Thirty-one transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstructions were performed after a delay period either of 1 week (group I, N = 15) or 2 weeks (group II, N = 16). The preliminary delay procedure consisted of bilateral deep inferior epigastric and superficial inferior epigastric artery and vein ligation. In group I the diameter and flow in the superior epigastric artery increased from baseline values of 1.3 +/- 0.3 mm and 7.25 +/- 0.8 ml per minute to 1.8 +/- 0.3 mm and 18.2 +/- 2.7 ml per minute at 1 week. In group II the diameter and flow in the superior epigastric artery increased from baseline values of 1.2 +/- 0.3 mm and 5.85 +/- 1.5 ml per minute to 1.7 +/- 0.4 mm and 23.4 +/- 6.2 ml per minute at 2 weeks. The differences between 1 and 2 weeks were not statistically significant. The complication rate in either group was similar. We conclude that a preliminary delay procedure is highly effective at augmenting TRAM flap vascularity and may be implemented between 1 and 2 weeks prior to TRAM flap breast reconstruction in high-risk patients.