Elevation of a transverse rectus abdominis musculocutaneous (TRAM) flap results in diminution of the blood supply to the umbilicus.Those at higher risk of partial or total umbilical loss are smokers, having more than double the rate of umbilical necrosis (27.5%) than nonsmokers (11.8%). The delay phenomenon has been demonstrated to be effective in enhancing blood supply by dilating the choke vessels communicating with the adjacent angiosome.

A retrospective chart review was conducted for all patients undergoing pedicled TRAM flap breast reconstruction between 2000 and 2016. Patient demographics (smoking status, body mass index, history of chemotherapy, and medical comorbidities) were evaluated and donor site complications including abdominal hernia and bulge formation and rates of umbilical necrosis. Umbilical delay was performed under general anesthesia 14 days before reconstruction by making an incision around the umbilicus down to the level of the rectus fascia. Delay of the pedicled TRAM flap was performed in the same setting by making the superior and inferior flap incisions and ligating the superficial and deep inferior epigastric arteries

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doi.org/10.1097/GOX.0000000000002124