Reply: Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps

Background: With advances in technology and technique, the goal of microvascular breast reconstruction has transitioned from flap success to minimizing complications and maximizing aesthetic outcome and efficiency. In an effort to evaluate efficiency, the authors implemented a rigorous process analysis in their practice to evaluate deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods: A prospective implementation of process analysis was instituted on 147 DIEP flaps. The eight critical maneuvers for a DIEP flap are (1) skin to perforator identification, (2) perforator decision making, (3) perforator dissection, (4) pedicle dissection, (5) flap harvest, (6) preparation for microsurgery, (7) venous anastomosis, and (8) arterial anastomosis. Surgeons with variable experiences (faculty, faculty with senior resident/fellow, and supervised chief resident) used these eight steps to perform DIEP flap reconstruction. The outcomes and time of each maneuver were tracked. Results: The total flap harvest time among the three groups was 54.8 minutes for faculty surgeons, 98.3 minutes for senior resident/fellow working with faculty, and 178.8 minutes for supervised chief resident (p < 0.001). The largest difference was seen in perforator dissection. Increasing the number of perforators resulted in longer flap harvest times. Perforator location did not have an impact on times, but harvesting multiple rows took longer for less experienced surgeons. Body mass index and flap weight did not have an impact on time. Conclusions: The authors share their experience using process analysis for DIEP flap reconstruction. They defined eight critical maneuvers to maximize efficiency and safety. By communicating efficient processes and integrating them into the workflow of a given operation, surgeons can continue to improve throughout the arc of their careers.