Bipedicled Transverse Rectus Abdominis Myocutaneous Flap

A unipedicled conventional TRAM will reliably perfuse all of zone I, 20 percent of zone II, and 80 percent of zone III.95 An alternative technique or flap choice is warranted if tissue requirements exceed these specifications. Indications for a bipedicled TRAM include those patients who insist on autogenous reconstruction, who require additional volume, and for whom microsurgical reconstruction is not possible due to an absence of reasonable recipient axillary vessels. The indications parallel those for surgical vascular delay.

The lower abdominal pannus is isolated on the medial and lateral row of perforators, bilaterally. Once the upper abdominal apron is elevated, each superior epigastric pedicle is isolated with the assistance of doppler mapping, and a split bipedicle muscle harvest is performed. The flap is transposed and inset in much the same way as for an unipedicled TRAM flap.

Multiple reports have investigated the long-and short-term impact of bilateral rectus harvest. Hartrampf reported that 64 percent of patients could not perform a single situp after bipedicled reconstruction, compared to 17 percent in the unipedicled group. Petit reported a 20 percent incidence of subsequent severe back pain in bipedicled patients.96

The bipedicled flap has reduced the incidence of partial flap loss and fat necrosis in much the same manner as the free technique. The use of mesh has markedly reduced the incidence of abdominal hernia formation and bulging. Although these patients have objective loss of abdominal function, subjective interference with daily activity is rare. There are reports of an increased incidence of long-term lower back pain.

Use of the bipedicled TRAM for unilateral reconstruction has invoked substantial controversy in the plastic surgery literature. Antagonists claim the morbidity from bilateral muscle harvest, including abdominal wall weakness and the propensity toward future back pain, "can no longer be defended" in the current realm of reliable microsurgical capability and surgical delay.97 Conversely, proponents claim that the split muscle technique and addition of mesh reinforcement limit functional morbidity and that the resultant abdominal wall integrity is dependent upon the closure technique used.98 They adhere to its use as a reliable alternative in high-risk patients.

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