TRAM flap vascular delay for high-risk breast reconstruction.

The purpose of this study was to evaluate the intraoperative changes in physiologic blood pressure following vascular delay of the TRAM flap. Ligation of the superficial and deep inferior epigastric vessels 2 weeks prior to the TRAM flap was performed. The incidence of fat necrosis was 4.3 percent in 23 high-risk patients who underwent 30 immediate breast reconstructions. Direct measurement of blood pressure in the deep inferior epigastric artery and vein was performed in a control group without delay consisting of 13 low-risk patients and in the study group of 7 high-risk patients who underwent vascular delay. Changes in TRAM flap perfusion pressure were examined following the change in location of the flap from the abdomen to the chest. Blood pressure measurements demonstrated that arterial pressure in the proximal stump of the deep inferior epigastric artery was 64 percent in the study group prior to delay and 72 percent in the control group. The physiologic response to vascular delay included an overall increase in arterial pressure with a decrease in venous congestion. TRAM flap perfusion pressure was significantly increased from 13.3 mmHg (control) to 40.3 mmHg (delayed) in the region of the midrectus perforators (p < 0.05). These data suggest that the technique of TRAM flap delay may increase the reliable tissue volume and improve the safety of the TRAM flap.