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

Background: Deep inferior epigastric perforator (DIEP) flaps are nuanced, multistep, complex procedures. Recent studies have hinted that operational flow can be a sensitive barometer for safety, efficiency, and overall outcomes. The authors critically assess the utility of implementing deliberate practice and process mapping as a research tool in the context of morbidity and operative time. 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 of 2018 to February of 2019), the flap harvest and microsurgery steps were assessed. During the 8-month period (January to August of 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, morbidity and operative time were compared between groups. Results: Time intervals completed before the first study had comparable morbidity and operative time. During the first study, there was an immediate 83.8% (P < 0.001) decreased risk in morbidity. Operative time during the second study decreased by 2.19 hours (P < 0.001). Morbidity and operative time continued to decrease until the end of data collection [62.1% decreased risk in morbidity (P = 0.023) and decreased operative time of 2.22 hours (P < 0.001)]. Conclusions: Deliberate practice and process analysis are powerful tools. Implementation of these tools can generate immediate and sustained decreases in morbidity and operative time for patients undergoing procedures such as DIEP flap breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.