Supercharging of delayed pedicled transverse rectus abdominis myocutaneous flaps, is it a viable option?

Arterial and venous insufficiency may become evident even in delayed pedicled TRAM flaps. This study assesses the possibility of using the previously ligated deep inferior epigastric vessels for microvascular supercharging during reconstruction.

Twenty-two patients underwent delay by ligation of the inferior epigastric vessels prior to TRAM flap breast reconstruction. The deep inferior epigastric vessels were excised at the time of reconstruction 10-14 days after delay and microscopically examined for vascular compromise that might prevent use in microvascular anastomosis at the time of reconstruction.

20/22 (91%) of the deep inferior epigastric vessels (20 arteries and accompanying veins) showed clot immediately adjacent to the ligature only and 2/22 (9%) showed clot extending only 5-10 mm. None of these vessels (0%) showed clot in the distal 2 cm of their length (adjacent to the flap). Evidence of intramural hematoma, delamination, and endothelial abnormalities were not found in any of the vessels. An additional patient who was a 48-year-old female underwent bilateral pedicled TRAM flap breast reconstruction and one of the flaps exhibited inadequate capillary refill intraoperatively after transfer to the mastectomy defect. Supercharging of the flap utilizing the previously ligated inferior epigastric artery improved capillary refill and the flap survived completely postoperatively.

Our findings demonstrate patency of the inferior epigastric vessels after ligation for TRAM delay during the time frame usually used for delay to take effect.