Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 ± 5.8 percent (control) to 13.5 ± 3.3 percent (p < 0.001).
After completion of the animal studies, clinical application of a “minimally invasive” TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that “endoscopic delay” has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure. (Plast. Reconstr. Surg. 101: 1503, 1998.)
Richard J. Restifo, M.D.
Yale University School of Medicine
333 Cedar Street, YPB 2
P.O. Box 208041
New Haven, Conn. 06520-8041
From the Yale University School of Medicine, Section of Plastic Surgery, and the University of Massachusetts Medical Center. Received for publication January 21, 1997; revised June 30, 1997.
Presented in part at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, in Dallas, Texas, November 9-13, 1996.