|Year : 2020 | Volume
| Issue : 1 | Page : 19-24
Analysis of wound complications of patients with meningomyelocele
Koray Gursoy, Galip Gencay Ustun, Burkay Akduman, Melike Oruc Ozpostaci, Yuksel Kankaya, Ugur Kocer
Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara Training and Research Hospital, Ankara, Turkey
|Date of Submission||10-Feb-2019|
|Date of Acceptance||27-Mar-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Koray Gursoy
Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara Training and Research Hospital, Ankara
Source of Support: None, Conflict of Interest: None
Aims: During the closure of meningomyelocele defects, complications such as dehiscence, flap loss, or cerebrospinal fluid (CSF) leaks may be encountered. There are multiple variables that have not been studied including defect size, surgical method for closure, or patient weight that may take a role during this process. Subjects and Methods: Records of patients operated between February 2015 and August 2018 were retrospectively reviewed. Age and weight at the time of operation, gender, location and size of the defect, method of closure, operative time, pre- and post-operative hemoglobin (Hb) levels, postoperative complications, and revision surgeries if needed were reviewed. Results: Among 28 patients included in the study, 9 (32.1%) patients had postoperative wound complications including partial flap loss, dehiscence, and CSF leaks. Pre- and post-operative Hb levels showed statistically significant difference between primary cases and revision cases (P < 0.001). Defect size, change in Hb levels, and postoperative complication rates did not differ between techniques for closure, yet operative time was significantly increased in butterfly flap group. Increasing defect size was found to be associated with longer operative time and postoperative CSF leakage (P = 0.002 and P = 0.05, respectively) but showed no significant relationship with flap necrosis, dehiscence, and intraoperative blood loss (P = 0.110, P = 0.113, and P = 0.84, respectively). Conclusions: Rotation/advancement fasciocutaneous flaps provide a durable single-stage reconstruction for meningomyelocele defects. The need for transfusion must be kept in mind during primary cases. Correct choosing and application of each method limits complications even with larger defects; however, increasing defect size leads to CSF leaks and prolonged operative time.
Keywords: Complication analysis, meningomyelocele, meningomyelocele complications
|How to cite this article:|
Gursoy K, Ustun GG, Akduman B, Ozpostaci MO, Kankaya Y, Kocer U. Analysis of wound complications of patients with meningomyelocele. Turk J Plast Surg 2020;28:19-24
|How to cite this URL:|
Gursoy K, Ustun GG, Akduman B, Ozpostaci MO, Kankaya Y, Kocer U. Analysis of wound complications of patients with meningomyelocele. Turk J Plast Surg [serial online] 2020 [cited 2020 Jul 12];28:19-24. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/19/274435
| Introduction|| |
Meningomyelocele, the most severe form of spina bifida, involves incomplete closure of spinal cord with protruding neural tissue. National data reveal that neural tube defects are frequent situations with a prevalence rate of 0.3%. Known risk factors are genetic predisposition, exposure to radiation, antiseizure medications, low folate consumption, advanced maternal age, and low-socioeconomic status.,
Like any other congenital anomaly, meningomyelocele defects bring multiple challenges to the table. The first of these is the stabilization of the newborn, who is trying to get used to the outside world and prone to all kinds of morbidity. Although the frequency of concomitant anomalies is reported as 19.1%–21.0% in international studies,,, this rate increases to 50% in national publications. These anomalies may possess specific challenges to surgeon and anesthesia team. Early closure with microsurgical techniques is warranted for the protection of the exposed neural tissue that is considered to be functional during labor. Overlying skin closure has to be tension free, durable, and waterproof for the protection of neural tissue and prevention from meningitis and cerebrospinal fluid (CSF) leaks. Even with the best patient management; neurologic deficits including mental retardation, hydrocephalus, inability to walk, bladder incontinence, and mortality up to 23.6% are encountered in the long term. With these physical challenges in hand, it is a completely different challenge to calm down and inform parents who have lost their dreams of having “the perfect child” and do not know what they will face in the future.
In this process, the plastic surgeon is most frequently involved in the repair of early skin defects. Defects smaller than 5 cm may be repaired by neurosurgeons with direct closure; however, it is usually inadequate for larger defects and kyphotic spines. The plastic surgeon takes place in closure of these problematic defects with techniques in his/her armamentarium. Among numerous techniques described for closure of meningomyelocele defects, fasciocutaneous flaps are the method of choice for authors. Fasciocutaneous flaps are described by Pontén in 1981 for closure of lower leg defects. Our modifications, published before, are based on the same flap harvesting principles with geometrical modifications., Rotation advancement V-Y fasciocutaneous flaps are used for closure of meningomyelocele defects with the advantage of facilitating defect and donor site closure [Figure 1]. At least in our judgment, with proper planning, this easy-to-learn one-step technique offers enhanced vascularity, minimal donor site morbidity, and preservation of muscle function.
|Figure 1: Meningomyelocele defect reconstruction with butterfly (four-flap rotation/advancement) flaps. (a) Intraoperative view of the defect and planning of flaps, (b) immediate postoperative view, (c) partial flap loss and wound dehiscence, (d) late postoperative view|
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Wound complications involving dehiscence, CSF leak, and partial/total flap necrosis may be seen during healing process. These complications may be limited and heal only by secondary intention [Figure 1] yet may also result with catastrophe [Figure 2]. Predicting complications beforehand helps avoiding them. There are multiple variables including defect size, surgical method for closure, or patient weight that may take a role during this process. On the other hand there are only few reports regarding the timing of the surgical intervention as a variable., Our study aims to analyze different variables on probable complications.
|Figure 2: Postoperative view of patient treated with butterfly (four-flap rotation/advancement) flaps. Partial flap necrosis leads to wound dehiscence|
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| Subjects and Methods|| |
Following approval of Hospital Medical Board, records of patients operated for meningomyelocele defects at Ankara Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Turkey, between February 2015 and August 2018 were retrospectively reviewed. Age and weight at the time of operation, gender, location and size of the defect, pre- and post-operative hemoglobin (Hb) levels, postoperative complications, and revision surgeries if needed were reviewed. The method of closure (single flap vs. double flaps vs. four flaps), operative time, and need for intraoperative blood transfusion were extracted from surgical notes. Pre- and post-operative photographs taken during the follow-up were reviewed. Informed consents were taken from all of the patients' parents enrolled in the study before data analysis.
All of the methods used for closure of the defects were fasciocutaneous flaps without an identified perforator. The choice for method of closure was based on the surgeon's judgment of the defect and presence of kyphosis. After dural repair by neurosurgery with proper method, patients were evaluated for the technique of closure. Single-flap technique was applied relatively to small rhombic-like defects and involved elevation of a transposition flap superolateral to the defect for using the laxity of the flank region and facilitating primary closure of donor area. Double flaps were modified V-Y rotation/advancement flaps described by Sungur et al., on each side of the defect [Figure 3]. Four-flap technique (also known as butterfly flap) involved division of the defect to four parcels and preparing a V-Y rotation/advancement flap for closure of each quartile on each corner of the defect [Figure 4]. All of the flaps were elevated to the point of adequate mobilization. After flap inset, donor areas were closed in primary fashion using Z-plasty if needed. For revision cases, flaps were reapproximated for closure.
|Figure 3: Meningomyelocele defect reconstruction with double V-Y rotation/advancement flaps. (a) Preoperative view of the defect, (b) planning of flaps after dural closure, (c) elevation of flaps, (d) early postoperative view|
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|Figure 4: Meningomyelocele defect reconstruction with butterfly (four-flap rotation/advancement) flaps. (a) Preoperative view of the defect, (b) elevation of flaps, (c) early postoperative view, (d) 6-month postoperative view|
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Statistical analysis included descriptive statistics of patients with meningomyelocele was conducted using IBM SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, NY, USA). Normality of continuous data was decided using the Kolmogorov–Smirnov test. Quantitative variables were reported using means and standard deviations or median ( first–third quartiles) whereas categorical variables expressed by frequencies and percentage. Comparisons of continuous variables with two groups were conducted using Mann–Whitney U-test. Kruskal–Wallis test with Dunn-Bonferroni pairwise comparison test was performed to compare quantitative variables which include more than two groups. Categorical variables were compared using Pearson's Chi-square test or Fisher's exact test, which was appropriate. A two-sided P < 0.05 was considered statistically significant.
| Results|| |
For cases of primary surgery (15 females and 13 males), mean age of operation was 11.75 days (range: 2–60 days). For cases of revision (5 females and 2 males), it was 42.71 days (range: 16–60). Mean patient weight is 2842.5 ± 617.12 g for primary cases and 3152.9 ± 611.6 g for revision cases. Thoracolumbar and lumbar regions are the most common locations for defects (32.1%). The mean defect size was measured 53.25 ± 36.16 cm2 for study group before primary surgery (mean defect size for single-, double-, and four-flap techniques was 31 cm2, 49 cm2, and 63 cm2, respectively). Among all, the butterfly flap technique was the most common technique for closure, followed by double-flap and single-flap techniques (46.4%, 39.3%, and 14.3%, respectively). Mean follow-up rate was 16.1 ± 5.3 months (range: 3–23 months) for whole group and 19.1 ± 2.41 months (range: 16–23) for revision cases. Nine patients (32.1%) had postoperative wound complications including partial flap loss, dehiscence, and CSF leaks. Neither of these patients had meningitis or septicemia. Ten patients needed blood transfusion in the postoperative course. Seven of these patients needed a revision and two were healed by secondary intention [Table 1].
Pre- and post-operative Hb levels showed statistically significant difference between primary cases and revision cases (P < 0.001) [Table 2]. Defect size, change in Hb levels, and postoperative complication rates did not differ between techniques for closure, yet operative time was significantly increased in butterfly flap group [Table 3].
Increasing defect size was found to be associated with longer operative time and postoperative CSF leakage (P = 0.002 and P = 0.05, respectively) but showed no significant relationship with flap necrosis, dehiscence, and intraoperative blood loss (P = 0.110, P = 0.113, and P = 0.84, respectively). The patient weight showed no significant relationship with postoperative complications and intraoperative blood loss (P = 0.156 and P = 0.161, respectively).
| Discussion|| |
During the planning of meningomyelocele surgery, timing and technique of the operation are important considerations. Given the functionality of exposed neural tissue, early surgery to maximize neurological outcome seems logical. Yet, operating on a newborn with possible other anomalies has considerable risks, and stabilization of patient after delivery, preparation of anesthesia team for surgery, informing parents, and taking consent from them may take time. Earlier surgery before 3–5 days after delivery has been reported to have shorter hospital stay and lower complication rates., In another study, operating on the 1st day after delivery had higher complication rates comparing later operative timings. According to the current literature and also our personal experience, operating between 1 and 5 days after delivery is appropriate. However, as a tertiary referral center, referral of patients may be later than expected, and even the first examination of a patient by surgical team may take weeks. The relatively later operation date of ~12 days is due to these delayed cases.
There are few significant criteria for successful closure of meningomyelocele defects. First is durable, waterproof cover of neural repair in a single-stage operation. Flap vascularity must be taken into consideration, and any tension along the suture lines must be eliminated [Figure 5]. Second is that donor area morbidity must be limited to minimum. Third, resulting reconstructed defect and donor area must follow natural body contour. With these criteria in hand, reconstructing the defect with skin grafts is a rather historic method for reconstruction lacking durability., It is also nonapplicable to cases with synthetic dural patches. Musculocutaneous flaps have been proposed for enhancing vascularity. However, this advantage comes with severe consequences. In addition to increased blood loss and prolonged operative time, sacrification of latissimus dorsi and paraspinal muscles is intolerable for a patient who may use crutches or wheelchair in the future. Other limiting factor is giving up the opportunity of reconstructing the future possible pressure ulcer defects with local options. Propeller fasciocutaneous flaps offer robust blood supply, but they are technically demanding, handheld Doppler is needed, and possible harm to the pedicle may lead to catastrophic results. Fasciocutaneous flaps are reliable options, providing sufficient vascularity without the need for microdissection while preserving muscle function. Primary closure of the donor area is almost always possible, as grafting or healing by secondary intention of donor areas prolongs healing period, may lead wound infections, and is destined to unfavorable scars. Various fasciocutaneous flap designs have been proposed with complications rates between 0% and 22.8%.,,, In their series of 48 patients with an average defect size of 31 cm2, Jabaiti et al. reported 17% complication rates with the use of single lobe fasciocutaneous flaps comparing to our 32% complication rate with four patients having CSF leakage. While evaluating the frequency of the complications such as CSF leakage or dehiscence, it should be kept in mind that the only variable is not the plastic surgeon. During reconstruction of dura, neurosurgeons may prefer to use materials such as fibrin glue or absorbable hemostatic gelatin sponge. We think that the use of these foreign materials may increase complication rates as a result after closure.
|Figure 5: Tension along the suture line compromising vascularity seen as bleaching of skin flaps|
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A matter of debate is placing suture lines during reconstruction. Some studies are claiming, and midsagittal linear closure is the most satisfactory method. Yet, CSF leaks up to 17% have been reported after meningomyelocele closure. As a principle in plastic surgery, during layered reconstruction, overlapping incisions facilitate possible leakage and should be avoided. This claim has been supported by other studies. Ying-yang fashion suturing of rotation/advancement flaps helps changing the angle of closure and precludes overlapping of incisions. In cases needing revision, simple readvancement of these delayed flaps provides successful closure.
Wound complications following surgery prolong hospitalization and antibiotic usage. Such burden should not be underestimated in a neonate. Predicting such complications is the first step for preclusion, too. There are only a few reports examining different variables' effect on postoperative wound complications. The timing of operation is one of the variables studied and as has been said before in this article, 1–5 days after labor are optimal time for reconstruction. Spina bifida has the risk of preterm birth, so prematurity and low birth weight are commonly seen. For another variable studied in the literature, Cherian et al. reported low weight does not affect 30-day complication rate. According to our results, patient weight is not related with postoperative complications and intraoperative blood loss, which is compatible with these results.
Intraoperative blood transfusion may be needed during the surgery. Monitorization of blood loss may be done noninvasively with sponge counting or invasively by arterial blood gas/complete blood count screening. Blood loss, which is thought to be more than 50 ml, Hb values lower than 8 g/dL, or tachycardia, may reveal the indication of intraoperative blood transfusion. Even though the intraoperative need for transfusion is limited to 4 (11.4%) patients, our study concluded that there was a significant blood loss during primary surgery, with 35.7% of patients needing transfusion in the postoperative course. Need for transfusion is a poorly studied subject in patients with spina bifida having flap closure. Adeleye reported a zero transfusion rate using electrocautery in a patient population comprising 48 spina bifida patients; however, blood loss is inevitable and preoperative preparation of blood products is essential., Increasing defect size leads to longer operative time and postoperative CSF leakage. We have observed that CSF leak does not always follow flap necrosis or dehiscence. Waterproof closure and prevention of overlapping suture lines may prevent leakage and should be aimed. With proper planning, reconstruction of larger defects is possible without flap necrosis or dehiscence while minimizing blood loss.
Considering surgical techniques, defect size, change in Hb levels, and postoperative complication rates did not differ between techniques for closure. However, double-flap group has a higher rate of wound complications, even if it does not reach statistical significance (P = 0.478). The authors believe that the choice of double-flap closure in mid-large size defects during flap selection may have increased the wound tension and increase the complication rate of this group. Insignificant relationship with defect size and technique is supporting this hypothesis (P = 0.282).
| Conclusion|| |
Rotation/advancement fasciocutaneous flaps provide durable single-stage reconstruction for meningomyelocele defects. The need for transfusion must be kept in mind during primary cases. Correct choosing and application of each method limits complications even with larger defects; however, increasing defect size leads to CSF leaks and prolonged operative time.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]