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 .
Incidence of Hematoma Complication with Heparin Venous Thrombosis Prophylaxis after TRAM Flap Breast Reconstruction
Background : R and omized controlled studies provide ample evidence that heparin is effective in reducing the risk of thromboembolic complications . Nevertheless , plastic surgeons are often reluctant to use heparin chemoprophylaxis for fear of postoperative bleeding . The authors investigated whether heparin chemoprophylaxis was associated with postoperative hematoma that required evacuation in patients who underwent transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction . Methods : A multicenter retrospective review of consecutive TRAM flap cases identified 679 patients , 392 in the heparin-treated group and 287 in the control group .  The post hoc sample sizes were adequate to detect a 5 percent difference in hematoma rate with 89 percent power at an alpha level of 5 percent ( p < 0.05 ) . Outcome measures of reoperative hematoma , deep vein thrombosis , and pulmonary embolism were recorded . Results : Reoperative hematoma occurred in 0.5 percent of patients in the heparin-treated group and 1.0 percent of patients in the control group ; this difference was not statistically significant ( p = 0.66 ) . Thromboembolic events were detected at a low rate ( 0.8 percent in the heparin-treated group versus 1.4 percent in the untreated group ; p = 0.46 ) . Conclusions : The use of heparin for venous thrombotic prophylaxis did not increase the risk of reoperative hematoma after breast reconstruction with abdominal tissue . The authors propose a risk assessment that balances a statistical hematoma rate of 0.5 to 5 percent ( clinical ly observed rate , 0.5 percent ) with use of heparin prophylaxis against a rare ( clinical ly observed rate , 1.4 percent ) but morbid occurrence of thromboembolic complications when chemoprophylaxis is omitted
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 .