TRAM FLAP PERFORATOR LIGATION AND THE DELAY PHENOMENON - DEVELOPMENT OF AN ENDOSCOPIC LAPAROSCOPIC DELAY PROCEDURE/

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 likelihoo d of TRAM flap failure or fat necrosis, but the required extent of thi s delay procedure is not clearly defined. In an attempt to augment fla p vascularity while reducing surgical dissection and morbidity, six di stinct delay procedures and a nondelayed control were compared in a ra t TRAM flap model (n = 8 for all groups). An important feature that wa s incorporated into several groups was the ligation of the contralater al rectus perforators through minimal skin incisions (endoscopic analo gy, groups 4 to 7). The most effective delay procedure was the combina tion of contralateral rectus perforator ligation and ipsilateral domin ant pedicle ligation (group 7),which was achieved with two minimal ski n 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 def inite conclusions, we feel that ''endoscopic delay'' has potential as a modality that will increase flap vascularity but minimize the morbid ity of the preliminary procedure.