Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction was performed in 15 patients 1 week after a preliminary delay procedure. The indications for surgical delay were obesity, smoking, prior radiation therapy, a requirement for large volumes of transmidline tissue, or combinations of these risk factors. The delay procedure consisted of outpatient ligation of the deep and superficial inferior epigastric vessels. Prior to and 1 week following the delay procedure, noninvasive Doppler examinations of the superior epigastric vessels were performed. Following the delay procedure, the diameter of the superior epigastric artery increased from 1.3 +/- 0.2 to 1.8 +/- 0.3 mm (p < 0.001) and the calculated superior epigastric artery flow increased from 7.25 +/- 0.8 to 18.2 +/- 2.7 ml/min (p < 0.001). Breast reconstruction in these high-risk patients was successful without major ischemic complications, but a tendency toward unreliability of zone IV was noted. This clinical observation is consistent with the findings in our animal studies (part I). The preliminary delay procedure was well tolerated with minimal morbidity. We feel that a preliminary delay procedure is a very useful option for breast reconstruction patients at high risk for TRAM flap vascular compromise.