100 Steps of a DIEP Flap—A Prospective Comparative Cohort Series Demonstrating the Successful Implementation of Process Mapping in Microsurgery

Abstract

Background: The demand to improve the efficiency of microsurgical breast reconstruction is driven by increasing number of breast cancer and risk reducing cases, and the concurrent requirement for hospitals to cut costs. Businesses have successfully used process mapping as a tool to improve efficiency; however, process mapping has been sparsely used in surgery. This prospective cohort study has used process mapping to break down the individual components of a deep inferior epigastric artery perforator (DIEP) flap operation into a template of 100 streamlined steps. Methods: Through observation of the senior author’s uniform technique, refined from experience of over 5,000 cases, the DIEP flap operation was broken down into 100 individual steps, all arranged in a logical sequence with which to maximize efficiency and outcome. This created a 100-step process-mapped template. Subsequently, 2 cohorts of 10 unilateral DIEP cases were prospectively timed. One cohort following this process mapped template and the other control group was blinded to the template. Results: The process-mapped cohort was 56.1 minutes quicker than the control cohort, despite the addition of symmetrizing surgery being performed concurrently in 4 out of the 10 cases. Furthermore, there was no return to theater in the process-mapped cohort versus 1 return to theater in the control cohort with no flap loss in either group. Conclusions: This study uniquely presents an approach to process map the DIEP flap operation and demonstrates its utility in improving operative efficiency, without compromising outcomes. It also illustrates the possibility of symmetrizing surgery being carried out through parallel operating processes, without affecting overall operative times.

Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours

“…Others evaluated the DIEP flap as a 100-step procedure. 1 This is incredibly detailed, and while useful, we find this difficult to implement and track. We have therefore, categorized portions of DIEP flap breast reconstruction and divided each category into a few individual steps, which in our mind simplifies our process analysis.…”

Process mapping in healthcare: a systematic review

“…Phase 2: 85% of the studies stated that data and information had been gathered to inform the PM exercise as a substitute for (55%), or in addition to (30%), the group knowledge generated in the facilitated process mapping sessions. This included evidence-based best practice recommendations [ 34 – 155 ], interviews [ 64 , 73 – 148 , 154 , 156 , 158 , 160 ], and more detailed approaches such as observations, operational data collection, time-and-motion studies, and video footage [ 48 , 78 – 81 , 141 , 143 – 146 , 150 , 159 , 163 – 169 ].…”

The Sc-GAP makeover flap: eliminating the need for position changes in gluteal flap breast reconstruction

“…Patients who underwent a LTP flap for breast reconstruction almost always desire secondary corrections with lipofilling of their breasts because of this squared shape. Beveling the Sc-GAP makeover flap results in smooth transition of the flap edges, like those of the DIEP flap, and ensures volume of the upper pole of the reconstructed breast [14]. Figure 5 b shows that the Sc-GAP makeover flap is actually similar to the DIEP flap, which is the first choice and can be considered the gold standard for autologous breast reconstruction.…”