Background: Over the last decade, TRAM flap breast reconstruction has become a popular method for autogenous tissue reconstruction of the breast. However, the use of TRAM flaps in “high risk” patients is often plagued with complications including fat necrosis, skin paddle loss, and flap failure. The vascular delay technique has been proposed to reduce the complications of TRAM flap breast reconstruction. Previous work has demonstrated an increase in blood flow and arteriolar diameter in the main inferior epigastric system following TRAM delay. However, no studies have evaluated perfusion to the peripheral fat in the TRAM flap. We present our successful experience with 70 consecutive “high-risk” patients who received TRAM delays prior to definitive reconstruction. In addition, we will correlate our clinical experience in these patients with an evaluation of perforator blood flow using quantitative color-doppler ultrasound.

Methods: A retrospective review of 70 consecutive patients undergoing delay of TRAM Flap breast reconstruction was performed. Each patient underwent surgical ligation of both the deep and superficial inferior epigastric arteries of the contralateral rectus muscle, and ligation of the superficial inferior epigastric artery of the ipsilateral rectus muscle. “Delay” procedures were performed two weeks prior to definitive unipedicled TRAM surgery for each patient. At the conclusion of the chart review, an ultrasound evaluation of the mechanism behind the “delay” procedure was performed. Patients were selected who were scheduled to undergo vascular delay of their TRAM flap prior to definitive reconstruction. A baseline intra-operative ultrasound scan was performed using a high frequency ultrasound probe prior to the initiation of the delay procedure after the patient had been anesthetized. Prior to each scan the patients’ abdomen was marked to indicate the four zones of the TRAM flap. Each zone was further subdivided into four quadrants. 20 digitized images were taken at approximately .5cm increments in each quadrant of each zone. A second scan was performed at the conclusion of the delay procedure prior to waking the patient. After a two week delay period, a final scan was performed prior to the definitive TRAM procedure. The images obtained were then analyzed using proprietary HDI5000 imagetool analysis software developed by the University of Pennsylvania Department of Radiology.

Results: Seventy consecutive “high-risk” patients underwent TRAM delay 2 weeks prior to TRAM surgery. These patients were deemed “high-risk” on the basis of a history of cigarette smoking, previous radiation therapy, diabetes, or an increased size requirement. Qualitative observations of these patients revealed a significant increase in bleeding at the time of TRAM surgery. The overall incidence of complications in these patients was quite low. Significant fat necrosis which required secondary reconstruction occurred in only 3 patients (4.2%). Small fat necrosis less than 2 cm occurred in 5 patients (7.1%). There were no flap failures or skin paddle losses or infections. These results prompted an evaluation of flow to the fat overlying the TRAM flap using Doppler ultrasound. Data from each of seven patients were examined using color-flow Doppler ultrasonography. Measurements of flow were obtained in each zone of the TRAM flap. All zones experienced a decline in flow immediately following the delay procedure (between 60-70% of baseline flow). Furthermore, all zones experienced a modest increase in flow in the 2 week period immediately preceding the TRAM procedure. Perfusion to Zone 3 and 4 however showed the greatest percentage improvements (35% and 25% increases from the post-delay perfusion respectively). The differences in perfusion noted for zones 3 and 4 were statistically significant (p=.003 and p=.0023 respectively)

Conclusion: We present our successful experience with the use of the “Delay” procedure in a series of 70 patients. When used for patients who are at high risk for TRAM (i.e. obese patients, smokers, and patients receiving radiotherapy), our results confirm reports in the literature concerning the utility of the delay procedure. We have experienced a significant reduction in the complication rates than commonly described in patients undergoing conventional TRAM reconstruction.