Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap

Purpose. The delay phenomenon has been used for breast reconstruction with pedicled flaps but has not been widely reported with free flaps. Our goals were to (1) describe our operative technique for vascular delay of deep inferior epigastric artery perforator (DIEP) flaps when a large percentage of the contralateral hemiabdomen would be needed for added volume of a breast reconstruction, (2) document any clinical improvement in flap vascularization after the delay period, and (3) develop a patient selection algorithm for this procedure. Methods. From August 2008 through July 2009, six patients at The Johns Hopkins Breast Center underwent autologous breast reconstruction with vascularly delayed DIEP flaps, a technique that preserves lateral skin bridges to the flap. This technique was used based on preoperative three-dimensional computed tomography angiograms showing potential vascular compromise. We assessed length of delay, flap weight, length of stay, and outcome. Results. Transfer delay averaged 15.8 ± 4.1 days from the original surgery. Transferred flap weight averaged 620.2 ± 156.7 g. The flaps in all six patients developed adequate arterial inflow and/or venous drainage on reassessment at final transfer. Preoperative screening with three-dimensional computed tomography angiography of the abdominal wall and modification of the flap harvest technique, including use of the clamp test to establish need for delay, were thought to be paramount for patient selection. Conclusion. In a very select group of patients undergoing breast reconstruction whose DIEP flaps showed vascular compromise before detachment, the delay phenomenon successfully enhanced vascularity and prevented fat necrosis.