Operative efficiency in autologous breast reconstruction: a systematic review

Abstract

Breast cancer is a leading cause of cancer in women worldwide. With increased public awareness of routine breast cancer screening, the incidence of mastectomy and, therefore, breast reconstruction continues to increase year over year. Value-based healthcare has become a universal priority in medical systems. A systematic review of the literature was performed in March 2024 across four electronic databases (PubMed, Embase, Google Scholar, and MEDLINE) and in accordance with the PRISMA guidelines. Screening was performed at two levels (title/abstract and full text screening) by two independent reviewers. Data items extracted included: year, authors, country, study size, duration, strategy implemented, main aims, area of application, study design and methodology, outcomes, relevant statistical analysis, and follow-up. Eleven articles were identified that met all inclusion criteria. Six were retrospective reviews and five were prospective cohort studies. The efficiency models implemented included Lean Six Sigma, the Four Disciplines of Execution, and process mapping and analysis. Emphasizing efficiency is pivotal in delivering outstanding breast reconstruction services and enhancing the overall patient journey.

Keywords

Autologous breast reconstruction / microsurgery / DIEP / efficiency / process analysis

References

[1] Jagsi R,Momoh A.Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States.J Clin Oncol2014;32:919-926. PMCID:PMC4876312

[2] Albornoz CR,Mehrara BJ.A paradigm shift in U.S. breast reconstruction: increasing implant rates.Plast Reconstr Surg2013;131:15-23.

[3] Masoomi H,Clemens MW.Autologous breast reconstruction trends in the United States: using the nationwide inpatient sample database.Ann Plast Surg2021;87:242-247.

[4] Shah JK,Cevallos P.Updated trends and outcomes in autologous breast reconstruction in the United States, 2016–2019.Ann Plast Surg2024;92:e1-e13.

[5] Dempsey K,Brennan M.The role of breast reconstruction choice on body image patient-reported outcomes at four years post-mastectomy for breast cancer: a longitudinal prospective cohort study.Psychooncology2022;31:54-61.

[6] Liu C,Momeni A.Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q.Breast Cancer Res Treat2014;146:117-126.

[7] Metcalfe KA,Quan M.Changes in psychosocial functioning 1 year after mastectomy alone, delayed breast reconstruction, or immediate breast reconstruction.Ann Surg Oncol2012;19:233-241.

[8] Santosa KB,Kim HM.Long-term patient-reported outcomes in postmastectomy breast reconstruction.JAMA Surg2018;153:891-899. PMCID:PMC6233781

[9] Retrouvey H,Metcalfe KA.Psychosocial functioning in women with early breast cancer treated with breast surgery with or without immediate breast reconstruction.Ann Surg Oncol2019;26:2444-2451.

[10] Dempsey K,Brennan M.Patient-reported health-related quality of life outcomes following mastectomy for breast cancer, with immediate, delayed or no breast reconstruction: four-year follow-up from a prospective cohort study.The Breast2023;71:122-131. PMCID:PMC10428140

[11] Nelson JA,Myers PL.Matched preliminary analysis of patient-reported outcomes following autologous and implant-based breast reconstruction.Ann Surg Oncol2022;29:5266-5275. PMCID:PMC9253052

[12] Polanco TO,Parikh RP.Quality of life in breast reconstruction patients after irradiation to tissue expander: a propensity-matched preliminary analysis.Plast Reconstr Surg2023;152:259-269. PMCID:PMC10390648

[13] Gopie JP,Kleijne A.Women’s motives to opt for either implant or diep-flap breast reconstruction.J Plast Reconstr Aesthet Surg2011;64:1062-1067.

[14] Nelson JA,Polanco T.Association of radiation timing with long-term satisfaction and health-related quality of life in prosthetic breast reconstruction.Plast Reconstr Surg2022;150:32E-41E. PMCID:PMC9453854

[15] Qiu CS,Dorfman RG.Surgical duration impacts venous thromboembolism risk in microsurgical breast reconstruction.J Reconstr Microsurg2018;34:47-58.

[16] Cheng H,Po-Han Chen B.Prolonged operative duration is associated with complications: a systematic review and meta-analysis.J Surg Res2018;229:134-144.

[17] Allan J,Moradi P.The effect of operative time on complication profile and length of hospital stay in autologous and implant-based breast reconstruction patients: an analysis of the 2007-2012 ACS-NSQIP database.J Plast Reconstr Aesthet Surg2020;73:1292-1298.

[18] Fogarty BJ,Ashall G.Complications of long operations: a prospective study of morbidity associated with prolonged operative time (> 6 h).Br J Plast Surg1999;52:33-36.

[19] Elliott LF,Bergey P.The 3-hour muscle-sparing free TRAM flap: safe and effective treatment review of 111 consecutive free TRAM flaps in a private practice setting.Plast Reconstr Surg2007;120:27-34.

[20] Marsh D,Rozen WM,Sharma H.Three routine free flaps per day in a single operating theatre: principles of a process mapping approach to improving surgical efficiency.Gland Surg2016;5:107-114. PMCID:PMC4791348

[21] Canizares O,Soto E,Sadeghi A.Optimizing efficiency in deep inferior epigastric perforator flap breast reconstruction.Ann Plast Surg2015;75:186-192.

[22] Haddock NT.Efficient DIEP flap: bilateral breast reconstruction in less than four hours.Plast Reconstr Surg Glob Open2021;9:e3801 PMCID:PMC8423400

[23] Steele TN,Haddock NT.Efficiency in microvascular breast reconstruction.Curr Surg Rep2024;12:89-96.

[24] Porter ME.What is value in health care?.N Engl J Med2010;363:2477-2481.

[25] Tsevat J.Value-based health care meets cost-effectiveness analysis.Ann Intern Med2018;169:329-332.

[26] Teisberg E,O’Hara S.Defining and implementing value-based health care: a strategic framework.Acad Med2020;95:682-685. PMCID:PMC7185050

[27] Jones LK,Becker A,Scharf E.MACRA and the future of value-based care.Neurol Clin Pract2016;6:459-465. PMCID:PMC5765906

[28] Squitieri L.Value-based payment reform and the medicare access and children’s health insurance program reauthorization act of 2015: a primer for plastic surgeons.Plast Reconstr Surg2017;140:205-214. PMCID:PMC5487279

[29] McChesney C,Huling J. The four disciplines of execution. New York: Simon and Schuster. 2012. Available from: https://books.google.com/books?hl=zh-CN&lr=&id=4w1VrlxDYZIC&oi=fnd&pg=PA19&dq=The+four+disciplines+of+execution.+New+York:+Simon+and+Schuster&ots=tocfeQQyuF&sig=V2IslsVtOcJL8R9SObRPtqGTBdA#v=onepage&q=The%20four%20disciplines%20of%20execution.%20New%20York%3A%20Simon%20and%20Schuster&f=false

[30] Easton J,Lax E,Dale E.using a business model (the 4 disciplines of execution) to improve consistency, efficiency, and length of stay in microvascular autologous breast reconstruction.Ann Plast Surg2022;89:532-537.

[31] Stein MJ,Lerman OZ.Lean and six sigma methodology can improve efficiency in microsurgical breast reconstruction.Plast Reconstr Surg Glob Open2021;9:e3669. PMCID:PMC8376386

[32] Mason SE,Darzi A.The use of lean and six sigma methodologies in surgery: a systematic review.The Surgeon2015;13:91-100.

[33] Hultman CS,Lee CN.Implementation and analysis of a lean six sigma program in microsurgery to improve operative throughput in perforator flap breast reconstruction.Ann Plast Surg2016;76 Suppl 4:S352-S356.

[34] Najjar PA,Kaplan RS.Time-driven activity-based costing for surgical episodes.JAMA Surg2017;152:96-97.

[35] Mericli AF,Kruse B,Rebello E.Time-driven activity-based costing to model cost utility of enhanced recovery after surgery pathways in microvascular breast reconstruction.J Am Coll Surg2020;230:784-794.e3.

[36] Sharma HR,Mathur B.100 steps of a DIEP flap—a prospective comparative cohort series demonstrating the successful implementation of process mapping in microsurgery.Plast Reconstr Surg Glob Open2019;7:e2016. PMCID:PMC6382232

[37] Haddock NT.Deconstructing the reconstruction: evaluation of process and efficiency in deep inferior epigastric perforator flaps.Plast Reconstr Surg2020;145:717e-724e.

[38] Lee BT,Yueh JH.Design and impact of an intraoperative pathway: a new operating room model for team-based practice.J Am Coll Surg2008;207:865-873

[39] Todd AR,Schrag C,Matthews J.Improved operative efficiency and surgical times in autologous breast reconstruction: a 15-year single-center retrospective review.Plast Reconstr Surg Glob Open2023;11:e5231 PMCID:PMC10752470

[40] Wade RG,Wormald JCR,Figus A.Perforator mapping reduces the operative time of DIEP flap breast reconstruction: a systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography.J Plast Reconstr Aesthet Surg2018;71:468-477.

[41] Vasile JV.Magnetic resonance angiography in perforator flap breast reconstruction.Gland Surg2016;5:197-211. PMCID:PMC4791349

[42] Thiessen FEF,Cloostermans B.Dynamic InfraRed thermography (DIRT) in DIEP-Flap breast reconstruction: a review of the literature.Eur J Obstet Gynecol Reprod Biol2019;242:47-55.

[43] Speck NE,Fluetsch A,Lardi AM.Comparing complications and perioperative teams in microsurgical breast reconstruction: retrospective cohort study.Gland Surg2022;11:1754-1763. PMCID:PMC9742050

[44] Cevik J,Rozen WM.The importance of perioperative team familiarity and its contribution to surgical efficiency and outcomes in microsurgical breast reconstruction.Gland Surg2023;12:1-4. PMCID:PMC9906097

[45] Bauermeister AJ,Newman M,Medina MA.Impact of continuous two-team approach in autologous breast reconstruction.J Reconstr Microsurg2017;33:298-304.

[46] Weichman KE,Wilson SC.The impact of two operating surgeons on microsurgical breast reconstruction.Plast Reconstr Surg2017;139:277-284.

[47] Haddock NT,Pezeshk RA.Co-surgeons in breast reconstructive microsurgery: what do they bring to the table?.Microsurgery2018;38:14-20.

[48] Mericli AF,Sisk GC.Microvascular breast reconstruction in the era of value-based care: use of a cosurgeon is associated with reduced costs, improved outcomes, and added value.Plast Reconstr Surg2022;149:338-348.

[49] Haddock NT.Five steps to internal mammary vessel preparation in less than 15 minutes.Plast Reconstr Surg2017;140:884-886.

[50] Malagón-López P,Carrasco-López C.Intraoperative indocyanine green angiography for fat necrosis reduction in the deep inferior epigastric perforator (DIEP) flap.Aesthet Surg J2019;39:NP45-NP54.

[51] Malagón-López P,García-Senosiain O,Del-Río M,Julian-Ibáñez JF.When to assess the DIEP flap perfusion by intraoperative indocyanine green angiography in breast reconstruction?.Breast2019;47:102-108.

[52] Ludolph I,Beier JP,Arkudas A.Leaving the perfusion zones?.J Plast Reconstr Aesthet Surg2022;75:52-60.

[53] Hembd AS,Zhu H,Teotia SS.Intraoperative assessment of DIEP flap breast reconstruction using indocyanine green angiography: reduction of fat necrosis, resection volumes, and postoperative surveillance.Plast Reconstr Surg2020;146:1e-10e.

[54] Martinez CA.Outpatient microsurgical breast reconstruction.last Reconstr Surg Glob Open2020;8:e3109. PMCID:PMC7544295

[55] Martinez CA,Rednam R.The outpatient diep: safety and viability following a modified recovery protocol.Plast Reconstr Surg Glob Open2018;6:e1898. PMCID:PMC6191230

[56] Tapp MW,Steele TN.Postoperative day 1 discharge in deep inferior epigastric artery perforator flap breast reconstruction.Plast Reconstr Surg Glob Open2023;11:e5064. PMCID:PMC10266520

[57] Haddock NT,Boyle CE,Teotia SS.Defining enhanced recovery pathway with or without liposomal bupivacaine in diep flap breast reconstruction.Plast Reconstr Surg2021;148:948-957.