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Gidumal et al. Plast Aesthet Res 2021;8:42 https://dx.doi.org/10.20517/2347-9264.2021.27 Page 3 of 15

Figure 1. Overview of perioperative ERAS interventions. The interventions highlighted in this review have been chosen because they
have demonstrated compelling evidence to merit their inclusion in an ERAS program, but they still lack universal acceptance among
those providing care for patients undergoing head and neck oncologic surgery.

after surgery, and fewer overall complications [13-16] .

Rather than focusing on the clinical outcomes of implementing a comprehensive ERAS pathway as many
groups have already done successfully, we instead direct our attention to individual interventions
themselves and the physiology that explains their success. These enhanced recovery interventions are
chronologically organized into three categories: (1) preoperative, which includes both pre-and post-
admission interventions; (2) intraoperative; and (3) postoperative, which includes both pre-and post-
discharge interventions. We seek to shed light on select interventions within each category that have
demonstrated clinical success and have sound physiologic explanations but have not yet been established in
widespread use; we make a case for their implementation in future ERAS protocols.

Preoperative interventions
Patient education and anxiolytics
Patients undergoing major head and neck surgery often present stress and anxiety on the day of surgery.
Fear of surgical and anesthetic complications, anxiety about a prolonged hospital stay, and the uncertainty
surrounding a cancer treatment course are all factors that can contribute to increasing a patient’s
psychological stress levels. Furthermore, previously published bio-behavioral models of stress have
demonstrated that psychological stress worsens wound healing and increases the risk of tumor recurrence
through the same mechanisms as physiological stress. These mechanisms include increased insulin and
cortisol secretion, increased production of arachidonic acid, and increased catabolism [8,17,18] .

A patient’s understanding of their planned treatment is often limited to that discussed in a preoperative
clinic visit, which may parallel diagnostic discovery related to their disease process. Enhanced preoperative
communication between surgeon and patient may alleviate patient anxiety and mitigate increased stress
levels before surgery. It may be done by building a shared understanding of the surgical plan and setting
expectations regarding the pre-and post-operative course [17-19] . Additionally, an independent discussion with
the anesthesiologist in the preoperative setting has been shown to reduce stress levels [18,19] . While the value of
these discussions is obvious, the time required to adequately counsel patients undergoing complex head and
neck surgery is often a barrier in the real-world setting, given the pressures of clinical practice. While these
discussions’ most effective timing and exact content have not been well described, managing patient