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Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction
Abstract
PURPOSE: Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center. METHODS: Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and χ analysis. RESULTS: Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P < 0.01), across the study period, with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (P < 0.01). Length of stay decreased from 6.3 to 5.2 days (P = 0.01). Overall complication rates (35.9% vs 30%, not significant) and take-back rates (20.5% vs 23.9%, not significant) remained similar over the 5-year period. Physician revenue/minute increased from US $6.28 to US $7.59, whereas hospital revenue/minute increased from US $21.84 to US $25.11. CONCLUSIONS: A Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.
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“with the use of DMAIC, the ones that stood out the most were decreased lead time, reduced length of stay and decreased costs [21,30,38,48,55].”
From Lean Healthcare Tools for Processes Evaluation: An Integrative Review. (2021) · cites this paper as [48]
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“review of work processes [38,46,47,48,49]”
From Lean Healthcare Tools for Processes Evaluation: An Integrative Review. (2021) · cites this paper as [48]
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“there are effects of “increase in revenue” and “costs reduction” [21,38,48].”
From Lean Healthcare Tools for Processes Evaluation: An Integrative Review. (2021) · cites this paper as [48]
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Research works printed but not linked: 25
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Lean Healthcare Tools for Processes Evaluation: An Integrative Review.
de Barros, L. B., Bassi, L. D. C., Caldas, L. P., Sarantopoulos, A., Zeferino, E. B. B., Minatogawa, V., & Gasparino, R. C. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18147389 · Cited by 90
“In this sense, there are effects of “increase in revenue” and “costs reduction” [21,38,48].”
BackgroundMethod
Metadata
- Authors
- Hultman, C. S., Kim, S., Lee, C. N., Wu, C., Dodge, B., Hultman, C. E., Roach, S. T., & Halvorson, E. G.
- Affiliations
- Brigham and Women's Hospital (US)
- University of North Carolina Health Care (US)
- ORCID
- Lee, Clara N.
- Venue
- Annals of Plastic Surgery
- Published
- 2016-06
- Volume
- 76
- Issue
- Supplement 4
- Pages
- S352-S356
- ISSN
- 0148-7043 (ISSN-L)
- OpenAlex
- W2397857202
- Cited by
- 33
- References
- 0
- Citations by year
- 2026: 3 · 2025: 1 · 2024: 7 · 2023: 1 · 2022: 7 · 2021: 3 · 2020: 4 · 2019: 2 · 2017: 2 · 2016: 2
- FWCI
- 3.45
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Plastic Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Decision Sciences › Management Science and Operations Research › Healthcare Operations and Scheduling Optimization
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Quality and Management
- Health Sciences › Medicine › Surgery › Reconstructive Surgery and Microvascular Techniques
- Keywords
- Six Sigma, lean manufacturing, microsurgical breast reconstruction, perforator flap, operative time, length of hospital stay, workflow analysis, continuous quality improvement, learning curve, hospital revenue, surgical efficiency
- MeSH terms
- Academic Medical Centers, Adult, Aged, Efficiency, Female, Humans, Microsurgery, Middle Aged, North Carolina, Mammaplasty, Workflow, Quality Improvement, Perforator Flap, Operative Time
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- CoChat. (2026). Citation check: Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction. https://app.cochat.ai/papers/10.1097/sap.0000000000000786
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- Hultman, C. S., Kim, S., Lee, C. N., Wu, C., Dodge, B., Hultman, C. E., Roach, S. T., & Halvorson, E. G. (2016). Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction. Annals of Plastic Surgery. https://doi.org/10.1097/sap.0000000000000786
