A New Approach to Closure of Large Lumbosacral Myelomeningoceles: The Superior Gluteal Artery Perforator Flap

Abstract

The most common form of neural tube defect is the myelomeningocele, developing during the fourth week of gestation. The era of early closure of myelomeningoceles began in the sixties with the demonstration that these patients had a lower rate of mortality. 1 The goals of early surgical closure are to (1) prevent infection, (2) eliminate cerebrospinal fluid leaks, (3) preserve neural function, and (4) diminish negative late sequelae such as pain over the closure site and possibly even tethered cord. 2 After closure of the neural tube and dura, the majority of these patients have enough local skin to allow for simple closure of the skin over the dural closure. When the skin defect is large or the surrounding skin quality is poor, more elaborate methods of obtaining stable skin closure over the dural closure must be devised. 3 Multiple methods of soft-tissue closure for larger lumbosacral myelomeningocele defects have been described, including skin grafting, 4 random flaps, 5 skin undermining with relaxing incisions, 6 and musculocutaneous flaps. 7,8 None of these approaches are ideal, however, particularly when the skin defect is large and/or the quality of the surrounding skin is poor. We have developed a new approach to closure of large lumbosacral defects with superior gluteal artery perforator flaps. PATIENTS AND METHODSSix patients were operated on over an 18-month period. During this period, our neurosurgical group treated a total of 34 myelomeningocele patients. Plastic surgical consultation was initiated by the pediatric neurosurgeon when he felt the defect was too large for closure with simple skin advancement flaps. The average birth weight of the six patients was 3237 grams and the average cutaneous defect covered with the superior gluteal artery perforator flaps was 4.8 ϫ 6.8 cm. The flaps were designed to match the cutaneous defect. Two of the patients were prenatally diagnosed with the myelomeningocele. All of the patients were operated on within 36 hours of birth. All patients were operated on in the prone position under general endotracheal anesthesia. The average blood loss during the procedures was 12 cc, and no patients required blood transfusions intraoperatively. The average operative time for the combined procedure was 190 minutes; the average plastic surgical operative time for flap elevation and insetting was 115 minutes. Neurosurgical management included initial placode dissection, spinal cord reconstruction and closure, and dural elevation and closure. 9 The first patient this approach was used on showed a very large myelomeningocele with very poor quality surrounding skin. Figure 1 demonstrates the flap design and marked perforators before the start of the operation; the neural tube has been imbricated and dural closure is about to be performed.The plastic surgical component of the operation begins with Doppler identification and From Medical City Dallas and the

Comparison of dorsal intercostal artery perforator propeller flaps and bilateral rotation flaps in reconstruction of myelomeningocele defects

“…During the initial operation to harvest DICAP propeller █ DISCUSSION Plastic surgery and neurosurgery teams perform a combined operation for reconstruction of the neural tube defect and soft tissue early in the postpartum period (2). Since the introduction of perforator flaps by Koshima and Soeda in 1989, their use in reconstruction of various defects throughout the body, including myelomeningocele defects, has become widespread (2,3,17).…”

Bilateral Modified V-Y Advancement Flaps for Closing Meningomyelocele Defects

“…18 The surgical options available for closing a meningomyelocele defect include primary closure, 1 skin grafting, 4 local flap, 2,3,5,6,8 musculocutaneous flap, 9 -15 and fasciocutaneous flap. 16,17 Primary closure can be accomplished by undermining the wound edges in patients with a small meningomyelocele defect. Patterson and Till reported that only 14 (25%) of a group of 56 patients required more elaborate closure techniques than primary closure.…”

“…Various surgical techniques for closing a meningomyelocele defect have been reported, including a rotation flap, advancement flap, Limberg flap, bipedicled flap, musculocutaneous flap, and perforator-based flap. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] We describe a new method that uses a combination flap consisting of a vertical bipedicled flap and V-Y advancement flap. This method offers several advantages compared with previously reported methods: 1) no skin grafts are needed; 2) no muscle tissue is killed; 3) it is simple and easy, leading to less blood loss and minimal operative time; and 4) it is safe and produces reliable results while eliminating wound dehiscence and skin necrosis.…”

Superior gluteal artery perforator flap for meningomyelocele defect: A saviour when other options vanish

“…[3] Leaving a small cuff of muscle around the pedicle can be beneficial in decreasing the risk of harming the pedicle or vasospasm. Yet, caution should be taken, as leaving a cuff of muscle around the pedicle will hide small vascular branches and lead to a more bloody dissection if they go unnoticed.…”

“…[345] Of these studies, Duffy et al . used the SGAP flap in six patients with large primary meningomyelocele defects.…”