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Der transversale Rectus-abdominis-Muskel- (TRAM-)Lappen

„Second defensive line“ zur mikrovaskulären Rekonstruktion von Defekten im Kopf-Hals-Bereich

The transverse rectus abdominis muscle (TRAM) island flap as a second defensive line in microvascular reconstructions of defects in the head and neck area

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Zusammenfassung

Hintergrund

Der mikrovaskulär anastomosierte transversale Rectus-abdominis-Muskel- (TRAM-)Lappen wird seit über 10 Jahren von Allgemein- und plastischen Chirurgen erfolgreich zur Rekonstruktion und Augmentation in der Mammachirurgie eingesetzt. In der rekonstruktiven Kopf-Hals-Chirurgie ist dieser Lappen nur wenig bekannt.

Methodik

Wir haben an 8 Leichen Präparation und anatomische Varianten des TRAM untersucht. An einem klinischen Fall mit kompletter Rekonstruktion der äußeren Nase nach Ablatio nasi und Totalverlust eines zuvor transplantierten radialen Unterarmlappens bei Tumorrezidiv werden Lappenformung und -modellierung des TRAM demonstriert.

Ergebnisse

Das relativ große Gefäßkaliber sowie der einfache primäre Hebedefektverschluss machen den TRAM zur Reserve für Defektverschlüsse im Kopf-Hals-Bereich. Nach Ausdünnung des subkutanen Fettgewebes kann er gut modelliert werden und wurde zum Defektverschluss nach Ablation von Nase/Mittelgesicht eingesetzt.

Fazit

Bei Berücksichtigung entsprechender chirurgischer Kautelen ist die Gefahr einer iatrogenen Eröffnung des Peritoneum oder einer Hernia abdominalis als gering anzusehen. Als myokutaner und somit voluminöser Lappen kann der TRAM aber den fasziokutanen radialen Unterarmlappen nicht ersetzen. Bei ungünstigen Wundverhältnissen im Empfängergebiet ist er für den Kopf-Hals-Chirurgen jedoch eine Alternative.

Abstract

Background

The microvascular anastomosed transverse rectus abdominis muscle (TRAM) island flap has been successfully used in plastic surgery for more than 10 years. In reconstructive head and neck surgery, however, it is not yet established.

Method

We analysed the preparation and anatomical variation in TRAM flaps in an examination of eight cadavers. In a clinical case with complete reconstruction of the nose after nasal ablation and complete loss of a radial lower forearm flap that had been transplanted previously due to a recurrent tumor, the possibility of forming and modeling a TRAM flap is demonstrated.

Results

The flap vessels of the TRAM are comparable to the radial forearm flap, and the donor site may be primarily closed. The TRAM proved to be a suitable alternative to close lesions of the head and neck area in selected cases. The myocutaneous TRAM is bulkier than the fascio-cutaneous radial forearm flap. The subcutaneous abdominal fat of the TRAM can be reduced in relation to the vascular distribution of the perforator vessels. If the subcutaneous fat of the flap is reduced, the flap can be shaped and formed well. In the described case, it was used to close the lesion after ablation of the nose and middle face.

Conclusion

The risk of an iatrogenic lesion of the peritoneal fascia or postsurgical herniation of the abdominal wall is low if several surgical prerequisites are taken into consideration. The myocutaneous TRAM will not replace the fascio-cutaneous radial forearm flap in microvascular head and neck surgery, but the large diameter of the donor vessels and the highly vascularized flap tissue makes it an alternative as a second line procedure in cases of unfavorable wound conditions.

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Authors and Affiliations

  1. Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde und Poliklinik, Universitätsklinikum Freiburg

    J. Schipper, T. Klenzner, I. Arapakis & W. Maier

  2. Abteilung für Plastische Chirurgie, Chirurgische Universitätsklinik Erlangen

    R. Horch

  3. Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde und Poliklinik, Universitätsklinikum Freiburg, Killianstraße 5, 79106, Freiburg

    J. Schipper

Authors
  1. J. Schipper
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  2. T. Klenzner
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  3. I. Arapakis
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  4. W. Maier
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  5. R. Horch
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Corresponding author

Correspondence to J. Schipper.

Additional information

Dieser Beitrag wurde auszugsweise anlässlich der 34. Jahrestagung der Deutschen Plastischen Chirurgen sowie der 8. Jahrestagung der Vereinigung der Deutschen Ästhetisch-Plastischen Chirurgen, 30.09.–05.10.2003, Freiburg vorgetragen.

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Schipper, J., Klenzner, T., Arapakis, I. et al. Der transversale Rectus-abdominis-Muskel- (TRAM-)Lappen. HNO 54, 20–24 (2006). https://doi.org/10.1007/s00106-005-1286-2

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  • DOI: https://doi.org/10.1007/s00106-005-1286-2

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