The Delay Phenomenon: A Compilation of Knowledge across Specialties

Objective The purpose of this article is to review and integrate the available literature in different fields to gain a better understanding of the basic physiology and optimize vascular delay as a reconstructive surgery technique. Methods A broad search of the literature was performed using the Medline database. Two queries were performed using “vascular delay,” a search expected to yield perspectives from the field of plastic and reconstructive surgery, and “ischemic preconditioning,” (IPC) which was expected to yield research on the same topic in other fields. Results The combined searches yielded a total of 1824 abstracts. The “vascular delay” query yielded 76 articles from 1984 to 2011. The “ischemic preconditioning” query yielded 6534 articles, ranging from 1980 to 2012. The abstracts were screened for those from other specialties in addition to reconstructive surgery, analyzed potential or current uses of vascular delay in practice, or provided developments in understanding the pathophysiology of vascular delay. 70 articles were identified that met inclusion criteria and were applicable to vascular delay or ischemic preconditioning. Conclusion An understanding of IPC's implementation and mechanisms in other fields has beneficial implications for the field of reconstructive surgery in the context of the delay phenomenon. Despite an incomplete model of IPC's pathways, the anti-oxidative, anti-apoptotic and anti-inflammatory benefits of IPC are well recognized. The activation of angiogenic genes through IPC could allow for complex flap design, even in poorly vascularized regions. IPC's promotion of angiogenesis and reduction of endothelial dysfunction remain most applicable to reconstructive surgery in reducing graft-related complications and flap failure.

Reliance on double pedicle TRAM flap technique in breast reconstruction based on mammographic evidence

ABSTRACTBreast reconstruction is now a part of the overall treatment of breast cancer. Its main drawback is rather the suspicion to conceal any probable recurrence. Fat necrosis is a particularly important finding because it can be mistaken for a local recurrence. Alternatively, local recurrences may be dismissed as areas of fat necrosis. Fat necrosis is a relatively minor complication of TRAM flap breast reconstruction but one that can induce anxiety, expense, and inconvenience for patients and concerns about tumor recurrence. The techniques selected for reconstruction must carry the least risks for these awful complications.15 breast cancer cases were treated in our center by using Bostwick′s principles. These include double-pedicle technique in cases with one or two risk factors and added vascular delay two weeks prior to this procedure in cases with more risk factors.During the follow up period, neither the patients nor her physicians experienced any nodules in their treatment sites clinically. One case is the only exception that she felt hardness but it softened. Mammographically, no images of fat necrosis were observed in any of the cases.In contrary to other studies reporting no advantages of double pedicle technique to lessen the risk for fat necrosis, we observed fat necrosis only in one of 15 cases. This may be because both sides of the flap are supplied axially and delay procedures are added in high risk patients.