title: Three routine free flaps per day in a single operating theatre: principles of a process mapping approach to improving surgical efficiency.
abstract: BACKGROUND
  Breast reconstruction is a multi-stage process, involving many individual procedures and many healthcare professionals which take the patient through from diagnosis of breast cancer to the completion of cancer treatment and ultimate breast reconstruction. With an experience of over 3,000 autologous breast reconstructions, we have refined both our surgical technique and overall approach to breast reconstruction to improve the efficiency in free flap based breast reconstruction surgery.
  
  
  METHODS
  Through a process mapping approach similar to that employed by large-scale industry, we have broken down free flap based breast reconstruction into multiple smaller processes. By looking at various steps as a simple component of the whole, we have improved our theatre efficiency to maximize patient throughput and improve our outcomes for breast reconstruction patients.
  
  
  RESULTS
  Since beginning free flap breast reconstruction surgery, we have improved overall efficiency by applying a process mapping approach. In our early experience, we undertook a single patient undergoing breast reconstruction with a free flap per theatre list, moving to two patients having breast reconstruction, and now carry out three free flap based reconstructions in a single theatre per day as a routine. Specific times are demonstrated, with no increased complication rate.
  
  
  CONCLUSIONS
  Through clearly defined processes, operative efficiency in autologous breast reconstruction can achieve three free flaps per day in a single theatre.
authors.affiliation: 1 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, UK ; 2 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia.
authors.forename: Dan
authors.initials: D
authors.lastname: Marsh
authors.affiliation: 1 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, UK ; 2 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia.
authors.forename: Nakul Gamanlal
authors.initials: NG
authors.lastname: Patel
authors.affiliation: 1 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, UK ; 2 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia.
authors.forename: Warren Matthew
authors.initials: WM
authors.lastname: Rozen
authors.affiliation: 1 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, UK ; 2 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia.
authors.forename: Muhammed
authors.initials: M
authors.lastname: Chowdhry
authors.affiliation: 1 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, UK ; 2 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia.
authors.forename: Hrsikesa
authors.initials: H
authors.lastname: Sharma
authors.affiliation: 1 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, UK ; 2 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia.
authors.forename: Venkat V
authors.initials: VV
authors.lastname: Ramakrishnan
keywords: Deep inferior epigastric artery; free flap; microsurgery; perforator flap