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Haddock et al. Plast Aesthet Res 2024;11:47 https://dx.doi.org/10.20517/2347-9264.2024.60 Page 5 of 12

Figure 1. Mapping diagram of a delayed bilateral DIEP flap breast reconstruction in a 58-year-old patient with a BMI of 25.6. The first
DIEP flap had one intermediate perforator and the second DIEP flap had three lateral perforators. There were no revisions. The
procedure was completed in 3 h and 25 min. De-ep: De-epithelialization; TAP: transversus abdominus plane; DIEP: deep inferior
epigastric perforator flap.

(breast AND reconstruction) AND (microsurgery OR free flap OR autologous) AND (efficiency OR process
analysis OR lean OR six sigma OR four discipline). 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.

Screening was performed at two levels (title/abstract and full text screening) by two independent reviewers
(T. S. and N. H.). The initial criteria for full text screening included articles describing the implementation
of efficiency models in microvascular breast reconstruction. Studies were excluded if they were not available
in the English language, animal or cadaveric studies, studies published before the year 2004, publications
formatted as a letter, editorial, or conference abstract, those that did not list a process or depicted the
process as a map, or did not have a novel process-mapping for the selected center(s). Due to the lack of
randomized control trials and a diverse range of study aims and outcomes, meta-analysis was not
applicable.

RESULTS
A total of 256 records were identified through the literature search [Figure 2]. After removing duplicates
and screening titles/abstracts, 29 full-text publications were reviewed. Eleven articles met all inclusion
criteria [Table 1]. Six were retrospective reviews and five were prospective cohort studies. Six articles
centered around the standardization of operative technique without a predefined “model of efficiency”,
whereas five articles highlighted a specific implementation protocol of an efficiency model. Of these five,
one used a Lean Six Sigma model, one used a 4DX model, and three used a process mapping and analysis
model.

DISCUSSION
Microvascular breast reconstruction represents a sophisticated, multi-stage procedure necessitating the
collaboration of a sizable surgical team. The degree of complexity inherent in the process, as well as the
involvement of numerous personnel, underscores the potential benefits of employing process analysis for