Application of Enhanced Recovery After Surgery in oral and maxillofacial surgery: a narrative review

Introduction

Background

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary evidence-based, perioperative care approach aimed at accelerating postoperative recovery, shortening hospital stay, and minimize complications (1). Surgeons, anesthesiologists, and nursing teams constitute the three core pillars of this coordinated strategy. In oral and maxillofacial surgery (OMFS), ERAS implementation in OMFS poses unique challenges due to the region’s complex anatomy, limited operative space, and the requirement for precise techniques, particularly in airway management (2). Moreover, postoperative recovery in OMFS involves restoration of essential functions such as eating, speaking, and breathing, pain control which further increases the demands on perioperative care.

Rationale and knowledge gap

Originally developed for colorectal surgery, ERAS has since improved outcomes across various surgical fields, including orthopedics, gynecology, thoracic surgery, and neurosurgery—where it consistently led to improved postoperative recovery, reduced length of stay, and fewer complications (3,4).

Although ERAS has demonstrated substantial benefits across colorectal, orthopedic, gynecologic, thoracic, and neurosurgical procedures, its uptake in OMFS remains limited. The complexity of facial anatomy and the need to rapidly restore functions like speech, chewing, and breathing present unique challenges. While interest is growing, current evidence on ERAS in OMFS is scarce, recent reviews indicate that multidisciplinary ERAS pathways with multimodal analgesia (MMA) shorten hospitalization, hasten recovery, and reduce opioid use without raising complications, but the evidence is limited by single-center designs, heterogeneity, few randomized controlled trials (RCTs), inconsistent components, and short follow-up, underscoring the need for robust prospective studies across OMFS subspecialties.

Existing OMFS studies often evaluate single elements (e.g., perioperative nutrition or MMA) rather than comprehensive pathways, and few reviews synthesize barriers specific to OMFS (5). A focused narrative review is needed to map current evidence, identify gaps, and guide implementation.

Objective

This review aims to evaluate the current application of ERAS protocols in OMFS. Specifically, we seek to (I) summarize existing ERAS strategies implemented across the perioperative continuum in OMFS; (II) assess their impact on patient outcomes such as recovery time, complication rates, and quality of life; and (III) identify key challenges and opportunities for optimizing ERAS pathways tailored to the unique needs of OMFS patients. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-29/rc).

Methods

The methods are described in Table 1. A bibliographic search was conducted in PubMed, and Google Scholar, and Web of Science for articles published between January 2000 and June 2025 using keywords such as “ERAS”, “oral and maxillofacial surgery”, “perioperative care”, and “multimodal analgesia”. Only English-language studies were considered. Literature selection was based on clinical relevance, with data extracted on perioperative interventions, patient outcomes, and implementation barriers.

Preoperative

The preoperative phase is an essential component of the ERAS protocol, with the primary goal of preparing patients both physiologically and psychologically through a series of targeted interventions, thereby optimizing postoperative recovery outcomes. Figure 1 summarizes the key ERAS components across the preoperative, intraoperative, and postoperative phases in OMFS.

Figure 1 Core components of ERAS in oral and maxillofacial surgery. ERAS, Enhanced Recovery After Surgery; OMFS, oral and maxillofacial surgery.

Education

Preoperative anxiety is a common concern among patients undergoing OMFS, often driven by uncertainty, fear of pain and concerns about surgical outcomes. Studies report that approximately 39% of patients in head and neck outpatient clinics suffer from anxiety disorders (6,7). Patients with previous negative medical experiences tend to exhibit more intense fear responses. While mild anxiety is frequently observed in routine procedures such as tooth extraction (8), more complex interventions including orthognathic surgery, jaw cyst enucleation, or tumor resection, tend to provoke greater psychological distress. This is due to factors such as procedural complexity, prolonged recovery periods, and potential impact on facial appearance or oral function (9). Comprehensive preoperative education plays a critical role in addressing these concerns. Structured counseling that clearly explains the surgical steps, intraoperative expectations and postoperative recovery has been shown to reduce anxiety, enhance patient compliance, and improve overall satisfaction with care (10-12). In addition to standard educational approaches, non-pharmacological intervention have emerged as effective adjuncts in alleviating preoperative anxiety, for example, hypnotherapy has demonstrated significant benefits in patients undergoing third molar extraction, helping to induce relaxation and reduce both preoperative tension and pain perception (13). Similarly, meditation-based relaxation therapies have shown promise in reducing preoperative anxiety and stress in patients with oral and maxillofacial squamous cell carcinoma (14).

Nutrition

The role of preoperative nutrition has gained increasing attention in perioperative care due to its critical impact on immune function, wound healing, and postoperative recovery (15-18). In OMFS, patient often experience difficulties or pain with eating due to the lesion’s location, and some may even develop food aversion driven by psychological distress. These factors significantly increase the risk of preoperative malnutrition, which can comprise surgical outcomes if left unaddressed. To mitigate these risks, clinicians are encouraged to conduct routine nutritional assessment during the perioperative period. Commonly used indicators include body mass index (BMI), prealbumin, total cholesterol levels, as well as validated tools like the prognostic nutritional index (PNI). Notably, a PNI ≤40 has been associated with a higher incidence of postoperative complications and poorer long-term outcomes in patients with oral, maxillofacial, and head and neck tumors (16). Evidence from a meta-analysis of 19 studies (n=2,047) confirms that preoperative nutritional therapy significantly reduces the risk of complications, mortality, and prolonged hospital stay in patients undergoing head and neck or gastrointestinal cancer surgery (5). Additionally, Tsai et al. suggest that preoperative serum cholesterol may serve as a predictive marker for survival in patients with oral cavity squamous cell carcinoma (19).

These findings reinforce the importance of early nutritional intervention in OMFS patients, using validated tools such as PNI and serum markers, and to implement timely nutritional support for at-risk individuals to improve postoperative outcomes. Current recommendation include optimizing preoperative nutritional status to achieve a PNI >45, daily protein intake of 1.2–2.0 g/kg, and maintaining serum cholesterol ≥160 mg/dL, to reduce postoperative complications and improve recovery (20-22).

Preoperative fasting

Preoperative fasting is a standard component of surgical preparation, designed to reduce the risk of gastric content regurgitation and aspiration, and thereby preventing serious intraoperative or postoperative complications (23). Guidelines from the American Society of Anesthesiologists (ASA) recommend that healthy patients may consume clear fluids (up to 400 mL) until 2 hours before anesthesia, and should avoid solid foods for at least 6 hours prior to surgery (24). However, the role of carbohydrate loading remains controversial. A randomized controlled trial (RCT) by Wu et al. found that oral intake of carbohydrates 2 hours before surgery was a safe and effective for elderly patients with oral cancer undergoing free flap reconstruction, helping to alleviate preoperative physiological stress (25). Conversely, a systematic review of 4,936 patients reported that while preoperative carbohydrate loading may contribute to postoperative insulin resistance and infections, it did not significantly improve patient comfort (26). These conflicting results underscore the patient-specific nature of carbohydrate loading’s effects. In particular, elderly patients may have reduced metabolic capacity, existing insulin resistance, in which can impact carbohydrate utilization and increase the risk of perioperative hyperglycemia. As such, the expected benefits—such as improved insulin sensitivity or reduced catabolic response—may not be universally observed in this population. Given these considerations, individualized preoperative fasting and nutrition strategies, tailored to age, comorbidities, and surgical complexity, are essential to maximize safety and recovery outcomes within ERAS pathways for OMFS.

In 2016, a survey of 431 oral surgeons found that 99.1% did not follow ASA fasting guidelines, showing a gap between recommendations and practice (27). The reasons for this discrepancy may include insufficient awareness among physicians of the latest fasting guidelines, misunderstandings about the importance of preoperative fasting management, and poor patient compliance with fasting requirements. In addition, the urgency of actual surgical scheduling and individual patient differences may also affect the implementation of fasting durations. In the future, the integration of artificial intelligence (AI) to develop personalized preoperative fasting protocols—based on individual factors such as blood glucose and protein levels—may represent a promising direction for optimizing perioperative care.

Another emerging consideration in preoperative metabolic management is the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as semaglutide and liraglutide, which are increasingly prescribed for type 2 diabetes and obesity. While these agents have favorable effects on glycemic control and weight loss, their delayed gastric emptying properties raise concerns about aspiration risk during anesthesia. Recent case series and safety alerts have highlighted instances of residual gastric contents despite prolonged fasting in patients taking GLP-1 RAs. As a result, some anesthesia societies now recommend withholding GLP-1 RAs for at least 24 to 72 hours prior to elective procedures requiring sedation or general anesthesia, particularly in patients receiving long-acting formulations or with known gastroparesis (28). However, consensus is still evolving, and individualized risk stratification is advised.

Anesthesia

In OMFS, preoperative anesthesia evaluation is particularly crucial due to the frequent involvement of complex airway management, prolonged operative time, significant surgical trauma, and the complexity of patients’ underlying medical conditions (29-31). Routine airway assessment includes evaluation of mouth opening, Mallampati classification, thyromental distance, and neck mobility, which help identify patients at risk for difficult intubation. Airway management strategies range from orotracheal and nasotracheal intubation to fiberoptic-guided intubation, awake intubation, percutaneous cricothyrotomy, as well as submental intubation as an alternative in selected cases. A systematic review involving 2,229 patients indicated that submental intubation is associated with minimal complications and requires a relatively short procedural time. It may serve as a valuable alternative to tracheostomy during surgical reconstruction of selected cases of maxillofacial fractures (32). Challenges such as limited mouth opening, aspiration risk, cervical spine injury, or patient agitation due to hypoxia may further complicate airway management, especially when handled by providers with limited experience (31). These scenarios necessitate careful planning, multidisciplinary coordination, and sometimes the use of advanced techniques such as video laryngoscopy or awake fiberoptic intubation.

Equally important is the evaluation of coagulation status to anticipate perioperative bleeding risk (33). Coagulation tests (e.g., prothrombin time, activated partial thromboplastin time, platelet count) should be routinely performed, especially in patients with underlying hematologic conditions (34). A retrospective review showed a 4.44% incidence of bleeding complications in OMFS patients with inherited bleeding disorders, with significantly increased risk in those with hemophilia (35). For such patients, preoperative optimization includes achieving safe thresholds [e.g., platelet count ≥50×10⁹/L, international normalized ratio (INR) ≤1.5, activated partial thromboplastin time (APTT) ≤1.5× normal] and ensuring the availability of necessary blood products and coagulation factors to manage intraoperative and postoperative hemorrhage (36,37).

Perioperative

In the ERAS protocol, intraoperative management serves as the core link between preoperative preparation and postoperative recovery. Its quality directly affects surgical safety, the speed of patient recovery, and the incidence of complications.

Minimal invasive surgery

Minimally invasive techniques in OMFS generally refer to procedures that limit tissue disruption, such as arthrocentesis, arthroscopy, endoscopic approaches, and robot-assisted surgeries which are increasingly applied in various OMFS procedures. A systemic review involving 44 articles found that patients undergoing minimally invasive orthognathic surgery experienced fewer complications and recovered more quickly (38). A systematic review and meta-analysis incorporating three RCTs demonstrated that minimally invasive surgery (e.g., arthrocentesis and arthroscopy) yielded superior outcomes in postoperative pain relief and functional recovery compared to open surgery for patients with temporomandibular disorders (TMD). However, no statistically significant differences were observed in maximum incisal opening (MIO >35 mm), mandibular dysfunction, or clinical manifestations (e.g., joint clicking, tenderness, or crepitus) (39). In recent years, robot-assisted surgery has become popular, with studies showing reduced intraoperative blood loss, faster postoperative recovery, and shorter hospital stays in patients who underwent robotic-assisted salvage procedures (40-42). These findings suggest that minimally invasive surgical techniques can significantly enhance the ERAS process and facilitate faster recovery. However, successful implementation requires experienced surgeons who can appropriately tailor the surgical approach to each patient’s unique anatomy and clinical condition. The goal should always remain achieving optimal surgical outcomes, not simply procedural speed, to stay aligned with the fundamental principles of ERAS.

Temperature

Body temperature is a vital sign, and maintaining an intraoperative temperature above 36 ℃ is recommended to reduce complications such as infections, delirium, and bleeding (43). Factors like duration of surgery, patient body mass, surgical site exposure, and temperature of irrigation fluid can influence intraoperative temperature (44). A retrospective observational study showed that even mild intraoperative hypothermia, was significantly associated with an increased risk of postoperative delirium (POD) compared to normothermia (45). However, a meta-analysis including 9 RCTs and 11 observational studies found that even when the threshold for hypothermia was lowered to <35.5 ℃ or <35.0 ℃, no statistically significant differences were observed in other adverse events beyond shivering (46). Ju et al.’s study focused specifically on POD as the primary outcome and predominantly included high-risk patients undergoing prolonged surgeries, whereas the Xu et al.’s meta-analysis encompassed a wide range of surgical types, and active temperature control in the RCTs may have mitigated hypothermia-related effects. Future research with larger procedure-specific cohorts is necessary to clarify the relationship between intraoperative hypothermia and adverse outcomes. In clinical practice, for high-risk patients undergoing complex oral and maxillofacial surgeries, such as free flap reconstruction, evidence-based intraoperative temperature tramadol

management should include continuous core temperature monitoring (e.g., nasopharyngeal or esophageal probes), multimodal warming strategies (combining forced-air warming blankets and fluid warmers), and maintaining the operating room temperature at or above 21 ℃, in order to minimize the risks associated with hypothermia (47,48).

MMA

Anesthesia and pain management are recurring priorities throughout the entire perioperative period (49). MMA is a key component of the ERAS protocol and has been effectively implemented as a core strategy in colorectal surgery, gynecologic oncology, and spine surgery (50-52). The fundamental goal is to provide effective analgesia while minimizing reliance on opioids, which are associated with well-documented side effects such as nausea, vomiting, pruritus, addiction, and gastrointestinal hypomotility. In line with ERAS principles, it is strongly recommended to reduce opioid consumption wherever possible, particularly in the context of the ongoing opioid crisis in the United States. In the field of OMFS, MMA strategies are especially important due to the complex and sensitive nature of surgical sites. By integrating various analgesic modalities—including local anesthetics, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, lidocaine, and N-methyl-D-aspartate (NMDA) receptor antagonists—clinicians can effectively control pain while decreasing opioid requirements (53). For example, Castellanos et al. reported that the average opioid consumption in the MMA group decreased significantly: postoperative day 0, from 37.7 to 10.8 mg (P=0.002); day 1, from 65.9 to 19.9 mg (P<0.001). Additionally, the proportion of patients discharged with opioid prescriptions was markedly lower in the MMA group (71.4%) compared to the non-MMA group (98.3%) (P<0.001) (54). Beyond pharmacologic combinations, regional anesthesia also plays a critical role in MMA strategies for OMFS. Perisanidis et al. demonstrated the effectiveness of ultrasound-guided combined intermediate and deep cervical plexus blocks. In their study, 19 patients required no additional analgesic medications within 24 hours postoperatively, suggesting that regional techniques may offer viable pain control for patients not suited to general anesthesia (55). These findings highlight the value of MMA as a cornerstone of ERAS-based perioperative care in OMFS, emphasizing its potential to reduce opioid use, enhance comfort, and facilitate faster recovery.

Postoperative nausea and vomiting (PONV)

Studies have shown that the incidence of PONV following OMF surgery is approximately 24–70% (56-58). Established risk factors for PONV include female gender, non-smoker, history of motion sickness prior episodes of PONV. Patients undergoing maxillofacial surgery may be particularly susceptible due to factors such as swallowed blood, altered diet, hypotensive anesthesia and presence of Ryle’s tube (57). A prospective study showed that neutrophil-lymphocyte ratio (NLR) easily calculated from a standard complete blood count, as a potential biomarker for predicting PONV risk, offering a simple, accessible tool for risk stratification (59). Several preventive strategies have been shown to reduce PONV in OMF procedures, particularly in Le Fort I osteotomies. These include the use of total intravenous anesthesia (TIVA); prophylactic antiemetics such as ondansetron, steroids, scopolamine, and droperidol; gastric decompression at the end of surgery; multimodal, opioid sparing analgesia; avoidance of emetogenic opioids like morphine and codeine; and adequate perioperative fluids management (at least 25 mL/kg). In addition, for surgical procedures that can be safely performed under local anesthesia, the use of regional may further reduce the incidence of anesthesia-induced nausea and vomiting (55).

Fluid management

Intraoperative fluid management plays a pivotal role in the ERAS protocol for OMFS (60,61). For short, low-risk procedures such as outpatient tooth extractions, fluid requirements are minimal and easy to manage, maintenance needs can typically be met with 1–3 mL/kg/h of a balanced crystalloid solution (49). However, inadequate or excessive fluid administration during complex surgeries can increases the risk of postoperative complications, including delirium, tissue edema, and pulmonary issues. For example, evidence from head and neck cancer surgeries indicated that large intraoperative fluid volumes are associated with significantly higher complication rate, including a four to five-fold increased risk of POD when intake exceeds 3,000–4,150 mL, depending on surgical complexity (62,63). In these higher-risk cases, goal-directed fluid therapy (GDFT) offers a tailored and dynamic approach by continuously monitoring hemodynamic variables such as cardiac output, stroke volume variation, and pulse pressure variation (64). Tapia et al. demonstrated that in head and neck tumor surgeries, the implementing of GDFT improved postoperative outcomes following free flap reconstruction and significantly reduced both patients length of stay and overall costs in general wards and intensive care units (65). Therefore, adopting GDFT in complex or prolonged OMFS procedures can promote faster recovery, aligning with ERAS principles (65). Currently, no clear consensus exists on whether crystalloids or colloids are superior for fluid supplementation. However, recent studies suggest that both crystalloids and colloids can maintain hemodynamic stability during free flap surgeries, with crystalloids typically administrated in volumes. Importantly, neither fluid type appears to impair microcirculation, or compromises flap survival (66).

Postoperative

Although the postoperative phase is the final step in the ERAS protocol, it does not signify the end of the enhanced recovery process. On the contrary, it serves as a continuation and consolidation of the preceding stages. Postoperative nutritional support and physical rehabilitation are equally critical components of the ERAS protocol, playing a vital role in promoting functional recovery, shortening the rehabilitation period, and improving patients’ quality of life.

MMA

Effective pain management is a cornerstone of ERAS protocols and should be tailored to the specific needs of OMFS. Due to the unique surgical sites involved, postoperative pain can provoke psychological distress and impair essential functions like eating and chewing, ultimately delaying recovery. Therefore, optimized and multimodal analgesic strategies are particularly crucial. In addition to pharmacologic MMA, non-pharmacological interventions such as thermal therapy (heat and cold) have shown clinical benefits. A prospective study demonstrated that patients who received Hilotherm cold therapy reported significantly lower postoperative pain compared to those receiving conventional cooling (67). This analgesic effect is likely mediated by a reduction in peripheral nerve conduction velocity induced by lower temperatures (68,69).

Furthermore, photobiomodulation therapy (PBMT) has emerged as a promising adjunct for postoperative pain control. a review of 46 clinical studies demonstrated that PBMT was most effective in reducing pain after tooth extraction when administrated wavelengths of 650–980 nm, with power settings between 4–300 mW, and energy density of 3–85.7 J/cm². PBMT also showed efficacy in reducing facial swelling when applied at wavelengths of 660–910 nm, power of 4–500 mW, and energy density from 2–480 J/cm² (70). These adjunct therapies not only enhance patient comfort and accelerate recovery but also contribute to reduced opioid consumption, and aligned with the core objectives of ERAS protocol.

Early mobilization

Early postoperative mobilization is one of the core principles of ERAS. It effectively helps prevent thrombosis and muscle atrophy and shortens hospital stays (71). Dort et al. recommend that patients should begin mobilization ideally within 24 hours after surgery (62). Evidence supports the safety of early mobilization, even in complex procedures such as free flap reconstruction, with no adverse impact on flap survival (72). In fact, patients in the early mobilization protocol experience earlier catheter removal times, fewer suctioning episodes, and significantly reduced length of hospital stays. To support early mobility and oral intake, the timely removal of medical devices is critical, drainage tubes should be discontinues as soon as clinically safe. In oral cancer surgeries involving microvascular reconstruction, early tracheostomy decannulation has been shown to accelerate recovery by facilitating nasogastric tube removal and reducing hospital stay (73). In summary, the integration of early mobilization and timely removal of supportive device represents a safe and effective strategy to enhance postoperative recovery in OMFS, consistent with ERAS principles.

Nutrition

Early postoperative feeding is a key element of the ERAS protocol, as it promotes gastrointestinal motility, enhances nutrient absorption and contributes to overall recovery. Traditionally, patients undergoing oral cancer resection with free flap reconstruction have been required to fast for 6 to 12 days postoperatively to minimize the risk of wound dehiscence and ensure adequate healing. However, recent systemic review involved 1,097 patients showed that early feeding was not significantly associated with an increased risk of postoperative complications, such as fistulas formation, hematoma or seroma, or flap failure (74). The implementation strategy of early nutrition should be different for different types of OMFS. In procedures with minimal trauma and limited scope (such as local tumor resection and alveolar bone surgery) patients can typically resume a liquid or soft food diet within 24 hours after surgery (75); for moderately complex surgeries such as fracture reduction or bone transplantation, it is recommended to start early enteral nutrition about 48 hours after surgery (76); and for complex surgeries such as oral cancer resection and free flap reconstruction, it is necessary to start with caution based on wound healing and fistula risk, usually gradually start liquid diet 3–5 days after surgery (77). Close monitoring for complications is essential during this period. In summary, early nutrition support should be individualized based on patient’s general health condition, surgical complexity and potential risks. A balanced approach can safely enhance recovery and support the goals of ERAS in OMFS.

For patients unable to initiate oral intake safely, enteral nutrition via nasogastric tube remains a practical and effective approach within ERAS protocols. Nasogastric feeding supports early gastrointestinal stimulation and nutrient delivery, especially after complex surgeries such as free flap reconstruction. A French retrospective study showed that early tube feeding in mandibular fracture patients was well-tolerated and allowed early nutritional support without increasing complications (76). Tailoring the route and timing of nutrition to patient status and surgical complexity is essential to optimize outcomes.

Strengths and limitations

This review has several strengths. It summarizes current evidence on the application of ERAS in OMFS and highlights key elements of perioperative management from multiple disciplines. The discussion integrates available data and provides practical insights for developing evidence-based ERAS pathways in this field.

However, some limitations should be noted. As a narrative rather than a systematic review, potential selection bias may exist. The number of studies on ERAS in OMFS is still limited, and most have small sample sizes and heterogeneous designs. More multicenter and prospective studies with standardized outcome measures are needed to confirm the effectiveness of ERAS protocols in this specialty.

Conclusions

The application of ERAS in OMFS is still in an exploratory and developmental phase. Larger and high quality studies are urgently needed to establish procedure-specific ERAS protocol tailored to the diverse spectrum of OMFS procedures, including orthognathic and oncologic surgery. Future efforts should focus on leveraging AI technologies to support the implementation of ERAS across all perioperative phases—from preoperative optimization and intraoperative MMA to early postoperative rehabilitation. A synergistic approach combining ERAS principles with AI-driven innovations holds great promise for improving patient outcomes and standardizing perioperative care in OMFS.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-29/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-29/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-29/coif). J.W. serves as the unpaid Deputy Editorial-in-Chief of Journal of Oral and Maxillofacial Anesthesia from March 2025 to February 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Golder HJ, Papalois V. Enhanced Recovery after Surgery: History, Key Advancements and Developments in Transplant Surgery. J Clin Med 2021;10:1634. [Crossref] [PubMed]
2. Merola R, Troise S, Palumbo D, et al. Airway management in patients undergoing maxillofacial surgery: State of art review. J Stomatol Oral Maxillofac Surg 2025;126:102044. [Crossref] [PubMed]
3. Smith TW Jr, Wang X, Singer MA, et al. Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties. Am J Surg 2020;219:530-4. [Crossref] [PubMed]
4. Semenkovich TR, Hudson JL, Subramanian M, et al. Enhanced Recovery After Surgery (ERAS) in Thoracic Surgery. Semin Thorac Cardiovasc Surg 2018;30:342-9. [Crossref] [PubMed]
5. Sagawa M, Matsui R, Sano A, et al. Perioperative or combined preoperative and postoperative standard nutrition therapy for patients with head and neck or gastrointestinal cancer: A systematic review and meta-analysis. Clin Nutr ESPEN 2025;67:567-77.
6. Veer V, Kia S, Papesch M. Anxiety and depression in head and neck out-patients. J Laryngol Otol 2010;124:774-7. [Crossref] [PubMed]
7. Ni K, Zhu J, Ma Z. Preoperative anxiety and postoperative adverse events: a narrative overview. Anesthesiology and Perioperative Science 2023;1:23.
8. Tarazona B, Tarazona-Álvarez P, Peñarrocha-Oltra D, et al. Anxiety before extraction of impacted lower third molars. Med Oral Patol Oral Cir Bucal 2015;20:e246-50. [Crossref] [PubMed]
9. Zhang Y, Yu J, Liu T, et al. Core preoperative symptoms and patients' symptom experiences in oral cancer: a mixed-methods study. Support Care Cancer 2025;33:319. [Crossref] [PubMed]
10. van den Heuvel SF, Jonker P, Hoeks SE, et al. The effect of stand-alone and additional preoperative video education on patients' knowledge of anaesthesia: A randomised controlled trial. Eur J Anaesthesiol 2025;42:313-23. [Crossref] [PubMed]
11. Kocaturk S, Gur ZB, Gursoytrak B. Can Verbal Interview Decrease Preoperative Anxiety and Postoperative Discomfort in Oral and Maxillofacial Surgery Patients?: A Randomized Clinical Trial. J Oral Maxillofac Surg 2024;82:1425-32. [Crossref] [PubMed]
12. Kumar A, Saravanan R, Krishnan B. Does an Audio-Visual Preoperative Patient Education Influence Anxiety and Retention of Information for Impacted Mandibular Third Molar Removal?-A Randomized Blinded Trial. J Maxillofac Oral Surg 2025;24:569-76. [Crossref] [PubMed]
13. Leonan-Silva B, Penna ÍSS, Meireles MR, et al. Hypnosis in controlling anxiety during third molar extraction: a critical review. Am J Clin Hypn 2025;67:218-26. [Crossref] [PubMed]
14. Raut SJ, Shetty L, Chhatriwala A, et al. Effect of meditation and relaxation therapy on preoperative anxiety and stress in oral squamous cell carcinoma patients scheduled for oral and maxillofacial surgery: An experimental study. Natl J Maxillofac Surg 2024;15:67-74. [Crossref] [PubMed]
15. Çelik ZM, Bayram F, Aktaç Ş, et al. Evaluation of pre- and postoperative nutrition and oral health-related quality of life in orthognathic surgery patients. Nutrition 2024;123:112418. [Crossref] [PubMed]
16. Yoshimura T, Suzuki H, Takayama H, et al. Impact of Preoperative Low Prognostic Nutritional Index and High Intramuscular Adipose Tissue Content on Outcomes of Patients with Oral Squamous Cell Carcinoma. Cancers (Basel) 2020;12:3167. [Crossref] [PubMed]
17. Shida A, Ida M, Ueda M, et al. Preoperative underweight is associated with adverse postoperative events in patients undergoing microvascular reconstruction surgery for oral and maxillofacial cancer. Int J Oral Maxillofac Surg 2021;50:598-603. [Crossref] [PubMed]
18. Hiraoka SI, Shimada Y, Kawasaki Y, et al. Preoperative nutritional evaluation, surgical site infection, and prognosis in patients with oral cancer. Oral Surg Oral Med Oral Pathol Oral Radiol 2022;134:168-75. [Crossref] [PubMed]
19. Tsai YT, Tsai MH, Kudva A, et al. The Prognostic Value of Preoperative Total Cholesterol in Surgically Treated Oral Cavity Cancer. Biomedicines 2024;12:2898. [Crossref] [PubMed]
20. Yu J, Hong B, Park JY, et al. Impact of Prognostic Nutritional Index on Postoperative Pulmonary Complications in Radical Cystectomy: A Propensity Score-Matched Analysis. Ann Surg Oncol 2021;28:1859-69. [Crossref] [PubMed]
21. Hartl WH, Kopper P, Bender A, et al. Protein intake and outcome of critically ill patients: analysis of a large international database using piece-wise exponential additive mixed models. Crit Care 2022;26:7. [Crossref] [PubMed]
22. Morimoto M, Nakamura Y, Yasuda Y, et al. Serum Total Cholesterol Levels Would Predict Nosocomial Infections After Gastrointestinal Surgery. Indian J Surg 2015;77:283-9. [Crossref] [PubMed]
23. Dorrance M, Copp M. Perioperative fasting: A review. J Perioper Pract 2020;30:204-9. [Crossref] [PubMed]
24. Joshi GP, Abdelmalak BB, Weigel WA, et al. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology 2023;138:132-51. [Crossref] [PubMed]
25. Wu HY, Yang XD, Yang GY, et al. Preoperative oral carbohydrates in elderly patients undergoing free flap surgery for oral cancer: randomized controlled trial. Int J Oral Maxillofac Surg 2022;51:1010-5. [Crossref] [PubMed]
26. Tong E, Chen Y, Ren Y, et al. Effects of preoperative carbohydrate loading on recovery after elective surgery: A systematic review and Bayesian network meta-analysis of randomized controlled trials. Front Nutr 2022;9:951676. [Crossref] [PubMed]
27. Johnson RE 3rd, Eckert PP, Gilmore W, et al. Most American Association of Oral and Maxillofacial Surgeons Members Have Not Adopted the American Society of Anesthesiologists-Recommended Nil Per Os Guidelines. J Oral Maxillofac Surg 2016;74:1926-31. [Crossref] [PubMed]
28. Collins L, Costello RA. Glucagon-Like Peptide-1 Receptor Agonists. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
29. Mayhew JF. Airway management for oral and maxillofacial surgery. Int Anesthesiol Clin 2003;41:57-65. [Crossref] [PubMed]
30. Jose A, Nagori SA, Agarwal B, et al. Management of maxillofacial trauma in emergency: An update of challenges and controversies. J Emerg Trauma Shock 2016;9:73-80. [Crossref] [PubMed]
31. Barak M, Bahouth H, Leiser Y, et al. Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach. Biomed Res Int 2015;2015:724032. [Crossref] [PubMed]
32. Goh EZ, Loh NHW, Loh JSP. Submental intubation in oral and maxillofacial surgery: a systematic review 1986-2018. Br J Oral Maxillofac Surg 2020;58:43-50. [Crossref] [PubMed]
33. Seo MH, Eo MY, Mustakim KR, et al. Reasonable necessity of preoperative laboratory tests in office-based oral and maxillofacial surgery. J Korean Assoc Oral Maxillofac Surg 2023;49:142-7. [Crossref] [PubMed]
34. Fenger-Eriksen C. Perioperative Coagulation Monitoring. Anesthesiol Clin 2021;39:525-35. [Crossref] [PubMed]
35. Landart C, Barbay V, Chamouni P, et al. Management of patients with inherited bleeding disorders in oral surgery: A 13-year experience. J Stomatol Oral Maxillofac Surg 2022;123:e405-10. [Crossref] [PubMed]
36. Tamim H, Habbal M, Saliba A, et al. Preoperative INR and postoperative major bleeding and mortality: A retrospective cohort study. J Thromb Thrombolysis 2016;41:301-11. [Crossref] [PubMed]
37. Samama CM, Djoudi R, Lecompte T, et al. Perioperative platelet transfusion: recommendations of the Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSaPS) 2003. Can J Anaesth 2005;52:30-7. [Crossref] [PubMed]
38. AlAsseri N, Swennen G. Minimally invasive orthognathic surgery: a systematic review. Int J Oral Maxillofac Surg 2018;47:1299-310. [Crossref] [PubMed]
39. Al-Moraissi EA. Open versus arthroscopic surgery for the management of internal derangement of the temporomandibular joint: a meta-analysis of the literature. Int J Oral Maxillofac Surg 2015;44:763-70. [Crossref] [PubMed]
40. Borumandi F, Cascarini L. Robotics in oral and maxillofacial surgery. Ann R Coll Surg Engl 2018;100:19-22. [Crossref] [PubMed]
41. Bandara DL, Kanmodi KK, Salami AA, et al. Quality of life of patients treated with robotic surgery in the oral and maxillofacial region: a scoping review of empirical evidence. BMC Oral Health 2024;24:276. [Crossref] [PubMed]
42. Ho JOY, Riva FMG. Robotic Surgery: Advancements and Applications of Robotic Surgery in Craniomaxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2025;37:543-52. [Crossref] [PubMed]
43. Sessler DI. Perioperative thermoregulation and heat balance. Lancet 2016;387:2655-64. [Crossref] [PubMed]
44. Ma Z, Ma P, Huang N, et al. Incidence of Unintentional Intraoperative Hypothermia and Its Risk Factors in Oral and Maxillofacial Surgery: A Prospective Study. J Perianesth Nurs 2023;38:876-80. [Crossref] [PubMed]
45. Ju JW, Nam K, Sohn JY, et al. Association between intraoperative body temperature and postoperative delirium: A retrospective observational study. J Clin Anesth 2023;87:111107. [Crossref] [PubMed]
46. Xu H, Wang Z, Guan X, et al. Safety of intraoperative hypothermia for patients: meta-analyses of randomized controlled trials and observational studies. BMC Anesthesiol 2020;20:202. [Crossref] [PubMed]
47. Torossian A, Bräuer A, Höcker J, et al. Preventing inadvertent perioperative hypothermia. Dtsch Arztebl Int 2015;112:166-72. [Crossref] [PubMed]
48. Grote R, Wetz AJ, Bräuer A, et al. Prewarming according to the AWMF S3 guidelines on preventing inadvertant perioperative hypothermia 2014 : Retrospective analysis of 7786 patients. Anaesthesist 2018;67:27-33. [Crossref] [PubMed]
49. Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001;87:62-72. [Crossref] [PubMed]
50. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS(®)) Society Recommendations: 2018. World J Surg 2019;43:659-95. [Crossref] [PubMed]
51. Debono B, Wainwright TW, Wang MY, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J 2021;21:729-52. [Crossref] [PubMed]
52. Bansal T, Sharan AD, Garg B. Enhanced recovery after surgery (ERAS) protocol in spine surgery. J Clin Orthop Trauma 2022;31:101944. [Crossref] [PubMed]
53. Wick EC, Grant MC, Wu CL. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg 2017;152:691-7. [Crossref] [PubMed]
54. Castellanos CX, Paoletti M, Ulloa R, et al. Opioid Sparing Multimodal Analgesia for Transoral Robotic Surgery: Improved Analgesia and Narcotic Use Reduction. OTO Open 2023;7:e17. [Crossref] [PubMed]
55. Perisanidis C, Saranteas T, Kostopanagiotou G. Ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in oral and maxillofacial surgery. Dentomaxillofac Radiol 2013;42:29945724. [Crossref] [PubMed]
56. Apipan B, Rummasak D, Wongsirichat N. Postoperative nausea and vomiting after general anesthesia for oral and maxillofacial surgery. J Dent Anesth Pain Med 2016;16:273-81. [Crossref] [PubMed]
57. Silva AC, O'Ryan F, Poor DB. Postoperative nausea and vomiting (PONV) after orthognathic surgery: a retrospective study and literature review. J Oral Maxillofac Surg 2006;64:1385-97. [Crossref] [PubMed]
58. Brookes CD, Berry J, Rich J, et al. Multimodal protocol reduces postoperative nausea and vomiting in patients undergoing Le Fort I osteotomy. J Oral Maxillofac Surg 2015;73:324-32. [Crossref] [PubMed]
59. Arpaci AH, Işik B, Ilhan E, et al. Association of Postoperative Nausea and Vomiting Incidence With Neutrophil-Lymphocyte Ratio in Ambulatory Maxillofacial Surgery. J Oral Maxillofac Surg 2017;75:1367-71. [Crossref] [PubMed]
60. Zhu AC, Agarwala A, Bao X. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clin Colon Rectal Surg 2019;32:114-20. [Crossref] [PubMed]
61. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002;89:622-32. [Crossref] [PubMed]
62. Dort JC, Farwell DG, Findlay M, et al. Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society. JAMA Otolaryngol Head Neck Surg 2017;143:292-303. [Crossref] [PubMed]
63. Farwell DG, Reilly DF, Weymuller EA Jr, et al. Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg 2002;128:505-11. [Crossref] [PubMed]
64. Kan CFK, Skaggs JD. Current Commonly Used Dynamic Parameters and Monitoring Systems for Perioperative Goal-Directed Fluid Therapy: A Review. Yale J Biol Med 2023;96:107-23. [Crossref] [PubMed]
65. Tapia B, Garrido E, Cebrian JL, et al. Impact of Goal Directed Therapy in Head and Neck Oncological Surgery with Microsurgical Reconstruction: Free Flap Viability and Complications. Cancers (Basel) 2021;13:1545. [Crossref] [PubMed]
66. László I, Janovszky Á, Lovas A, et al. Effects of goal-directed crystalloid vs. colloid fluid therapy on microcirculation during free flap surgery: A randomised clinical trial. Eur J Anaesthesiol 2019;36:592-604. [Crossref] [PubMed]
67. Rana M, Gellrich NC, Joos U, et al. 3D evaluation of postoperative swelling using two different cooling methods following orthognathic surgery: a randomised observer blind prospective pilot study. Int J Oral Maxillofac Surg 2011;40:690-6. [Crossref] [PubMed]
68. Abramson DI, Chu LS, Tuck S Jr, et al. Effect of tissue temperatures and blood flow on motor nerve conduction velocity. JAMA 1966;198:1082-8.
69. Santos TS, Osborne PR, Jacob ES, et al. Effects of Water-Circulating Cooling Mask on Postoperative Outcomes in Orthognathic Surgery and Facial Trauma. J Craniofac Surg 2020;31:1981-5. [Crossref] [PubMed]
70. Hosseinpour S, Tunér J, Fekrazad R. Photobiomodulation in Oral Surgery: A Review. Photobiomodul Photomed Laser Surg 2019;37:814-25. [Crossref] [PubMed]
71. Tazreean R, Nelson G, Twomey R. Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements. J Comp Eff Res 2022;11:121-9. [Crossref] [PubMed]
72. Yang Y, Wu HY, Wei L, et al. Improvement of the patient early mobilization protocol after oral and maxillofacial free flap reconstruction surgery. J Craniomaxillofac Surg 2020;48:43-8. [Crossref] [PubMed]
73. Adhikari A, Noor A, Mair M, et al. Comparison of postoperative complications in early versus delayed tracheostomy decannulation in patients undergoing oral cancer surgery with microvascular reconstruction. Br J Oral Maxillofac Surg 2023;61:101-6. [Crossref] [PubMed]
74. Dean YE, Motawea KR, Bamousa BAA, et al. Early oral feeding and its impact on postoperative outcomes in head and neck cancer surgery: a meta-analysis. Maxillofac Plast Reconstr Surg 2024;46:11. [Crossref] [PubMed]
75. Yang Y, Li M, Wu Y, et al. Nanoscaled self-alignment of Fe3O4 nanodiscs in ultrathin rGO films with engineered conductivity for electromagnetic interference shielding. Nanoscale 2016;8:15989-98. [Crossref] [PubMed]
76. El Khatib K, Gradel J, Danino A, et al. Enteral feeding by nasogastric tube in mandibular fracture osteosynthesis. Rev Stomatol Chir Maxillofac 2005;106:13-5. [Crossref] [PubMed]
77. Barlow J, Sragi Z, Rodriguez N, et al. Early feeding after free flap reconstruction of the oral cavity: A systematic review and meta-analysis. Head Neck 2024;46:1224-33. [Crossref] [PubMed]