Deliberate Practice and Process Analysis in DIEP Flap Breast Reconstruction: An Immediate and Sustained Decrease in Morbidity and Operative Time 

Nicholas T. Haddock, MD John T. Tycher, BS; Sumeet S. Teotia, MD
Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, US

• Deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. • Operative efficiency can be a sensitive barometer for complications, pain, length of stay and aesthetic outcomes. • Various industries and surgical disciplines leverage process mapping and analysis to identify inefficiencies. • Senior authors (N.T.H. and S.S.T.) implemented two prospective process analysis studies and defined steps critical to maximizing safety and efficiency in DIEP flaps.

This study objectively evaluates process analysis as a toolkit for immediate and sustained decrease in operative time and morbidity in DIEP flap reconstruction. 

• 375 bilateral DIEP flap patients were divided into eight consecutive 9-month intervals completed before, during and after the two studies (April 2015 to May 2021). • Two models: risk-adjusted multivariate regressions with a Difference contrast and GLM with a Repeated contrast. • Morbidity included any major flap, donor-site or medical complications requiring treatment in clinic or OR. • All continuous and categorical covariates were normally distributed across all time intervals.

• No differences in time intervals 1-4 • First & greatest decrease in morbidity coincides with the 2018 study. • Decreases in morbidity precede decreases in OT. • Effect is sustained after the completion of process analysis (i.e., during the 8th time interval patients are 62.1% less at risk for complications and procedures are completed in 2.22 hours less compared to intervals 1-7).