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Gidumal et al. Plast Aesthet Res 2021;8:42 https://dx.doi.org/10.20517/2347-9264.2021.27 Page 7 of 15

properties that exert an ameliorative effect on chronic pain syndromes [56-58] . Vitamin C, administered
intravenously shortly before surgery or shortly after anesthetic induction, appears to significantly reduce
[54]
pain scores and opioid use starting 1 h after surgery and lasting up to 48 h . Given the remarkably low
acute toxicity of vitamin C and the absence of any reported adverse effects of this practice, practitioners may
wish to consider intravenous administration of 3 g of vitamin C 30 min after anesthetic induction.

Avoiding routine tracheostomy
Routine tracheostomy is often used to secure the airway following reconstructive head and neck surgery
within the oral cavity. This practice reduces airway resistance, improves patient comfort, and reduces the
need to manipulate the newly reconstructed field in cases in which postoperative ventilatory support is
[59]
required . The practice of routine tracheostomy in head and neck surgery may also be rooted in anecdotal
surgical experience or anesthesiologist’s comfort levels. However, tracheostomy is associated with a high
complication rate of 8%-45% . These complications include tracheomalacia, tracheal stenosis, obstruction
[60]
of the tracheostomy cannula, tracheo-innominate and tracheoesophageal fistulas, pneumonia, and bleeding
to adjacent structures . Furthermore, the presence of a tracheostomy tube increases rates of dysphagia and
[61]
[59]
aspiration because the laryngeal elevation is restricted during swallowing .
As an alternative to routine tracheostomy, recent evidence supports overnight orotracheal or nasotracheal
intubation as a means to secure the airway against the risk of postoperative airway edema. In some cases,
extubation in the operating room with close observation is the most appropriate management. Compared
with patients who underwent tracheostomy, patients who were managed with overnight intubation were
found to have reduced overall length of hospital stay, the incidence of postoperative dysphagia, time to first
oral intake, and rates of lower respiratory infections [59,62,63] . The downsides of overnight intubation include
prolonged sedation, reliance on an intensive care setting to provide management for intubated patients
requiring a ventilator, and the lack of a secure airway once extubation is performed. Interestingly, the
outcomes classically associated with prolonged sedation such as atelectasis and increased length of stay,
however, have been shown to occur more frequently in patients with tracheostomies . Furthermore, the
[62]
increased cost associated with an ICU stay is more than offset by the reduction in cost associated with an
earlier time to discharge [64,65] . However, certain procedures may preclude the possibility of avoiding a
tracheostomy due to a less stable airway or aerodigestive reconstruction. While we recognized the
challenges of airway management and certainly favor a case-by-case approach, we recommend that routine
tracheostomy practices should be avoided.

Postoperative interventions
Early diet initiation
Early initiation of oral diet is an essential tenet amongst ERAS programs in all surgical fields [66-68] . It has been
established that early postoperative enteral, rather than parenteral, feeding reduces the risk of infection,
improves insulin resistance, improves nutritional uptake, and ultimately reduces the length of hospital stay
in surgical patients [60,69] . The increase in gastrointestinal (GI) hormone secretion associated with enteral
feeding has been shown to improve both macrophagic activity and absorptive function in the GI tract and is
the mechanism by which the clinical benefits of enteral feeding are attributed .
[70]

Head and neck patients represent a unique population due to violation of oral cavity and pharyngeal
structures and have traditionally been kept nothing-by-mouth after major head and neck surgery for six to
twelve days to avoid salivary fistula . Postoperative enteral nutrition, either through a nasogastric or
[71]
gastrostomy tube, is now common, with parenteral nutrition reserved only for patients with an absence of
intestinal function or with contraindications to enteral access . In the last decade, however, new evidence
[12]