Multidisciplinary ERAS Protocols in Flap Reconstruction: A Systematic Review of Outcomes, Challenges, and Specialty-Specific Adaptations

Meihui Xiao^*Ximei Su^*Li Yang^*

• The Second Xiangya Hospital of Central South University, Changsha, China

Enhanced Recovery After Surgery (ERAS) protocols have demonstrated significant potential in optimizing perioperative outcomes for flap reconstruction—a complex procedure for restoring cutaneous defects (caused by trauma, tumor excision, or diabetes) with high risks of vascular complications and delayed healing. This multidisciplinary systematic review, conducted in strict adherence to the PRISMA guidelines, synthesizes current evidence to evaluate ERAS's impact on clinical outcomes and identify specialty-specific management strategies. Preoperative interventions (e.g., nutritional optimization, smoking cessation) reduce inflammatory responses and enhance tissue resilience; intraoperative strategies (e.g., goal-directed fluid therapy [GDFT], multimodal analgesia) mitigate fluid overload and opioid-related morbidity while preserving microvascular integrity; postoperative measures (e.g., early mobilization, near-infrared spectroscopy [NIRS] monitoring) accelerate functional recovery and shorten hospital stays. Key outcomes show ERAS reduces postoperative complications by 15–20% (flap necrosis: 5% vs. 12% in traditional care; infection: 8% vs. 15%), shortens hospital stays by 1–2 days, and halves 30-day readmission rates (3% vs. 6%). Notably, ERAS achieves these efficiency gains without compromising care quality—data from a multicenter cohort study [27] (n=1820) shows the 30-day flap secondary intervention rate is 2.1% in the ERAS group versus 7.8% in the traditional care group (RR=0.27, 95%CI 0.15-0.49, I²=30%), confirming no increase in postoperative remedial surgery risk. Challenges include balancing fluid restriction (to prevent edema) and hypotension avoidance, stratified urinary catheter management across flap types, and institutional protocol variability. Specialty-specific adaptations (breast, head and neck, perineal, lower limb reconstruction) highlight ERAS versatility, but multidisciplinary collaboration—particularly between clinicians and nursing teams—remains pivotal. Future research should prioritize plastic surgery-specific ERAS algorithms (distinguishing reconstruction vs. aesthetic surgery with refined stratification), long-term functional outcomes, and AI-driven personalized monitoring. In conclusion, ERAS represents a transformative paradigm in reconstructive surgery, enhancing flap survival and patient recovery through evidence-based, stratified care.