Enhanced Recovery After Surgery (ERAS) Following Subcranial Lefort II/III or Transcranial Monobloc/Orbital Osteotomies and Complex Craniofacial Procedures

Purpose: Enhanced Recovery After Surgery (ERAS) protocols have demonstrated success in improving recovery and minimizing complications after surgical procedures. While the American Society of Craniofacial Surgeons has begun to develop and implement ERAS protocols for craniofacial surgeries, there is still no consensus perioperative guidelines regarding complex facial osteotomies. The primary aim of this article was to examine the existing literature regarding complex facial osteotomies and enhanced perioperative recovery protocols. We propose an ERAS protocol that includes elements that can be applied to transcranial, subcranial, or both approaches to facial osteotomies for midface advancement. Findings: Many of the central tenets of standard ERAS protocols can be applied to patients undergoing facial osteotomies including preoperative medical and nutritional optimization, minimization of fasting, nausea/vomiting prophylaxis, early return to diet, and mobility. Additional elements unique to facial osteotomies important to minimizing complications include anemia screening, use of cell saver and tranexamic acid intraoperatively, antibiotic choice and duration, management of intracranial dead space, consideration of early extubation, and distraction protocols. Several of these elements require modification for subcranial versus transcranial approaches as the complication profiles differ. Recommendation: We provide a comprehensive plan for initiation of an ERAS protocol that can be used for Le Fort II/III and monobloc/orbital osteotomies, with minor institutional variation. Future research is needed to review the implementation of this protocol and ultimately evaluate patient outcomes.