Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
Background : Enhanced recovery following surgery can be achieved through the introduction of evidence -based perioperative maneuvers .
This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery  and to provide evidence -based recommendations for an enhanced perioperative protocol .
Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets.
BACKGROUND Obesity is a growing epidemic in the United States ( US ) affecting more than 33 % of adults . We aim ed to use the World Health Organization ( WHO ) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP data base from 2005 to 2010 . STUDY DESIGN We review ed the 2005 to 2010 ACS-NSQIP data bases identifying encounters for Current Procedural Terminology ( CPT ) codes including either implant-based reconstruction ( immediate , delayed , and tissue exp and er ) or autologous reconstruction ( pedicled transverse rectus abdominis myocutaneous [ pTRAM ] , free TRAM , and latissimus dorsi flap with or without implant ) .  Patients were classified and compared based on WHO obesity criteria : nonobese ( body mass index [ BMI ] = 20 to 29.9 kg/m(2 ) ) , class I ( BMI = 30 to 34.9 kg/m(2 ) ) , class II ( BMI = 35 to 39.9 kg/m(2 ) ) , and class III ( BMI > 40 kg/m(2 ) ) . RESULTS During the study period 15,937 breast reconstructions were performed . The majority of reconstructions were immediate reconstructions ( 85.0 % ) and implant-based ( 79.1 % ) . The incidence of obesity was 27.1 % , with 16.3 % defined as class I obese , 6.9 % defined as class II obese , and 4.0 % defined as class III obese . The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions , higher American Society of Anesthesiologists ( ASA ) physical status ( p < 0.001 ) , longer operative times ( p = 0.0001 ) , and greater lengths of hospital stay ( p = 0.0001 ) . Progressively higher BMI s were associated with higher rates of complications , including wound ( p < 0.001 ) , medical ( p < 0.001 ) , infections ( p < 0.001 ) , major surgical ( p < 0.001 ) , graft and prosthesis loss ( p < 0.001 ) , and return to the operating room ( p < 0.001 ) . CONCLUSIONS This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large , prospect i ve multicenter data set . Increasing obesity is associated with increased perioperative morbidity . Data derived from this cohort study can be used to risk-stratify patients , enhance risk counseling , and advocate for institutional reimbursement in obese patients undergoing breast reconstruction
Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
Background : Enhanced recovery following surgery can be achieved through the introduction of evidence -based perioperative maneuvers .
This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery  and to provide evidence -based recommendations for an enhanced perioperative protocol .