The transverse rectus abdominis muscle (TRAM) flap has become the "gold standard" for autogenous breast tissue reconstruction. Complications are reported in 10 to 40 percent of patients undergoing this procedure, and many are related to soft-tissue necrosis secondary to ischemia. Various methods have been proposed to improve TRAM flap survival, including surgical delay of the flap. The beneficial effects of the delay phenomenon have been well established in laboratory studies and clinical evaluations. Many investigators agree that the delay phenomenon will enhance arterial inflow and venous outflow from the TRAM flap. No study has quantified the changes seen in the rectus abdominis muscle following a delay procedure. In this prospective, controlled, and blinded experiment, we evaluate the effect of a unilateral superficial inferior epigastric and deep inferior epigastric artery and vein ligation on the vascularity of the rectus abdominis muscles in rabbits. Thirty-eight rabbits underwent a left superficial inferior epigastric and deep inferior epigastric pedicle ligation as a delay procedure. The rectus abdominis muscle vasculature was then evaluated by lead oxide microangiography at 0, 5, 10, 15, 21, and 27 days following the delay procedure. Magnification (x 2) was used to count the number of vessels at the periphery of the deep inferior epigastric artery angiosomes in the microangiograms. An increase in the number of vessels from day 0 to day 27 was seen on both the ligated and nonligated sides in all the following: the number of large (> 0.5 mm) "choke" vessels and total number of vessels (all sizes) crossing the abdominal wall midline and the total number of vessels (all sizes) at the medial, superior, and lateral aspects of the right and left deep inferior epigastric artery angiosomes. A statistically significant increase in these vessels was not seen until day 21. The effect of the delay phenomenon was significantly greater on the ligated side compared with the nonligated side. The areas of the rectus abdominis muscles that were relatively more ischemic following left deep inferior epigastric pedicle ligation (medial aspect of the left deep inferior epigastric artery angiosome) showed greater increases in vascularity with the delay procedure than did areas of lesser ischemia (lateral aspect of the right deep inferior epigastric artery angiosome).
