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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:
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