Make Your Own Deep Inferior Epigastric Artery Perforator Flap: Perforator Delay Improves Deep Inferior Epigastric Artery Perforator Flap Reliability

Autologous breast free flap reconstruction remains a conflict between blood supply and abdominal wall morbidity. Early pedicled and free transverse rectus abdominal myocutaneous1 flap techniques pioneered by Hartrampf et al and Holmstrom favored blood supply at the cost of donor site.1,2 Later modifications including the deep inferior epigastric artery perforator (DIEP) free flap described by Koshima and Soeda3 and Allen and Treece4 minimized donor site morbidity at the cost of bloody supply, with DIEP free flap breast reconstruction fat necrosis rates—presumably from vascular insufficiency—averaging 14.4% compared with 6.9% for the free TRAM variant.5 The vascular delay phenomenon in plastic surgery can be credited to Gaspare Tagliacozzi's early descriptions of nasal reconstruction using the arm flap in the 16th century.6 This phenomenon results in transient tissue ischemia which stimulates vascular changes whether it be from metabolic changes, neovascularization, or dilation of choke vessels.7 Although the idea of vascular delay has been previously studied in selected patient populations in pedicled and free TRAM-based autologous breast reconstruction (ABR),8–11 the indications and efficacy in DIEP-based reconstruction remain largely unknown. Can vascular delay mitigate blood supply issues inherent to DIEP flap reconstruction while maximizing abdominal wall functionality? We present a novel 2-stage vascular delay technique of DIEP flap breast reconstruction to explore the flap and nonflap benefits associated with this technique. We hypothesized that DIEP delay (1) allows for reliable harvest of single-vessel flaps while minimizing fat necrosis, (2) decreases abdominal wall morbidity, and (3) improves breast and donor site esthetics.