Optimizing Efficiency in Lower Extremity Microsurgical Reconstruction Using Six Sigma: From Procedure to Process

BACKGROUND: Lower extremity reconstruction is complex and resource-intensive, yet reimbursement continues to decline. The COVID-19 pandemic further strained healthcare delivery, emphasizing the need for innovative strategies to sustain the viability of microsurgical care. While prior literature has focused on strategies to improve operative efficiency in breast microsurgery, the impact in lower extremity reconstruction is less defined. We evaluated the impact of a structured quality improvement (QI) initiative on efficiency and outcomes in lower extremity reconstruction. METHODS: A single-center QI initiative using a Six Sigma DMAIC framework was implemented in July 2021. Interventions included standardized preoperative planning, parallel operative workflows, process optimization, and increased co-surgeon utilization. After a three-month implementation phase, outcomes from October 2021 to May 2023 were compared with an 18-month pre-intervention cohort. Primary outcome was operative duration; secondary outcomes included limb salvage and operative throughput. Multivariable regression adjusted for case mix and operative characteristics. RESULTS: 103 free flaps were analyzed (53 pre-intervention, 50 post-intervention). Mean operative time decreased from 8.23±2.29 hours to 3.98±1.77 hours (p<0.001). Co-surgeon utilization increased from 22.6% to 79.2% (p<0.001). Limb salvage remained stable (96.0% versus 90.6% pre-intervention, p=0.438). The proportion of operative blocks accommodating additional procedures increased from 28.3% to 86.0% (p<0.001), enabling completion of 52 additional operations in the same block time post‑intervention. CONCLUSIONS: A structured QI initiative for lower extremity reconstruction significantly reduced operative time without increasing complications. Engaging stakeholders and optimizing workflows enhances efficiency, resource utilization, and surgical throughput, supporting the sustainability of complex microsurgical care within a strained healthcare environment.