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Table of Contents
Year : 2020  |  Volume : 28  |  Issue : 4  |  Page : 214-218

Role of perforator flaps in meningomyelocele defect repair

1 Department of Plastic Reconstructive and Aesthetic Surgery, Ankara University School of Medicine, Ankara, Turkey
2 Department of Neurosurgery, Ankara University School of Medicine, Ankara, Turkey

Date of Submission15-Dec-2019
Date of Acceptance29-Feb-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Burak Kaya
Department of Plastic Reconstructive and Aesthetic Surgery, Ankara University School of Medicine, Ankara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_96_19

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Background: With an incidence of 1–2 in 1000 live births, meningocele is a relatively frequent birth defect. The lumbosacral region is affected in threequarters of the cases. It may lead to urinary and fecal incontinence, as well as plegia or paresis in the lower extremity. A large number of techniques have been described for meningomyelocele defect repair. Aims and Objectives: We reviewed perforator flaps used in meningomyelocele defect repair on patients admitted to our clinic and compared it with literature. Materials and Methods: This study included 12 newborns operated between January 2012 and February 2019. Results: The meningomyelocele was located in the thoracolumbar area in five patients and the lumbosacral area in 7 patients. The patients weights were 1830–3800 g. The most commonly used flap was the superior gluteal artery flap (n:5). Other flaps that were commoly used are the dorsal intercostal artery perforator (DIAP) and the lumbar artery perforator flaps. In two patients CSF leak was seen and one patient distal necrosis was seen. Conclusion: Perforator flaps can be used safely with a relatively low complication rate in meningomyelocele defect repair. It seems to be an alternative for safe, rapid, less bleeding, and easy surgery resulting in a solution for the closure of large meningomyelocele defects.

Keywords: Lumbar tissue defect, meningomyelocele, perforator flap

How to cite this article:
Ozden NS, Kaya B, Kahilogullar G. Role of perforator flaps in meningomyelocele defect repair. Turk J Plast Surg 2020;28:214-8

How to cite this URL:
Ozden NS, Kaya B, Kahilogullar G. Role of perforator flaps in meningomyelocele defect repair. Turk J Plast Surg [serial online] 2020 [cited 2022 Dec 3];28:214-8. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/4/214/296479

  Introduction Top

Tissue defects at the back may be a result of trauma, neural tube defects, spinal surgery, radiation ulcers, decubitus ulcers, and malignant tumor surgery.[1] Neural tube defects occur when the neural tube fails to close correctly at the neurulation period during the first 4 weeks of gestation.[2] Neural tube defects range from anencephaly to spina bifida, with meningomyelocele as the most common form of spina bifida.[3]

Meningomyelocele incidence has been reported to range between 1 and 2/1000 live births.[4],[5] The defect location can reside anywhere between the cervical region and the sacrum. The lumbosacral region is affected in three-quarters of the cases. Functional prognosis worsens if higher segments are involved. Lesions between T10 and L4 levels mostly lead to paraplegia, and patient ambulation is currently not possible. If S2 and S3 nerve roots are affected, related sphincter dysfunction leads to urinary and fecal incontinence.[6]

Meningomyelocele defects require a multidisciplinary approach with a team consisting of pediatric neurosurgery, plastic surgery, orthopedics, and urology departments. There are four advantages to early surgical closure of these defects: preventing fatal infections such as meningitis, eliminating cerebrospinal fluid (CSF) leakage, preserving nerve function, and reducing risk of late complications such as pain in the incision line and tethered cord syndrome.[7]

In meningomyelocele defect repair, the surgeon's goal is tensionfree closure. Kemaloǧlu et al. developed an algorithm to decide between primary closure and flap reconstruction for meningomyelocele defect repair.[8]

  1. If the defect height/width (y/x) ratio is ≥1.5, two parameters are evaluated:

    1. If the length of between the two posterior axillary lines/defect width (2z + x/x) ratio is >3, primary closure is sufficient
    2. If the length of between the two posterior axillary lines/defect width (2z + x/x) ratio is <3, flap reconstruction is required.

  2. If the defect height/width (y/x) ratio is <1.5, flap reconstruction is required [Figure 1].
Figure 1: Decision-making algorithm based on height/width (y/x) ratio in meningomyelocele defects developed by Kemaloǧlu et al.

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Flap options include a paraspinal muscle turnover flap, latissimus dorsi muscle–skin flap, rotation–transposition fasciocutaneous flap, bilobed flap, bilateral VY advancement flap, lumbar artery perforator flap, and dorsal intercostal artery perforator flap.[9],[10],[11],[12],[13],[14]

The closure of myelomeningocele defects with a perforator flap was first performed in 2004 by Duffy et al. using the superior gluteal artery perforator (SGAP) flap.[15]

In this study, we reviewed perforator flap reconstruction surgeries performed in our clinic and compared them with the literature.

  Materials and Methods Top

Large meningomyelocele cases operated on by our faculty's neurosurgery department and our department, where we applied perforator flaps, were reviewed and analyzed in light of literature.

This study included 12 newborns operated between January 2012 and February 2019. The meningomyelocele was placed in the thoracolumbar area in five patients and the lumbosacral area in 7 patients. Eight of the children were girl and four were boy. In five patients, there was an additional congenital malformation. Ten patients were operated in the 1st week of their life, but for one case, operation time was at 1 month of age. The patients' weights were 1830–3800 g (mean: 2780 g). The details of the patients and clinical findings are summarized in [Table 1].
Table 1: Details of the patients and clinical findings

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Surgical technique

The patient is positioned in the prone position under endotracheal general anesthesia. Operative procedures were started by a neurosurgical team. The skin around the neural plate is excised circularly and removed. After the complete release of dura leaves from the surrounding tissue, the dura is closed with 4-0 Prolene. The next step is flap selection in line with the defect location. Defect sizes ranged from 6 cm × 5 cm to 11 cm × 9 cm. The flap design is determined after the closest perforators are detected through a hand Doppler with an 8 MHz probe. In the presence of an unreliable perforator, the reconstructive plan is changed in favor of a random pattern flap. The flap is elevated in the subfascial plane and perforators without skeletonization.

Two-layer closure was obtained without any tension, and a suction drain was placed under the flaps. In all patients, flap donor sites were closed primarily. In the immediate postoperative period, the wounds were inspected for any dehiscence or infection or CSF leakage [Figure 2] and [Figure 3].
Figure 2: (a) (Left) Preoperative photographs, (b and c) (right) intraoperative photographs

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Figure 3: Three months postoperative view

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  Results Top

In postoperative follow-up, hematoma, seroma, wound dehiscence, flap necrosis, or infection were not observed. Ventriculoperitoneal shunts were implanted in the five cases that postoperative hydrocephalus had occurred. In two patients due to CSF leak, suture was opened at the flap edge and was treated with primary repair. One patient had superficial necrosis of the distal part of the flap and secondary with dressing improvement was achieved.

The patients had a follow-up of 6–35 months, with a mean of 12 months, and no patient was observed with late breakthrough of the wound.

  Discussion Top

The principles of myelomeningocele repair have already been well described. It consists of preserving neural elements and fashioning a fourlayer closure, consisting of dura, fascia, subcutaneous tissue, and skin.[16]

Various options have been described for meningomyelocele defect repair. It has been reported in the literature that defects smaller than 4–5 cm can be treated with a primary closure.[16]

Although skin graft repair is simple and straightforward, it is not suitable because of increased ulceration and infection risk in the long term.[17],[18]

Random pattern flaps, such as transposition flap, Z-plasty, rotation flap, bilobed flap, and Limberg flap, have a high risk of distal necrosis due to the wide dissection area, which leads to high rates of wound dehiscence. In addition, flap viability is unpredictable in these flaps, as blood supply patterns are not known.[19]

Reliable musculocutaneous like latissimus dorsi and gluteus maximus flaps can be used to repair the meningomyelocele defects. These back and pelvic muscles are essential for ambulation. The majority of the meningomyelocele patients are going to be wheelchair dependent because of the paraplegia. Therefore, muscle tissue should be preserved as much as possible in meningomyelocele repair.[5],[14],[15]

Perforator flaps have the capacity to overcome all these problems. The reason perforator flaps are more difficult to apply in the pediatric population is that the perforators are as small as 1–2 mm in diameter and therefore susceptible to vasospasm. Leaving a thin layer of muscle around the perforator prevents vasospasm.[20],[21]

Many publications in the literature, including Arash et al., propose that perforator flaps might also be securely applied in the pediatric population with a relatively low rate of complication.[15],[22] In our case series, only 3 out of 16 patients had complications.

Lumbar artery perforator flap

Lumbar arteries originate from the posterior part of the abdominal aorta. It courses between erector spina and quadratus lumborum muscles, and after perforating erector spina and thoracolumbar fascia, it continues between transverse and internal oblique muscles. Of the five lumbar arteries, the second and fourth lumbar arteries are the largest. The flap is prepared from the posterior midline toward the anterosuperior iliac spine. The perforators are concentrated 5–9 cm from mid-line.[23] Many studies have reported that utilizing the lumbar artery perforator flap is highly effective in preventing infection and CSF leakage.[23],[24],[25] No cerebrospinal leakage was observed in the five flaps used in our study.

Dorsal intercostal artery perforator flap

Dorsal intercostal arteries originate from the posterior part of the aorta. The perforators are concentrated within a 5-cm radius with spinous processes of the vertebrae at the center. The lateral margin of the flap should not exceed the lateral margin of the latissimus dorsi muscle. The thoracolumbar fascia must be included in the flap.[26],[27]

In 27 patient case series by Isik et al., distal necrosis was reported in only two patients, and in our case series, only one patients' cerebrospinal leakage was observed.[14]

Superior gluteal artery perforator flap

Superior gluteal artery originates from the internal iliac artery. The perforators are concentrated at the junction of the 1/3 middle distal part from the upper boundary of the piriformis muscle. The dissection method could either be subfascial or suprafascial. In a series of six patients, Duffy et al. reported a 100% success rate of the flap, although early postoperative venous insufficiency was common.[15] In one of the five SGAP flaps used in our study, one flap suffered partial necrosis as a result of venous insufficiency and in another flap cerebrospinal leakage was observed.

Repair with free design perforator flap

In meningomyelocele, vascular anomalies are often seen below the affected segment due to concomitant kyphosis. Fromm et al. found lumbar and intercostal artery anomalies in 6 of 21 kyphosis patients, and Loder et al. reported anomalous lumbar artery in four of the six thoracic meningomyelocele patients. Iacobucci et al. also reported the presence of significant lumbar artery hypoplasia/aplasia in lumbosacral meningomyelocele.[28],[29],[30] For the above two reasons, the use of free style perforator flaps in meningomyelocele is increasingly common in the lumbosacral region. However, in this study, we did not use a free still perforator flap.

Imaizumi reported that they reconstructed meningomyelocele defects with a simple and low morbidity rate. It was independent from the perforator anatomy and with no need for wide perforator dissection, thanks to freestyle perforator flaps combined with Doppler ultrasonography.[31]

Late complications of meningomyelocele surgery include tethered cord syndrome and pain at incision lines. Tamaki et al. reported that this complication was seen at a rate as high as 15%. These complications develop due to fibrotic adhesion of the repair line to the underlying lamina.[32] Symptoms of tethered cord syndrome include pain in the back and legs, bladder function impairment, urinary incontinence, motor or sensory deficits in the lower extremities at different levels, and rapid progression to scoliosis. Bringing a flap that includes adipose tissue with a good blood supply, such as perforator flaps over dural repair, reduces the chance of late complications.[15],[32],[33] During the 3-year follow-up, no signs of tense cord syndrome were observed in patients.

In addition, it has been reported that the operative time is short, and the need for blood transfusion is less in patients undergoing a perforator flap repair. Similarly, in our case series, the median operation time was 3 h, and blood transfusion was not required in any of the operations.[15],[27]

This article is important because it is the first article to discuss each five perforator flaps used for large meningomyelocele defect closure [Figure 4].
Figure 4: Perforator flap selection algorithm used in our clinic according to the defect location. DIAP flap: Dorsal intercostal artery perforator flap, SGAP: Superior gluteal artery perforator flap

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  Conclusion Top

Surgical repair of large meningomyelocele defects is a challenging task. Each patient requires a special and personalized operation plan. In meningomyelocele patients who may develop paraplegia, perforator flaps, as opposed to muscle–skin flaps, help ambulation because they prevent muscle sacrifice and can be used without complications. Transferring a vascularized tissue over the dural layer prevents CSF leakage and infections. It is also known to prevent late complications such as tethered cord syndrome and pain in incision lines. In conclusion, as in our case series, perforator-based flaps are an effective and uncomplicated reconstruction option for large meningomyelocele defect repair.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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