Deliberate Practice and Process Analysis in DIEP Flap Breast Reconstruction: An Immediate and Sustained Decrease in Morbidity and Operative Time

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Introduction: DIEP flaps are nuanced, multi-step complex procedures. Recent studies have hinted that operational flow can be a sensitive barometer for safety, efficiency and overall outcomes. We critically assess the utility of implementing deliberate practice and process mapping as a research tool in the context of morbidity and operative time. Materials and Methods: Co-surgeons at a university hospital implemented deliberate practice and performed two prospective process analysis studies evaluating critical steps in DIEP flap reconstruction. During the 9-month period (June 2018-February 2019), the flap harvest and microsurgery steps were assessed. During the 8-month period (January-August 2020), the analysis was expanded to encompass the entire operation. To evaluate the immediate and sustained impact of process analysis, 375 bilateral DIEP flap patients were divided into eight consecutive 9-month intervals completed before, during and after the two studies. Using risk-adjusted multivariate regressions and a generalized linear model, morbidity and operative time was compared between groups. Experience was controlled for by using a difference contrast that compares that most recent time interval to the collective mean of prior time intervals. Results: Time intervals completed prior to the first study had comparable morbidity and operative time. During the first study, there is an immediate 83.8% (p<.001) decrease risk in morbidity. Operative time during the second study decreased by 2.19 hours (p<.001). Morbidity and operative time continue to decrease in every time interval until the end of data collection (62.1% decrease risk in morbidity, p=.023 and 2.22 hours, p<.001). Conclusion: Process mapping and analysis in DIEP flap breast reconstruction can lead to immediate and sustained decreases in morbidity and operative time. It is more effective at improving performance compared to experience alone due to its capacity to provide immediate feedback. This approach can be applied to other aspects of plastic surgery with the goal of overall improvement in outcomes and surgeon expertise.