A limited number of flaps have been described for reconstruction of extensive defects, including subtotal thigh and fillet flaps. Flaps based on the rectus abdominis system, such as transverse and vertical rectus abdominis myocutaneous (TRAM and VRAM) flaps, are reliable, but their size is typically limited by patient body habitus and donor-site closure. When more tissue is needed, previously reported clinical cases propose extending either the transverse or vertical component of the flap, or performing microvascular supercharging.1–3
In this article, we describe our experience with the combined TRAM-VRAM flap (cruciate flap), which contains both vertical and transverse cutaneous paddles. Its advantages include the ability to transfer large quantities of tissue while allowing for primary donor-site closure. In addition, the flap has four independent limbs, which confer greater flexibility during inset, especially for defects that possess significant three-dimensionality. Furthermore, because it is a pedicled flap, extensive defects may be reconstructed in patients who are not free flap candidates, without the need for microsurgical augmentation.
The flap is designed with a cruciate pattern that includes both vertical and transverse cutaneous components (Fig. 1). To maximize perfusion to this large flap, the transverse component should be centered on the periumbilical region in order to maximize the number of perforators included in the flap.4 This is especially pertinent in thin patients, in whom the vertical height of the transverse flap component is limited if the donor site is to be closed primarily. We typically harvest the flap with the entire rectus abdominis muscle to further maximize perfusion.
We have performed a cruciate flap in four patients since 2007 (one pedicled flap and three free flaps). The pedicled flap case involved a patient with a history of prostate cancer metastatic to the sternum who developed sternal osteoradionecrosis. Radical débridement resulted in an extensive soft-tissue and bony defect (Fig. 1). A pedicled cruciate flap was performed, which was advantageous given the patient’s thin body habitus and overall poor prognosis; the flap allowed for transfer of tissue from outside the zone of radiation. In another case, a free cruciate flap was performed in a patient with a radiated postpneumonectomy bronchopleural fistula, where its independent limbs facilitated inset for repair of the fistula and concurrent large dead space obliteration. Other cases involving free flaps included a pediatric patient (30 kg) with an extensive, traumatic, lower extremity soft-tissue defect with exposed prosthesis and a patient who sustained significant total body surface area burns but whose abdomen was spared from injury. Mean follow-up was 7.5 months. In all patients, primary donor-site closure was performed without wound breakdown, hernia, or abdominal bulge. There were no instances of partial or total flap loss.
We believe the combined TRAM-VRAM flap is a useful variant of flaps based on the rectus abdominis system. It may be performed as either a pedicled flap or a free flap for the reconstruction of extensive defects, while allowing for primary donor-site closure with little associated donor-site morbidity.
The authors have no financial interest to declare in relation to the content of this article.
Albert H. Chao, M.D.
Michelle Coriddi, M.D.
Michael J. Miller, M.D.
Department of Plastic Surgery
The Ohio State University
1. Kroll SS. Bilateral breast reconstruction in very thin patients with extended free TRAM flaps. Br J Plast Surg. 1998;51:535–537
2. Takayanagi S, Ohtsuka M. Extended transverse rectus abdominis musculocutaneous flap. Plast Reconstr Surg. 1989;83:1057–1060
3. Lee MJ, Dumanian GA. The oblique rectus abdominis musculocutaneous flap: Revisited clinical applications. Plast Reconstr Surg. 2004;114:367–373
4. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg. 1998;51:202–209
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