3. Cost Estimates Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) Drug Price (in US dollars)* Acetaminophen $11.99 (20 × 500 mg) $39.73 (1 vial) Bupivacaine $3.39 (1 vial) Bupivacaine, liposome $285 (1 vial) Celecoxib $186.99 (30 × 200 mg) Dexamethasone $28.99 (30 × 2 mg) Gabapentin $63.59 (30 × 600 mg) Methylprednisolone $20.99 (21 × 4 mg) Ondansetron $52.99 (30 × 8 mg) Promethazine $25.29 (30 × 25 mg) Scopolamine $17.99 (1 patch) Tramadol $17.39 (30 × 50 mg) *All estimates are made conservatively, do not include coupons, and are likely on the higher end of the price spectrum. View Large Study Design and Follow-Up The study was approved by the Institutional Review Board of the Houston Methodist Research Institute (IRB, protocol number 00014845). All patients signed informed consent at their preoperative visit. There were no changes in perioperative management in the control group from the surgeon’s typical routine. Perioperative nursing as well as anesthesia staff were all counseled on the ERAS study in order to ensure adherence to the protocol. A one night stay was included in the cosmetic surgery package, which is standardized at our institution, regardless of what procedure is performed. The decision to discharge or stay was not necessarily related to the surgical procedure. Patients were contacted on postoperative days (POD) 0, 1, 2, 3, 5, 7+, and asked a short series of 5 to 7 questions about their recovery (Appendix A, available online as Supplementary Material at www.aestheticsurgeryjournal.com) by the study coordinator (E.L.B.). POD 0 was defined as within 24 hours of the surgical procedure, POD 1 was defined as 24 to 48 hours after the surgical procedure, and so on. Timing of calls were standardized to the afternoon with the exception of POD 0 which was in the evening. Questions included level of discomfort on the visual analogue scale (VAS), nausea/vomiting, ability to ambulate, patient concern about discharge home, fatigue/drowsiness, and constipation. Results were given as a 0 to 10 Likert scale for VAS, and closed yes/no questions for the remaining variables. Statistics Demographic and surgical details were evaluated for all patients enrolled in this study. Next, univariate analysis compared the two cohorts for their preoperative characteristics and postoperative patient-reported outcomes. The statistical level of significance was set at 5% (P < 0.05) for all analyses using the unpaired sample t test for continuous and the chi-square test for categorical variables. All calculations were conducted using SPSS version 24.0 (IBM Corp., Armonk, NY). RESULTS Demographics and Surgical Management Ten patients were enrolled in the ERAS and twelve in the control arm of our clinical trial. All patients were of female gender due to the nature of this cosmetic population and the procedures performed. Mean age and body mass index (BMI) were 43.1 ± 12.1 years (range, 26-59 years) and 25.3 ± 3.0 kg/m2 (range, 22.0-29.4 kg/m2), respectively, in the study group. On average, control patients were 48.3 ± 19.1 years old (range, 17-75 years) and had a BMI of 24.9 ± 4.9 kg/m2 (range, 19.7-36.3 kg/m2). Overall, there were no significant differences between both groups in terms of their demographic characteristics (Table 4). Table 4. Demographic Characteristics Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 BMI, body mass index; ERAS, enhanced recovery after surgery; SD, standard deviation. View Large Table 4. Demographic Characteristics Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Gender -  Female 10 (100.0) 12 (100.0) Ethnicity 0.115  White 6 (60.0) 11 (91.7)  Black 1 (10.0) 1 (8.3)  Hispanic 3 (30.0) 0 (0.0) Age, years (mean ± SD, range) 43.1 ± 12.1, 26-59 48.3 ± 19.1, 17-75 0.541 BMI, kg/m2 (mean ± SD, range) 25.3 ± 3.0, 22.0-29.4 24.9 ± 4.9, 19.7-36.3 0.799 BMI, body mass index; ERAS, enhanced recovery after surgery; SD, standard deviation. View Large With regards to the surgical management of the patients participating in this study, no statistical differences were observed between both cohorts. The patients underwent a multitude of cosmetic operations, all under general anesthesia, ranging from breast surgeries to trunk and facial procedures. A large proportion received two or more procedures concomitantly. Anesthesia induction was performed following the same protocol with fentanyl as analgesic and propofol as hypnotic agent - both drugs were administered weight-adjusted by our anesthesiology colleagues. No significant differences were observed in their dosing. In the control group, 1/12 patients received Bupivicaine, compared with 7/10 patients in the ERAS group. The remaining 3/10 patients in the ERAS group received Liposomal Bupivicaine (P < 0.001*). When Liposomal Bupivicaine was used it was mixed with saline. All long acting anesthetics were infiltrated locally. No regional blocks were performed. Operative time, too, was similar for both study groups: 227 ± 102 minutes (range, 63-355 minutes) for ERAS and 260 ± 95 minutes (range, 82-413 minutes) for control patients. All patients in the ERAS group (100.0%) were operated on in the outpatient setting defined as a stay of up to 23 h while 91.7% of patients in the reference group were treated on inpatient basis (P < 0.001). Duration of stay was significantly shorter in the former group with 0.6 ± 0.5 days (range, 0-1 days) compared to control patients averaging 1.2 ± 0.6 days (range, 0-2 days) (P = 0.026, Table 5). Table 5. Surgical Details Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* ERAS, enhanced recovery after surgery; SD, standard deviation. *Procedure count higher than patient count due to multiple simultaneous procedures **P < 0.05 View Large Table 5. Surgical Details Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Procedure types* 0.905  Breast augmentation 3 (30.0) 2 (16.7) —  Breast reduction 3 (30.0) 5 (41.7) —  Breast mastopexy 1 (10.0) 3 (25.0) —  Breast capsulectomy 1 (10.0) 1 (8.3) —  Implant/TE exchange 1 (10.0) 1 (8.3) —  Abdominoplasty 3 (30.0) 2 (16.7) —  Brachioplasty 1 (10.0) 1 (8.3) —  Facelift 0 (0.0) 1 (8.3) —  Trunk liposuction 0 (0.0) 1 (8.3) — Anesthesia type  General anesthesia 10 (100.0) 12 (100.0) — Anesthesia induction  Fentanyl units (mean ± SD) 133 ± 63 180 ± 118 0.272  Propofol, mg (mean ± SD) 187 ± 33 203 ± 58 0.463 Scopolamine patch 5 (50.0) 7 (58.3) 0.696 Local anesthetic < 0.001*  Bupivacaine 7 (70.0) 1 (8.3) —  Bupivacaine, liposome 3 (30.0) 0 (0.0) — Operative time, min (mean ± SD, range) 227 ± 102 63-355 260 ± 95 82-413 0.443 Hospitalization < 0.001*  Outpatient (up to 23 h) 10 (100.0) 1 (8.3) —  Inpatient 0 (0.0) 11 (91.7) — Hospitalization duration, days (mean ± SD, range) 0.6 ± 0.5 0-1 1.2 ± 0.6 0-2 0.026* ERAS, enhanced recovery after surgery; SD, standard deviation. *Procedure count higher than patient count due to multiple simultaneous procedures **P < 0.05 View Large No complications, either in terms of surgical events or medication side effects, occurred within our standard follow-up period of 2 weeks when patients would be seen in clinic for their postoperative visit (Table 6). Table 6. Follow Up and Adverse Events Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — ERAS, enhanced recovery after surgery. Standardized follow-up period of 2 weeks View Large Table 6. Follow Up and Adverse Events Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — Variable ERAS group Control group P value Patients, % of total (N = 10) Patients, % of total (N = 12) Related to surgery (infection, bleeding, deep vein thrombosis, etc.) 0 0 — Adverse effects of medication 0 0 — ERAS, enhanced recovery after surgery. Standardized follow-up period of 2 weeks View Large Questionnaire Survey Following the cosmetic procedure, patients in the ERAS protocol reported significantly lower pain levels on a 0 to 10 visual pain scale for POD 0 through 3 (P < 0.01). Only on POD 5 of our study, both groups had similarly low levels of pain (Figure 1A). Additionally, patients in the ERAS group indicated a significantly more favorable pain experience to our study physician; 90% had less pain as they originally expected before surgery compared to only 25% in the control group (P = 0.009, Figure 1B). Nausea and/or vomiting were significantly less common on POD 1 and POD 2 in the ERAS cohort. These patients only experienced such discomfort immediately after their operation (POD 0) in 20% of cases and were completely free of symptoms afterwards. Due to the power of our study, the formidable differences did not read statistical significance on POD 0, POD 3, and POD 5 (Figure 2). Feeling of fatigue or drowsiness were reported by 83% of control patients on POD 0 and 50% on POD 1. No patient in our ERAS group experienced such symptoms (0%) leading to a significantly better outcome for both days (P < 0.01, Figure 3). In the same vein, no patient (0%) in the ERAS group reported inability to ambulate due to pain on any of the postoperative days. In contrast, 17% to 33% of control patients reported such discomfort depending on the day of follow up. These disparities reached significance for POD 0 and POD 3 (P < 0.05, Figure 4). Furthermore, patients undergoing cosmetic surgery and following the ERAS protocol required significantly less narcotics in the PACU (P < 0.001), were less likely to show reluctance to be discharged (P = 0.009), and to experience constipation (P = 0.003). Reluctance to be discharged was based on the level of concern regarding the transition to home on POD 0, regardless to whether patients were staying in house or not. Postoperative narcotic use was not compared to the experimental group as one dose of tramadol was given to one patient in the ERAS group and none further. No statistical disparities were found in terms of whether or not our patients would like to undergo the same surgery again; 90% of our ERAS cohort agreed that the additional costs of medication were worth the benefit (Table 7). Table 7. Additional Outcome Measures from Questionnaires Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — ERAS, enhanced recovery after surgery. *P < 0.05 **Administered in PACU for breakthrough pain; no further opioids needed after gabapentin initiation View Large Table 7. Additional Outcome Measures from Questionnaires Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — Variable ERAS group Control group P Value Patients, % of total (N = 10) Patients, % of total (N = 12) Opioids (Tramadol) use 1 (10.0)** 12 (100.0) < 0.001* Reluctance to be discharged 0 (0.0) 6 (50.0) 0.009* Constipation 0 (0.0) 7 (58.3) 0.003* Agreement with pre-written statements “Would undergo a similar procedure in the future.” 10 (100.0) 10 (83.3) 0.176 “The additional medication costs were worth it.” 9 (90.0) — — ERAS, enhanced recovery after surgery. *P < 0.05 **Administered in PACU for breakthrough pain; no further opioids needed after gabapentin initiation View Large Figure 1. View largeDownload slide (A) Postoperative pain scores on visual 0-10 scale. POD 0: P = 0.001*; POD 1: P < 0.001*; POD 2: P < 0.001*; POD 3: P = 0.002*; POD 5: P = 0.093; POD 7+: P = 0.156. (B) Response to the question, “Was the postoperative pain more than, less than, or just as expected?” P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 1. View largeDownload slide (A) Postoperative pain scores on visual 0-10 scale. POD 0: P = 0.001*; POD 1: P < 0.001*; POD 2: P < 0.001*; POD 3: P = 0.002*; POD 5: P = 0.093; POD 7+: P = 0.156. (B) Response to the question, “Was the postoperative pain more than, less than, or just as expected?” P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 2. View largeDownload slide Nausea/vomiting. POD 0: P = 0.069; POD 1: P = 0.044*; POD 2: P = 0.044*; POD 3: P = 0.105; POD 5: P = 0.198. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 2. View largeDownload slide Nausea/vomiting. POD 0: P = 0.069; POD 1: P = 0.044*; POD 2: P = 0.044*; POD 3: P = 0.105; POD 5: P = 0.198. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 3. View largeDownload slide Fatigue/drowsiness. POD 0: P < 0.001*; POD 1: P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 3. View largeDownload slide Fatigue/drowsiness. POD 0: P < 0.001*; POD 1: P = 0.009*. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 4. View largeDownload slide Inhibition of ambulation. POD 0: P = 0.044*; POD 1: P = 0.176; POD 2: P = 0.089; POD 3: P = 0.044*; POD 5: P = N/A. All P values marked with an asterisk show statistical significance with P < 0.05. Figure 4. View largeDownload slide Inhibition of ambulation. POD 0: P = 0.044*; POD 1: P = 0.176; POD 2: P = 0.089; POD 3: P = 0.044*; POD 5: P = N/A. All P values marked with an asterisk show statistical significance with P < 0.05. DISCUSSION Since its introduction into the colorectal literature in 1997, ERAS protocols have been expanding to multiple surgical specialties.3-8 Superior outcomes have been demonstrated including shorter length of hospital stay, decreased healthcare expenditure, and high overall patient satisfaction without affecting overall complication rates.13 Since its introduction within the plastic surgery specialty in 2013, a series of articles have been published in abdominal wall reconstruction, microvascular breast reconstruction, and, most recently, implant based reconstruction. Davidge et al were the first to publish a series of patients undergoing autologous breast reconstruction with pedicle transverse rectus abdominus myocutaneous (TRAM) flaps. Although the article does not describe their protocol in relation to ERAS, but rather “processes of care,” they follow the principles described by the ERAS Society and showed a progressive reduction in hospital stay with improved protocol compliance.20 Fayezizadeh et al were the first within the plastic surgery literature, in 2014, to describe their ERAS protocol and the rationale behind each of the elements.9 This article did not follow any cohort of patients thus no measureable outcome could be studied. In 2015, Batdorf et al then described their ERAS protocol with a retrospective cohort analysis of patients undergoing microvascular breast reconstruction. Hospital length of stay was shorter, morphine requirements were decreased, and time to ambulation was reduced in the ERAS cohort without any effect on complication profile.10 Then in 2017, Dumestre’s research team published their ERAS protocol as a partial prospective series evaluating patients undergoing implant based breast reconstruction. ERAS patients were discharged home on POD 0. They had less pain, nausea, felt better rested without any effect on complications or number of emergency room visits.11 Also in 2017, Afonso et al published an article describing their ERAS protocol within microvascular breast reconstruction. Their study showed a decrease in opioid requirement and hospital length of stay.21 These articles demonstrate the utility of ERAS protocols in the field of plastic surgery. However, there remains a void in the literature for their use in cosmetic plastic surgery. With rising healthcare costs, there is pressure to transition to outpatient type procedures to reduce hospital costs. Cash paying cosmetic patients also demand competitive fee for service procedures which require appropriate allocation of resources. In addition, in this current era of online physician reviews and social media, patient satisfaction is paramount to having a successful cosmetic practice. All in all, cosmetic plastic surgery patients make an ideal target population for ERAS protocols. ERAS protocols have been slow to be embraced within plastic surgery, especially at our institution. The protocol has been formulated by the senior author (N.H.R.) with good success in his clinical practice. It is hard to initiate change in any well-established practice thus this pioneer study was designed to show the utility of our ERAS protocol in a cosmetic surgery patient population. In this small prospective study of 22 patients, the application of our ERAS protocol translated to a decrease in postoperative pain, nausea and vomiting, decrease fatigue/drowsiness, less inhibition of ambulation, less concern over discharge, and less constipation. Although the sample size is small, there is promising data for use of ERAS protocols within this population. A number of outcome measures demonstrated statistically significant differences between the cohorts, which can be further substantiated when larger studies will be conducted. This ERAS protocol has been designed and improved based on the needs of our patients. The first and most important factor in any ERAS protocol is adequate counseling. The patients need to understand what the surgery entails and what the medications are used for. Expectations should be set and clear from the beginning. We do not use the word pain, but rather, discomfort as pain has a rather negative connotation. Patients are optimized in terms of nutrition in our practice by encouraging a healthy weight and eating habits. It is known that obese patients have a higher complication profile thus these patients are encouraged to be within their goal weight range prior to undergoing any elective procedure.22 Patients understand the nature of an outpatient surgery and are anticipated to ambulate on POD 0. When this expectation is set forth preoperatively and its significance explained, our experience has shown that patients are more likely to comply. The medication protocol has been in use for 7 years and has evolved based on our patient needs. This protocol is narcotic sparing, which is beneficial given the social, medical, and economic impact of narcotic abuse in the United States. Published in the Wall Street Journal, middle-aged Americans accounted for 44% of overdoses - an age bracket similar to that of our study participants. These medications have been overused and have led to chronic dependence and accidental death.14 This national epidemic has caught the attention of the nonmedical mainstream media which has translated to a heightened public awareness. The thought of avoiding narcotics altogether initially may sound unreasonable in the setting of cosmetic surgery, however, based on the results of this study it is clear that narcotics are not absolutely necessary.15 Many different medications protocols have been published but, in our opinion, the protocol presented in this report is advantageous due to the preloading effect and combination of multimodal therapy. Two doses of celecoxib and gabapentin are given prior to surgery: one the day prior to the surgical date and the second the morning of. This preloading is known as preemptive analgesia and is thought to prevent sensitization of central nervous system.23 The same applies to nausea with the antiemetic, ondansetron. If the patient has a history of motion sickness or is undergoing a forehead surgery, a scopolamine patch is used to act synergistically with ondansetron. After the induction of anesthesia, dexamethasone, and a promethazine suppository are given. Steroids decrease inflammation and contribute to pain reduction as well as nausea. They again act synergistically with other antiemetics and may even augment their efficacy.24 Promethazine acts, again synergistically, with ondansetron. A long-acting local anesthetic is always used during a surgical procedure. The senior author (N.H.R.) uses a long acting local anesthetic for each of his surgical procedures. All breast and upper extremity cases receive Bupivicaine and abdominal cases receive Liposomal Bupivicaine. Liposomal Bupivacaine (Exparel) has been shown to decrease postoperative narcotic requirements by many studies.25 These are injected at the end of the procedure as a local block in this study, however, a regional block could be performed as well for more complete coverage. IV acetaminophen is given prior to the cessation of the procedure because of its quick onset of action and also has been shown to decrease narcotic requirements.26,27 Gabapentin is given in the PACU prior to discharge home or one night stay. We found that after the initiation of gabapentin in the PACU, postoperative pain was significantly decreased. One patient in the study group required one dose of tramadol for breakthrough pain but once gabapentin was administered in the PACU, no additional breakthrough tramadol was needed. The mechanism of action of gabapentin is unknown however there is no question that it is efficacious as it has been shown to decrease the amount to narcotics needed to control postoperative pain.28 Celecoxib and gabapentin are given on a scheduled basis for 3 to 5 days postoperatively. Celecoxib is another powerful adjunct for controlling postoperative pain and it has not been shown to increase postoperative bleeding in this cohort or other patient populations studied in the literature.29 A methylprednisolone dose pack is given for patients without significant medical comorbidities, such as uncontrolled diabetes, as, in our experience, it contributes to pain reduction and may protect against sensitivity to medications.30 Steroids have known side effects such as glucose intolerance and insulin resistance; however, our patient population had a normal BMI without significant comorbidities. Short-term steroid31 use did not show any adverse effects on this patient population. Oral acetaminophen is used for intermittent discomfort but is not scheduled. Many of the medications used have mechanisms of action that are not well understood. Tables 1 and 2 list the theorized mechanism of action for the medications in the protocol and their side effect profiles.19 Despite the multitude of potential adverse reactions known in medical literature, none of our patients experienced any side effects. We contribute this to limited short-term use and safe dosing schedule. There is an additional cost related to the use of medications in the ERAS protocol. Although 90% of patients reported that the additional cost of medications was “worth it,” cost reduction is an important factor in cosmetic plastic surgery. With larger sample sizes, it may be more evident that the maximal efficacy is reached at a shorter time frame, thus limiting the amount to medications required. Reviewing the data in this study, it appears that maximum benefit is received for pain reduction by POD 3. Further treatment beyond this period may not be necessary as statistical significance was not reached after this time. This would drive down costs of medications as a result which is a drawback of the protocol. Additionally, less costly medications or generics could be evaluated as substitutions for some of the more expensive pharmaceuticals such as celecoxib. Ibuprofen is another anti-inflammatory medication commonly used for pain control. It is a nonselective cyclooxygenase (COX) inhibitor which has potential risk of gastrointestinal upset and platelet inhibition. The more selective COX-2 inhibitor, celecoxib, was chosen to mitigate these side effects, however, the utility of this medication in the protocol should be investigated. Being a pilot project in plastic surgery with initially unknown findings, this observational study was limited to the small sample size mandated by the IRB. In order to gain a better understanding of clinically significant outcomes, larger sample sizes are indeed needed. Therefore, we merely compared two cohorts of two different surgeons and did not modify routine care whatsoever. Detailed cost analysis of the ERAS medications (Table 3) were not performed since pricing may vary between institutions, geographical regions in the United States, or even between pharmacies. Completely matching procedures, surgical techniques, and only evaluating a single surgeon’s procedures would naturally allow for a better comparison between the groups as the results would be more likely related to medication effects. Blinding the individual contacting the patients could also limit any potential bias that was introduced by knowing which arm of the study patients are in. For these reasons, the study patients were aware about their enrollment in the ERAS group and thus, prone to the Hawthorne effect.32 Knowing that they were to receive additional treatment and enhanced recovery may have influenced their responses. Lastly, using a validated ERAS questionnaire instead of our self-designed one would strengthen our positive findings. Patients in the ERAS group experienced significantly less postoperative pain, nausea, and vomiting when compared with the control group without any effect on complication rates. Although the sample size is small, we can show that this is related to the multimodal approach and effects of preloading medications, given the prospective comparative study design. A similar clinical trial evaluating the impact of ERAS in a plastic surgery cohort undergoing cosmetic procedures has not been published to date and our report therefore has a pioneer function. CONCLUSION The results of our prospective study demonstrate that performing elective cosmetic procedures following the ERAS protocol leads to numerous improvements for our patients. Significantly decreased duration to discharge, lower postoperative pain, less nausea, vomiting, fatigue, and drowsiness were shown in addition to statistically lower opioid use and constipation without creating complications. This equates to enhanced safety and obviates narcotic use. We are hopeful that our perioperative management will be beneficial to others and that randomized controlled trials will validate our protocol. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. 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Aesthetic Surgery JournalOxford University Press

Published: Dec 14, 2017

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