Optimizing Costs in Plastic Surgery: A Systematic Review of Time-driven Activity-based Costing Applications

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This systematic review examined how time-driven activity-based costing (TDABC) has been used in plastic surgery to identify major cost drivers and opportunities for efficiency. The authors searched PubMed and, following PRISMA guidelines, included 17 peer-reviewed studies from the last 10 years that assessed TDABC, activity-based costing (ABC), or cost-to-charge ratio (CCR) in plastic surgery.<br /><br />The review found that the main cost contributors across complex reconstructive procedures were operating room (OR) time, staffing, and postoperative care. In particular, prolonged OR time and extended intensive care unit (ICU) stays were repeatedly shown to drive up costs, especially in free flap and microsurgical breast reconstruction. TDABC helped reveal inefficiencies such as unnecessary ICU utilization, delays in the OR, and resource use that may not always improve outcomes.<br /><br />Several studies identified cost-saving strategies, including better postoperative pathway design, reduced ICU length of stay, task shifting to lower-cost personnel, use of co-surgeons in complex cases, and enhanced recovery after surgery (ERAS) protocols. Virtual care and telehealth also showed promise in reducing patient and clinic costs while maintaining satisfaction.<br /><br />The review highlights that TDABC offers a practical framework for value-based care by giving a detailed view of where resources are spent and where savings may be possible without harming quality. However, the evidence base is limited by small numbers of studies, single-institution settings, and a strong focus on academic centers and high-cost reconstructive procedures. Cosmetic and outpatient procedures remain underexplored.<br /><br />Overall, the authors conclude that TDABC can improve cost transparency and support more efficient resource allocation in plastic surgery. Future research should expand to cosmetic surgery, outpatient care, diverse hospital settings, and automated integration with electronic health records.

Keywords

time-driven activity-based costing

plastic surgery

cost drivers

operating room time

intensive care unit

reconstructive surgery

efficiency

health care costs

enhanced recovery after surgery

telehealth