Enhanced Recovery after Surgery Protocol for Facial Feminization Surgery Reduces Pain and Length of Hospital Stay

Abstract

BACKGROUND: Patients undergoing gender-affirming surgeries represent a potentially vulnerable cohort for prolonged opioid use. In addition to gender dysphoria, transgender patients are frequently diagnosed with anxiety or depression, known risk factors for persistent opioid use after surgery. This study evaluates the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery (FFS). METHODS: Seventy-nine patients (mean age 32.5 +/- 10.2 years) who underwent single-stage facial feminization surgery before and after ERAS protocol implementation were retrospectively reviewed. Patient characteristics, length of surgery, complications, pain scores, opioid use in morphine equivalent dosing per kilogram (MED/kg), and length of hospital stay were compared between groups. RESULTS: Of the entire cohort, 75.9% of patients had a mental health diagnosis, of which anxiety and depression were the most common. Comparison of the pre-ERAS (n=38, 48.1%) versus the ERAS (n=33, 51.9%) groups demonstrated no differences in age, body mass index, mental health diagnoses, length of surgery, or complications. The ERAS group reported lower postoperative pain scores (mean+/- SD, 2.51.8 versus 3.7+/- 1.6, p=0.002) and total inpatient opioid usage (median 0.8 versus 1.5 MED/kg, p<0.001) compared to the pre-ERAS group. The length of hospital stay was also significantly reduced in the ERAS group compared to the pre-ERAS group (median 27.3 versus 32.4 hours, p<0.001). CONCLUSION: We report the design of the FFS ERAS protocol and demonstrate that implementation reduced pain scores, opioid use, and length of hospital stay after FFS.