Do multidisciplinary ERAS protocols improve flap reconstruction outcomes? A structured review of efficacy, implementation challenges, and specialty-driven adaptations

Abstract

Background Enhanced Recovery After Surgery (ERAS) pathways are increasingly used in reconstructive plastic surgery, but flap reconstruction presents specific challenges, including dependence on stable microvascular perfusion, procedure-specific immobilization, donor-site morbidity, and heterogeneous anatomic indications. Because available studies differ substantially in surgical setting, flap type, ERAS bundle composition, comparator care, and outcome reporting, this article is presented as a structured narrative synthesis rather than a de novo meta-analysis. Methods PubMed, Embase, Web of Science, and Google Scholar were searched for studies and reviews published from 1997 to 14 June 2026 that addressed ERAS, fast-track, or accelerated recovery pathways in flap reconstruction or closely related reconstructive plastic surgery settings. The review question was defined using PICOS: adult or pediatric patients undergoing flap-based reconstruction; perioperative ERAS or accelerated recovery bundles; conventional perioperative care or pre-implementation practice; clinical, recovery, safety, and patient-centered outcomes; and randomized, prospective, retrospective, implementation, and systematic-review designs. Because ERAS bundles, flap types, and outcome definitions were clinically heterogeneous, no formal quantitative pooling was performed. Results Across breast reconstruction, head and neck free-flap reconstruction, perineal or pelvic reconstruction, lower-limb reconstruction, and selected flap-based wound procedures, ERAS pathways were most consistently associated with shorter hospital stay, earlier mobilization or feeding, and reduced opioid exposure. Safety outcomes, including flap compromise, readmission, and return to theatre, were generally not worse in the cited studies, but certainty is limited by observational designs, single-center implementation studies, variable adherence, and inconsistent reporting. The components most relevant to flap surgery are preoperative optimization, multimodal analgesia, goal-directed fluid therapy, protocolized flap monitoring, early but protected mobilization, nutrition, and explicit nursing-clinician coordination. Conclusions ERAS appears feasible and potentially beneficial in flap reconstruction when adapted to flap type, anatomic site, comorbidity burden, and reconstructive goals. The current evidence supports cautious implementation and local auditing rather than universal adoption of a single protocol. Future research should use plastic surgery-specific ERAS definitions, report study-level outcomes transparently, separate reconstructive from aesthetic indications where clinically appropriate, and prioritize long-term function, patient-reported outcomes, cost, and flap-specific safety endpoints.