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Page 2 of 12 Haddock et al. Plast Aesthet Res 2024;11:47 https://dx.doi.org/10.20517/2347-9264.2024.60

[1,2]
based . However, recent studies have demonstrated an increasing rate of microsurgical autologous breast
[3,4]
reconstruction (MABR) compared to prosthetic breast reconstruction . MABR has demonstrated superior
long-term aesthetic outcomes, heightened patient satisfaction, and improved psychosocial and sexual well-
being compared to prosthetic reconstruction [5-10] . In the irradiated breast, MABR is considered the gold
standard [11,12] . It is highly probable that increasing trends of MABR will continue, given the increased
awareness among both patients and surgeons regarding implant-related risks, such as breast implant illness
(BII) and breast implant-associated lymphoma (BIA-ALCL). Primary obstacles to autologous
reconstruction are surgical factors, including prolonged operative times, increased scarring, and extended
hospital stays [13,14] .

Operative duration is among the primary challenges in MABR, impacting both patients and surgeons. This
intricate procedure involves recipient vessel preparation, dissection and harvesting of perforators and
pedicles, microsurgical anastomoses, flap placement, and donor site closure. In numerous practices, bilateral
MABR can extend beyond 12 h. Literature consistently highlights increased complication rates associated
with prolonged operative times across various surgical fields, including MABR [15-18] .

The current economic climate in healthcare is marked by declining reimbursements and rising care costs.
The benefits of improved efficiency include reduced surgery backlogs, optimized patient safety and
outcomes, and cost reduction through decreased operating room time and reduced hospital stays. There is a
burgeoning interest in enhancing operative efficiency within breast microsurgery, with several high-volume
practices demonstrating the safety and effectiveness of “efficient” microsurgical breast reconstruction in
four hours or less [19-23] . This systematic review aims to underscore the processes that can positively impact
operating room efficiency, with a focus on implications in MABR.

Value-based healthcare: the “why” of efficiency in microsurgery
Value-based healthcare represents a strategic shift in healthcare delivery, emphasizing the optimization of
patient outcomes while containing costs [24-26] . This model redefines the traditional fee-for-service approach
by centering on the value provided to patients, focusing on enhancing quality and efficiency in care delivery.
In surgery, the value-based framework prioritizes patient results and experiences, striving for favorable
outcomes while simultaneously controlling expenditures. This necessitates a thorough understanding of the
dynamics between cost, quality, and patient-centered outcomes, streamlining surgical interventions to
maximize effectiveness while minimizing avoidable complications or unnecessary procedures. As healthcare
systems globally pivot toward value-based care models, the operating theater will remain a heavily
scrutinized area both in terms of quality and cost of care.

Caution must be taken when considering the value of healthcare, specifically in surgery. Simply quantifying
cost reduction with no consideration for outcomes achieved may lead to false “savings” and potentially limit
effective care. Healthcare payment legislation passed in recent years has begun to prioritize outcomes as
opposed to fee-for-service models and represents an overall shift toward value-based care [27,28] .

Microsurgical autologous breast reconstruction (MABR) is a relatively standardized surgical procedure
where one can measure results versus costs. Regarding the “inputs” and “outputs” of the system, the outputs
of MABR are flap survival, time to discharge, overall aesthetic results, and patient-reported outcome
measures, whereas costs are operative time, the human cost of staff/surgical team (perioperative nursing,
scrub technicians, anesthesia), cost of medications (anesthesia, ERAS pathways), flap monitoring devices,
etc. This allows tracking both the input and output of the entire process. The overall goal of a value-based
[23]
system should be to reduce inputs while maintaining or increasing the outputs .