Enhanced Recovery After Cosmetic Surgery: The Anesthesia Advantage

Enhanced Recovery After Surgery (ERAS) protocols have transformed outcomes in colorectal and orthopedic surgery, and the same principles are now reshaping cosmetic procedures. Enhanced Recovery After Cosmetic Surgery (ERACS) applies multimodal strategies to reduce opioid use, accelerate recovery, and improve patient satisfaction. Anesthesia plays a central role in this transformation, directly influencing pain management, postoperative nausea and vomiting (PONV), fluid balance, and early mobility. This article outlines how Certified Registered Nurse Anesthetist (CRNA)-led anesthesia protocols support ERACS from the preoperative phase through day-three follow-up.

Key Phases of ERACS and Anesthesia’s Role

ERACS protocols are built around four distinct phases: preoperative preparation, intraoperative management, postoperative recovery, and discharge planning. Anesthesia directly impacts three of these phases.

In the preoperative phase, CRNAs guide patient education, support carbohydrate loading two hours before surgery, and avoid prolonged fasting to reduce insulin resistance. Intraoperatively, they administer total intravenous anesthesia (TIVA) or low-volatile techniques alongside multimodal analgesia. Postoperatively, CRNAs support opioid-sparing pain control and facilitate early oral intake and mobilization. Finally, anesthesia teams contribute to discharge success by ensuring patients have clear pain management plans and appropriate follow-up.

Preoperative Optimization Strategies

Preoperative measures within ERACS include:

• Administering a carbohydrate-rich clear liquid, such as 12 ounces of a sports drink, two hours before surgery to reduce insulin resistance and improve gut motility.
• Providing oral acetaminophen (1,000 mg) and celecoxib (200 mg) one hour before surgery as preemptive analgesia, which has been shown to reduce intraoperative opioid use by up to 50 percent.
• Applying a transdermal scopolamine patch for patients undergoing high-risk procedures for PONV, such as mastopexy or facelift.
• Pre-warming patients with a forced-air warming gown to reduce hypothermia incidence from 18 percent to 4 percent.

Intraoperative Multimodal Analgesia Protocol

CRNA-led intraoperative protocols include a combination of agents that work synergistically to minimize opioid use while maintaining effective pain control and hemodynamic stability. Typical regimens include:

• Ketamine administered as a 0.3 mg/kg bolus followed by a 0.2 mg/kg/hour infusion from induction to skin closure, supporting respiratory drive and reducing opioid demand.
• Lidocaine given at 1.5 mg/kg bolus and 1 mg/kg/hour infusion post-induction, helping to reduce PONV and neuropathic pain.
• Dexamethasone (10 mg IV) administered after induction to manage inflammation and nausea.
• Tranexamic acid (15 mg/kg IV) delivered pre-incision to minimize blood loss and reduce postoperative bruising.
• Ketorolac (15 mg IV) administered during closure to support long-lasting analgesia.

With this protocol, median intraoperative opioid use frequently falls below 50 morphine milligram equivalents (MME), even for longer body-contouring procedures.

Normothermia and Goal-Directed Fluid Management

Maintaining normothermia and avoiding excessive fluid administration are essential components of ERACS. CRNAs monitor core temperature to maintain a range between 36 and 37 degrees Celsius, using forced-air warming devices and warmed IV fluids. Goal-directed fluid therapy (GDFT) guided by stroke volume variation helps maintain optimal perfusion without exceeding 30 mL/kg of crystalloid, minimizing tissue edema and reducing wound tension.

Postoperative Recovery Pathway From Zero to 48 Hours

Anesthesia plays a vital role in the immediate postoperative period. Upon arrival in the post-anesthesia care unit (PACU), patients are encouraged to sip water, with 4 mg of ondansetron administered if nausea exceeds 2 out of 10. Within two hours, patients are assisted in ambulating to the bathroom, with a goal of completing their first walk within that timeframe. By four hours, patients typically tolerate a carbohydrate- or protein-rich snack.

IV fluids are discontinued between six and eight hours after surgery, and oral analgesia is transitioned with a balance of ketorolac and low-dose oxycodone. By 24 hours, a telehealth follow-up is completed to assess pain levels and incision appearance. Opioid use is limited to fewer than six tablets of 5 mg oxycodone on day one and is often replaced by nonsteroidal anti-inflammatory drugs (NSAIDs) by day three.

Outcomes From Early ERACS Adoption

Practices that have adopted ERACS protocols report measurable improvements across several metrics. PONV rates dropped from 38 percent to 14 percent. Average PACU length of stay decreased from 110 to 70 minutes. Unplanned patient contacts within 72 hours declined from 22 percent to 10 percent. Average drain duration was reduced from six to four days. Patient satisfaction, as measured by Net Promoter Score (NPS), rose from 56 to 81.

Implementation Recommendations for ERACS Success

To initiate ERACS protocols effectively:

• Begin with a pilot on a single procedure, such as abdominoplasty.
• Create a laminated ERACS checklist for the anesthesia station with reminders for medication timing and interventions.
• Hold weekly interdisciplinary huddles with the surgeon, CRNA, and PACU lead to review the previous week’s cases.
• Use visual cues, such as whiteboard updates in staff areas, to highlight successes in metrics like PONV reduction and PACU time.

Conclusion

Enhanced Recovery After Cosmetic Surgery is more than a clinical protocol—it is a strategic opportunity to deliver higher-value care. When CRNA-led anesthesia teams drive multimodal pain control, normothermia, fluid optimization, and post-discharge follow-up, practices benefit from faster recoveries, reduced complications, and increased patient satisfaction. These outcomes support marketing, improve word-of-mouth referrals, and align with the expectations of modern value-based care.