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 .
Prospective, Randomized, Double-Blind Trial of Local Anesthetic Infusion and Intravenous Narcotic Patient-Controlled Anesthesia Pump for Pain Management after Free TRAM Flap Breast Reconstruction
Background : This study assessed the efficacy of a continuous infusion pump system for postoperative pain control at muscle-sparing transverse rectus abdominis musculocutaneous ( TRAM ) flap donor sites . Methods : In this prospect i ve , r and omized , double-blind trial , a dual-catheter continuous infusion pump system was placed in the muscle-sparing TRAM flap donor-site area in all patients .  Bupivacaine ( 0.375 % ; continuous infusion pump group ) or isotonic saline ( control group ) was infused at 4 ml/hour . All patients also had a patient-controlled anesthesia system delivering intravenous narcotics on dem and .  Pain scores , patient satisfaction , narcotic use , milestones of surgical recovery , and side effects of narcotics were compared between the two groups . Results : Forty-eight patients were included in the study ( 23 continuous infusion pump patients and 25 control patients ) . The continuous infusion patients used less mean patient-controlled anesthesia narcotic during the first 2 postoperative days ( 78.0 mg versus 42.7 mg ; p = 0.019 ) and transitioned earlier to oral narcotics than did control patients . Patients ’ overall pain satisfaction scores were significantly better in the continuous infusion group than in the control group . There were no significant differences between groups with regard to overall abdominal pain intensity scores , total narcotic use , length of hospitalization , incidence of narcotic side effects , or milestones of surgical recovery . Conclusions : The continuous infusion pump system appears to be a safe and effective method for postoperative donor-site pain management in TRAM flap breast reconstruction patients and should be considered for postoperative donor-site pain management . However , continuous infusion pump local anesthetic delivery to the muscle-sparing TRAM flap donor site did not eliminate narcotic use for pain control
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 .