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Haddock et al. Plast Aesthet Res 2024;11:47 https://dx.doi.org/10.20517/2347-9264.2024.60 Page 7 of 12

Figure 2. Attrition chart of the systematic review performed.

Modifiable factors to improve efficiency in MABR
Preoperative
Patient selection is a critical component of any surgical intervention. Primary considerations for autologous
breast reconstruction include a thorough history and physical exam and extensive counseling on a patient’s
options. Prior surgical intervention such as abdominoplasty is an absolute contraindication for DIEP flap
breast reconstruction, necessitating alternative autologous flaps versus implant-based reconstruction. Severe
obesity, uncontrolled diabetes, cardiovascular disease, and coagulopathy are relative contraindications and
considered on a case-by-case basis. Preoperative CT angiogram has been repeatedly shown to reduce
operative time in MABR and has become the standard of care in the senior authors’ practice [38,39] . Other
authors have demonstrated similar results with MRI and thermography [40-42] . Preoperative imaging provides
several advantages regarding increased efficiency, including detailed anatomic assessment and vascular
mapping of the perforators, which reduces the time to perforator identification. Preoperative imaging has
also been shown to reduce operative risks and overall blood loss and enhance patient outcomes through
increased surgical success rates.

Perioperative
As with any surgical procedure, the expertise and familiarity of the surgical team are invaluable. It is
essential that the surgical staff, anesthesia providers, and postoperative nursing care team are well-versed in
all stages of microsurgical patient care [43,44] . Additionally, multiple studies have demonstrated decreased OR
time, improved patient outcomes, shorter hospital stays, and higher success rates with a co-surgeon [45,46] . In
the authors’ experience, overall morale is increased and surgeon fatigue is decreased with a co-surgeon
model. A review of our practice from 2011–2016 demonstrated an overall reduction in operative time by 193
min when comparing co-surgeon model to solo surgeon and showed reduced length of stay and decreased
wound occurrences . A 2022 retrospective review of 150 patients examined the cost of the co-surgeon
[47]
model in MABR, including the potential opportunity costs, and demonstrated that the co-surgeon model
significantly reduced both the operation duration by up to 132 min and costs by approximately $1,389.
Additionally, the presence of a co-surgeon was linked to fewer breast-site complications and a trend toward
reduced overall major complications. The co-surgeon model remains net-positive from a cost standpoint if
the co-surgeon is present for 320 min or less, depending on the level of the co-surgeon (assistant vs.
[48]
associate vs. full professor) .

Regarding efficiency and process mapping, our institution has implemented a protocol for process mapping
for all MABR cases [Figure 1]. Process mapping is a model of deliberate practice that has vastly improved
operative time and outcomes for patients in our practice. A typical bilateral DIEP flap breast reconstruction