A decision-making guide for the closure of myelomeningocele skin defects with or without primary repair

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>The closure of the skin defect in myelomeningocele (MMC) repair is an essential step that determines the quality of the surgical result. The success of surgical results is related to the decision to use the most suitable techniques, namely flaps or primary closure. The aim of this study was to evaluate the effectiveness of a decision-making guide to determine whether to use primary repair or a flap for the closure of skin defects that occur in MMC.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Fifty patients underwent surgery after neurosurgical repair and closure of the placode. A simple guide was generated according to the defect height/width and posterior axillary lines/defect width ratio. These 2 ratios were considered to determine which closure technique (with or without primary repair) should be used for the MMC defect reconstruction.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>By using this decision-making guide, 20 of the defects were repaired with various flaps, and those of the remaining 30 patients were repaired with primary closure. In all patients, a successful tension-free 1-stage closure was obtained. Except for 4 patients who had flap reconstruction with partial flap necrosis or minimal flap tip necrosis, healing was uneventful without any complications. There were no additional wound complications during the mean follow-up of 6.8 years (range 5 months to 14 years).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Because of various defect sizes and patient characteristics, no single protocol exists for the reconstruction of MMC defects. The guide suggested here might be effective in deciding which method is suitable for closure of MMC skin defects.</jats:p></jats:sec>

How much do plastic surgeons add to the closure of myelomeningoceles?

“…Previous literature has suggested that the diameter of the lesion should dictate its method of closure; traditionally flap reconstruction is recommended for defects that are > 5 cm in diameter [ 7 , 8 ]. Increasingly, a more tailored approach incorporating the location, shape and area, in addition to lesion length, has been reported [ 5 , 9 , 10 ]. Decisions on closure made on an individual basis instead of the width of the defect yield lower complication rates [ 5 ].…”

“…Increasingly, a more tailored approach incorporating the location, shape and area, in addition to lesion length, has been reported [ 5 , 9 , 10 ]. Decisions on closure made on an individual basis instead of the width of the defect yield lower complication rates [ 5 ]. The condition of the skin surrounding the lesion is also an important variable to consider when deciding upon the method of closure.…”

Wound closure in large neural tube defects: Role of rhomboid flaps

“…Every fourth patient who undergoes surgery for NTD will have a large wound, difficult to be closed primarily. [5] Effective closure provides tension-free repair, ensuring adequate soft tissue cover of the repaired site; thereby preventing cerebrospinal fluid leakage and promoting wound healing, especially in larger defects. Different local flaps and grafts have been described with variable results in literature.…”

“…Also, although all lipo-MMC could be closed primarily, all six patients with kyphosis and six patients with rachischisis needed rhomboid flaps for wound closure. In a recent study, Kemaloğlu et al [5] emphasized the importance of ratio of the dimensions of the wound in decision-making for wound closure. Campobasso et al [8] found Limberg’s flap to provide stable wound closure with minimal complications in their series of large MMC.…”

Local Flaps with Negative Pressure Wound Therapy in Secondary Reconstruction of Myelomeningocele Wound Necrosis

“…Wound necrosis with dehiscence following repair of MMC is a serious impediment to recovery that can result in CSF leakage, damage of exposed neural tissues and life-threatening infection. 7 The key etiologic factors in the pathophysiology of these wounds are hematoma formation, surgical-site infection and local tissue ischemia often associated with high wound tension. 8 Wound complications occur postoperatively in 24% of MMC patients, half of which are superficial wound dehiscence, while major flap necrosis requiring surgical reconstruction complicates 1–8% of repairs.…”