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Gidumal et al. Plast Aesthet Res 2021;8:42 https://dx.doi.org/10.20517/2347-9264.2021.27 Page 5 of 15

Figure 2. Formula for Onodera’s Prognostic Nutritional Index (PNI).

been shown to reduce fistula formation after surgery for oral and laryngeal cancer, with greater effect
associated with higher doses up to 20 g/day [33-35] .

Arginine also improves infection prevention. Firstly, the increased blood flow due to NO generation
improves microbial defenses by increasing white blood cell delivery to tissue. Secondly, through
mechanisms that are not completely understood, arginine increases the response of peripheral lymphocytes
to mitogenic stimulus and restores the activity of macrophages often depressed by physiologic stress [31,36] .
However, it is notable that adverse clinical outcomes have been reported with the administration of arginine
after the establishment of a severe infection rather than as infection prophylaxis, a finding that has been
attributed to the maladaptive reduction in blood pressure that can come from NO generation in the setting
[37]
of septic hypotension .
Very recent outcomes research has further substantiated claims that arginine improves both wound healing
and infection prevention. A Cochrane meta-analysis from 2018 of 19 randomized controlled trials
evaluating immunonutrition administration prior to head and neck surgery demonstrated a significant
reduction in the rate of fistula formation among patients who received the intervention . Furthermore, two
[38]
extensive studies published after this meta-analysis also demonstrated significant reductions in hospital
length of stay and wound infection complications [27,39] . While the most effective dosing and timing of
preoperative supplementation are not yet established, it is our view that all patients, particularly those with
malnutrition, should receive immunonutritional supplementation prior to scheduled head and neck surgery
to reduce the risk of wound complications and prolonged hospital stay.

Reduced fasting
For decades, patients have been instructed not to eat or drink after midnight the day before surgery in order
to mitigate the risks of aspiration during anesthetic induction and intubation. Nothing by mouth, or “nil per
os (NPO)”, after midnight is thought to cause dehydration, increase anxiety and physiologic stress, and
induce a catabolic state that increases insulin resistance and perioperative hyperglycemia . Perioperative
[40]
hyperglycemia is associated with numerous perioperative complications such as the increased risk of
infection, heart failure, and atrial fibrillation, and interventions that reduce hyperglycemia have successfully
reduced postoperative complications [41,42] . Furthermore, the instructions of nothing by mouth after midnight
might be misconstrued as instructions not to take certain daily medications, such as antihypertensives, the
abstinence from which can increase cardiac lability in the perioperative period [41-43] .

The American Society for Anesthesiologists (ASA) most recently published new preoperative fasting
guidelines in 2017, which are liberal than the conventional teaching of NPO after midnight and consider the
risks of complications imparted by more stringent fasting criteria . These updated guidelines allow for the
[44]
consumption of heavy foods up to 8 h before surgery, light foods up to 6 h before surgery, and clear liquids
up to 2 h before surgery. They assume normal gastrointestinal anatomy and function and apply to elective
procedures requiring general anesthesia, regional anesthesia, or sedation. Because many patients
undergoing major head and neck surgery have disease processes or comorbidities that may increase the risk
of aspiration (e.g., gastroesophageal reflux disease, altered anatomy along the upper aerodigestive tract),