Less Is More: A Minimalist Enhanced Recovery After Surgery Protocol for Pediatric Plastic Surgery in an International Setting

Enhanced recovery after surgery (ERAS) protocols have revolutionized perioperative care across surgical disciplines. In the field of plastic surgery, recent applications of ERAS principles to cleft surgery have demonstrated promising outcomes, including decreased postoperative opioid consumption, expedited return to oral feeding, and reduced hospital length of stay. However, these pathways have yet to be tested in a resource-limited environment. Therefore, a deliberately minimalist ERAS protocol was designed and implemented over several years in an international setting. The simplified regimen consisted solely of intraoperative local anesthetic, prophylactic dexamethasone, and scheduled acetaminophen and ibuprofen postoperatively. Forty-seven pediatric craniofacial operations were performed under these conditions. Despite the absence of adjunctive agents or postoperative opioids, outcomes were highly favorable: mean pain scores were 1.9/10 on the Wong-Baker FACES scale, first oral intake occurred at 6.5 hours, hospital length of stay was under 24 hours, and no readmissions or acute complications occurred. These findings challenge the prevailing assumption that enhanced recovery requires escalating protocol complexity. Instead, they suggest that simplicity-when guided by evidence-can achieve equivalent or superior outcomes. Moreover, simplified and cost-conscious protocols may be more feasible to implement broadly, increasing the applicability of enhanced recovery principles throughout the international surgical community and even in institutions with limited resources.