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Enhanced recovery for breast reconstruction means good information beforehand, stopping smoking for a month, a short fast with a sugary drink two hours before, anti-sickness and pain medicines that spare opioids, keeping warm, eating within a day and getting up within a day, with close checks on a flap in the first three days.
The ERAS Society consensus review (2017; 18 items, GRADE) is the only specialty guideline found for breast reconstruction. Every recommendation is graded strong; evidence is high for opioid-sparing multimodal postoperative analgesia and conventional sutures, and moderate or low (often extrapolated from other surgery) for the rest: detailed counselling; one month without smoking or heavy alcohol and weight reduction to a BMI of 30 or less (high evidence for obesity); CT angiography if perforators need mapping; clear fluids to 2 hours and a maltodextrin drink 2 hours before (low evidence); VTE risk assessment and LMWH or heparin with mechanical methods for those at higher risk; chlorhexidine and IV antibiotics within 1 hour of incision; multimodal antiemetics; total intravenous anaesthesia; active warming above 36°C; avoiding over- and under-filling with balanced crystalloid, goal-directed therapy and vasopressors where needed; food within 24 hours; mobilisation within 24 hours; frequent flap monitoring in the first 72 hours; and physiotherapy and support after discharge. NICE NG180 offers an enhanced recovery programme for elective major surgery.
Why: Women who understand the choices and what to expect have less regret and recover better.
“Patients should receive detailed preoperative counseling.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate. Recommendation grade: Strong (low harm).
Why: Smoking, obesity and heavy drinking each raise the risk of flap loss, wound breakdown and infection.
“For daily smokers, 1 month of abstinence before surgery is beneficial. For patients who are obese, weight reduction to achieve a body mass index less than or equal to 30 kg/m 2 before surgery is beneficial. For alcohol abusers, 1 month of abstinence before surgery is beneficial.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate for smoking; high for obesity; low for alcohol. Recommendation grade: Strong for all (high benefit, low harm).
Why: Mapping the main vessel before a DIEP flap shortens the operation and reduces flap and donor-site problems.
“If preoperative perforator mapping is required, computed tomographic angiography is recommended.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate. Recommendation grade: Strong.
Why: Clear drinks up to 2 hours before are safe, and a sugary drink reduces thirst, anxiety and the body's stress response.
“Preoperative fasting should be minimized and patients should be allowed to drink clear fluids up to 2 hours before surgery.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Fasting: Evidence level Moderate (based on extrapolated data), Recommendation grade Strong. Carbohydrate drink: Evidence level Low (based on extrapolated data), Recommendation grade Strong (low risk of harm) in the general patient population.
Why: Clots are more common after mastectomy with reconstruction than after mastectomy or lumpectomy alone.
“Patients should be assessed for venous thromboembolism risk. Unless contraindicated, and balanced by the risk of bleeding, patients at a higher risk should receive low-molecular-weight heparin or unfractionated heparin until they are ambulatory or discharged. Mechanical methods should be added.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate. Recommendation grade: Strong.
Why: Infection is more common after mastectomy with an implant or flap than after other clean surgery.
“Chlorhexidine skin preparation and intravenous antibiotics covering common skin organisms should be given within 1 hour of incision.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate (based on extrapolated data). Recommendation grade: Strong.
Why: Combinations prevent more sickness than one drug, and intravenous anaesthesia causes less sickness than anaesthetic gases.
“Women should receive preoperative and intraoperative multimodal medications to mitigate postoperative nausea and vomiting.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Antiemetics: Evidence level Moderate, Recommendation grade Strong (high benefit, low harm). Total intravenous anaesthesia: Evidence level Moderate, Recommendation grade Strong.
Why: Getting cold slows wound healing and triples the risk of wound infection.
“Temperature monitoring is required to ensure the patient’s body temperature is maintained above 36°C.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate (based on extrapolated data). Recommendation grade: Strong.
Why: Too much fluid harms a flap and the wound; too little risks a clot in the flap's vessels. Vasopressors do not harm free flaps.
“Overresuscitation or underresuscitation of fluids should be avoided, and water and electrolyte balance should be maintained. Goal-directed therapy is a useful method to achieve these goals. Balanced crystalloid solutions rather than saline is recommended. Vasopressors are recommended to support fluid management and do not negatively affect free flaps.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate for all (based on extrapolated data). Recommendation grade: Strong.
Why: Fewer opioids means less sickness and constipation and earlier walking.
“Multimodal postoperative pain management regimens are opioid-sparing and should be used.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: High. Recommendation grade: Strong.
Why: Early food helps wounds heal and early movement prevents clots, chest infection and muscle loss.
“Patients should be encouraged to take fluids and food orally as soon as possible, preferably within 24 hours after surgery.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Early feeding: Evidence level Moderate (based on extrapolated data), Recommendation grade Strong. Mobilisation: Evidence level Moderate (based on extrapolated data), Recommendation grade Strong (low risk).
Why: A clot in a flap's vessels happens in 2 to 5 in 100 flaps, mostly in the first three days, and early return to theatre saves the flap.
“Flap monitoring within the first 72 hours should occur frequently. Clinical evaluation is sufficient for monitoring, with implantable Doppler monitoring recommended in cases of buried flaps.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate. Recommendation grade: Strong (low harm).
Why: Early rehabilitation improves movement, pain and quality of life after breast surgery.
“Early physiotherapy, supervised exercise programs, and other supportive care initiatives should be instituted after discharge.”
ERAS Society (Plastic and Reconstructive Surgery) 2017 · Evidence level: Moderate (based on extrapolated data). Recommendation grade: Strong (low harm).
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The ERAS Society consensus review (2017) is the only graded specialty guideline for breast reconstruction found, and all 18 of its recommendations are strong; only opioid-sparing analgesia and conventional sutures rest on high-quality evidence, and many items are extrapolated from other operations. NICE NG180 supports an enhanced recovery programme for elective major surgery and the same 2-hour clear-fluid fast.
ERAS Society (Plastic and Reconstructive Surgery) 2017 · NICE 2020
Where it differs: Continues antibiotics after surgery until the drains are removed.
Evidence: The ERAS review calls this common practice and cites a systematic review of observational studies in which more than 24 hours of antibiotics was associated with higher infection rates in reconstructions using acellular dermal matrix; it recommends antibiotics within 1 hour of incision and does not recommend continuing them.
Where it differs: Uses regional anaesthesia as the main anaesthetic.
Evidence: The ERAS review reports that regional anaesthesia reduces opioid use but not pain, sickness, time to walking or hospital stay, and recommends general anaesthesia with total intravenous anaesthesia (moderate evidence, strong).
Enhanced recovery pathways feed people sooner, limit drips and drains and get them walking the day after an operation. Sixteen randomised trials in bowel surgery found 40 per cent fewer complications and stays more than two days shorter, but in 151 American hospitals given a full implementation programme, most failed to improve compliance with its elements.
Anaesthetic guidelines since at least 2011 say adults can drink clear fluids up to two hours before planned surgery and eat up to six hours before. In a study of 50 women having breast cancer surgery published in 2026, the average fast was 15 hours from food and 12 hours from fluids.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Offer an enhanced recovery programme for elective major or complex surgery “Offer an enhanced recovery programme to people having elective major or complex surgery .” | Not graded (NICE NG180 1.2.1) | NICE 2020 |
| Maltodextrin drink 2 hours before surgery “Preoperative maltodextrin-based drinks should be given to patients 2 hours before surgery.” | Evidence level: Low (based on extrapolated data). Recommendation grade: Strong (low risk of harm) in the general patient population. | ERAS Society (Plastic and Reconstructive Surgery) 2017 |
| General anaesthesia with total intravenous anaesthesia “General anesthesia with total intravenous anesthesia is recommended.” | Evidence level : Moderate. Recommendation grade : Strong. | ERAS Society (Plastic and Reconstructive Surgery) 2017 |
| Conventional sutures for closure; debridement and negative-pressure therapy for complex wounds “For incisional closure, conventional sutures are recommended. Complex wounds following skin necrosis are treatable with débridement and negative-pressure wound therapy.” | Evidence level : High for sutures; moderate for negative-pressure wound therapy. Recommendation grade : Strong. | ERAS Society (Plastic and Reconstructive Surgery) 2017 |
| Mobilise within the first 24 hours “Patients should be mobilized within the first 24 hours after surgery.” | Evidence level : Moderate (based on extrapolated data). Recommendation grade : Strong (low risk). | ERAS Society (Plastic and Reconstructive Surgery) 2017 |
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.