Surgical application of the keystone island flap for closure of thoracolumbar myelomeningocele defects - A case report

Abstract

Introduction Myelomeningocele (MMC) is the most common neural tube defect that can occur due to neural tube's failure to fuse properly during embryonic life. To prevent this, keystone island flap can be used for closure of large MMCs. Presentation of case A new-born girl born as a product of 36 weeks of gestation had a weight of 3.020 kg and had multiple congenital anomalies including hydrocephalus, thoracolumbar myelomeningocele at the level of (T10-L4) and an atrial septal defect. Preoperative evaluation showed a head circumference of 42 cm (n: mean 34.4 ± 2SD), no lower limbs movements and a thoracolumbar soft tissue defect around 4 × 8 cm with exposed neuronal tissue and prominent thoracic kyphosis, and no obvious urogenital or limbs anomalies. The large thoracolumbar myelomeningocele was treated at KFSHRC with a Keystone Design Perforator Island Flap (KDPIF) to reconstruct the soft tissue defect following the neurosurgical reconstruction. Discussion The keystone flaps were deemed as viable as all wounds were healed without any complications, such as flap necrosis, dehiscence, leakage of cerebrospinal fluid, or infection. The technique described in the case report offers a simple and effective method of wound closure in situations that would, otherwise, have required complex flap closure. Conclusion This flap can be an effective method for reconstruction of large thoracolumbar MMC defects that might improve outcome and minimize complications. It also ensures good watertight closure with minimal wound tension and breakdown.

Closure of meningomyelocele defects using various types of keystone-design perforator island flaps

“…Eight previous studies have discussed the use of KDPIFs for meningomyelocele defect closure [15,[18][19][20][21][22][23][24]. All of those studies also demonstrated satisfactory experiences in using KDPIFs for meningomyelocele closure.…”

“…All of those studies also demonstrated satisfactory experiences in using KDPIFs for meningomyelocele closure. The studies by Gutman et al [15], Park et al [19], Jamjoom et al [20], Mrad et al [21], and Gomez and Barrera [22] reported no complications after defect closure using keystone flaps in between one and five patients. Donaldson et al [18] reported that two out of six patients had wound complications after surgery.…”

Closure of Giant Dorsal Lumbosacral Myelomeningocele in Children Using Double Expanded Flaps: A Case Report and Literature Review

“…Putri et al 18 concluded that smaller defects (<15 cm²) tend to be closed with type II KDPIF, and larger defects (>30 cm²) are more often closed with bilateral type IV KDPIF. Mrad et al 19 proved that KDPIF is effective for locoregional fasciocutaneous reconstruction of large thoracolumbar MMC defects. An intercostal artery island flap has also been used to repair a huge lumbosacral MMC defect, 20 so an abdominal island flap does, 21 both of them can achieve repairment of defect which is limited by area.…”

Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review

“…1). 3,5,6,8,[12][13][14][15][16][17][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] In addition, a retrospective chart review of all MMC closures performed at Phoenix Children's Hospital from January 2015 to January 2020. After proper IRB approval, all closures performed by board-certified plastic surgeons were identified and further analyzed.…”