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Page 4 of 12 Haddock et al. Plast Aesthet Res 2024;11:47 https://dx.doi.org/10.20517/2347-9264.2024.60

Stein et al. published their experience with value stream mapping, finding that only 47% of instruments
[31]
within a given surgical tray were being used . By reducing the number of instruments needing to be
processed and sterilized in each case, they propose an overall decrease in waste and subsequent increase in
efficiency.

Time-driven activity-based costing
Time-Driven Activity-Based Costing (TDABC) is an innovative methodology designed to provide more
accurate cost assessments by focusing on the actual activities involved in providing a service and the time
required to perform these activities. Unlike traditional costing methods, which often allocate overhead costs
somewhat arbitrarily, TDABC assigns costs based on the efficient time required to perform each activity and
the cost per unit time of the resources used. This approach involves determining the cost of supplying
resources for each business process and then multiplying this by the time taken to carry out the process. A
key advantage of TDABC is its simplicity and flexibility, which make it easier to implement and update
compared to traditional activity-based costing systems, especially in dynamic environments like
healthcare .
[34]
TDABC has been applied to and analyzed within the context of MABR. Mericli et al. developed a decision-
analytic model to compare ERAS vs. standard of care recovery pathways following MABR . The authors
[35]
included 5 relevant studies and a total of 986 MABR patients: 596 in the standard-of-care arm, and 390 in
the ERAS arm. The mean length of stay was 1.5 days shorter in the ERAS cohort. The cost of the ERAS
pathway was found to represent a cost-savings of $735.04 per case and 1 additional day of quality-adjusted
life.

Process mapping and analysis
The Process Mapping and Analysis model is a structured approach used in surgical settings to systematically
diagram, assess, and optimize the sequence of activities within operative procedures. This model involves
creating visual representations of the entire surgical process, from preoperative preparation to postoperative
care, identifying steps, resources, and potential bottlenecks. By employing process mapping and analysis,
surgical teams can effectively identify and rectify operational inefficiencies, leading to smoother procedures,
minimized errors, and ultimately, improved patient outcomes. Sharma et al. outlined the “100 steps of a
[36]
DIEP flap” using a Process Mapping technique . The authors reviewed over 5,000 cases, subdivided the
procedure into 100 steps over 9 subcategories, and analyzed two cohorts: the Process Mapping group and
the non-Process Mapping group. They demonstrated an overall reduction in operative time from 219.2 min
(non-Process Mapping group) to 163.1 min (Process Mapping group), though significant differences
between the groups were reported.

Our own institution has significant experience with process mapping to improve efficiency for MABR . In
[37]
the seminal study covering a 10-month period (June 2018–April 2019), 147 bilateral DIEP breast
reconstructions were performed. The procedure was divided into eight critical maneuvers, and the time of
each of these steps was cataloged. Total operative time was reduced by 73 min, with significant differences
identified to correlate with the experience level of the surgeons [Figure 1].

METHODS
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. The
search strategy included selecting studies with patients undergoing autologous breast reconstruction, and
abstracts were reviewed to identify relevant literature. Searches were conducted with the following phrase: