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 .
The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap
Background : Immediate breast reconstruction using the transverse rectus abdominis musculocutaneous ( TRAM ) flap is associated with multiple risk factors for pulmonary thromboembolism , the incidence of which has been reported to be as high as 6.3 percent . The authors conducted a prospect i ve study of the efficacy of prophylactic use of low-molecular-weight heparin to prevent pulmonary thromboembolism . Methods : Six hundred fifty consecutive patients who underwent immediate breast reconstruction with TRAM flaps between August of 2001 and April of 2007 were included in this study .  No medical prophylaxis was administered for the former 450 consecutive patients ( group 1 ) . Since February of 2006 , enoxaparin was routinely given to the latter 200 consecutive patients ( group 2 ) for 7 days , from the day of surgery . Fifty-four patients in group 1 ( group 1c ) and 68 patients in group 2 ( group 2c ) were routinely examined for asymptomatic pulmonary thromboembolism . Incidences of symptomatic and asymptomatic pulmonary thromboembolism , decreases in hemoglobin , and bleeding-related complications were compared . Results : Although the incidence of symptomatic pulmonary thromboembolism did not differ significantly between groups 1 and 2 ( 1.8 percent versus 0 percent ; p = 0.107 ) , that of asymptomatic pulmonary thromboembolism was significantly higher in group 1c than in group 2c ( 16.7 percent versus 0 percent ; p = 0.009 ) . The hemoglobin decrease was significantly different ( 2.5 g/dl in group 1 versus 2.8 g/dl in group 2 ; p = 0.001 ) , but the incidences of transfusion , hematoma , and seroma showed no statistically significant difference . Conclusion : Prophylactic use of low-molecular-weight heparin was effective in preventing pulmonary thromboembolism without increasing problematic bleeding-related complications in TRAM flap immediate breast reconstruction patients
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 .