|Year : 2021 | Volume
| Issue : 3 | Page : 151-155
Is unilateral local flap reconstruction sufficient in large myelomeningocele treatment?
Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Pamukkale University, Denizli, Turkey
|Date of Submission||15-Sep-2020|
|Date of Acceptance||30-Nov-2020|
|Date of Web Publication||29-Jul-2021|
Dr. Enver Arpaci
Çamlaraltı, Kınıklı Cd. No: 37, Pamukkale-20160, Denizli
Source of Support: None, Conflict of Interest: None
Objective: Skin flaps are acceptable methods for surgical treatment of myelomeningocele defects in the neonatal period. Skin flaps (e.g., V-Y advancement, rotation or transposition flaps) are often preferred bilaterally for closure of myelomeningocele defects. This study evaluated the adequacy of an alternative unilateral flap method called “ice cream-cone flap” in repairing large myelomeningocele defects. Patients and Methods: Fifteen newborns who were operated with “ice cream cone flap” due to myelomeningocele defect were evaluated retrospectively. Surgical repair was carried out within 1–3 days of birth. The defect sizes were ranging 10 cm × 8 cm to 4 cm × 4 cm diameter with the mean diameter of 7.2 cm × 5.4 cm. This technique is mainly based on the planning of unilateral advancement flap that resembles the shape of the defect. The technique includes additional procedures such as anchoring of a deepithelialized skin tissue to provide redistribution of the wound closure tension to the lateral side of the flap, and transposition of a skin protrusion to shorten the peripheral border length of the wound. Results: Durable, stable soft-tissue coverage of the defect was obtained in all patients. No hematoma, seroma, infection, and flap necrosis were observed during the postoperative follow-up period. Two patients had partial wound dehiscence which was healed with secondary wound healing. Conclusion: “Ice cream-cone flap” technique is fast, reliable, and easily performed and has the advantage of shorter operative time, less blood loss with minimal wound closure tension.
Keywords: Advancement, curvilinear flap, myelomeningocele, unilateral
|How to cite this article:|
Arpaci E. Is unilateral local flap reconstruction sufficient in large myelomeningocele treatment?. Turk J Plast Surg 2021;29:151-5
| Introduction|| |
Myelomeningocele defects result from a failure of the spinal tube is one of the most common tube defects involving vertebral column and myocutaneous tissues., This composite defect must be surgically repaired immediately after birth. Traditional skin flaps (e.g., V-Y advancement, rotation or transposition flaps) are often preferred bilaterally due to the limited size and mobility of unilateral flaps.,, However, as the size of the defect increases, it is inevitable that the size of the planned flaps and the required dissection area also increase and wound closure tension is a major problem.
This study present the applicability of an unilateral skin flap called “ice cream-cone flap” to repair of medium- and large-sized myelomeningocele defects that can be designed according to the shape of the wound. Herein, the details of flap technique and the results of the clinical cases in which surgery is performed are presented.
| Patients and Methods|| |
We retrospectively reviewed 15 newborn infants with myelomeningocele defect who consulted by newborn intensive care department of study hospital from February 2016 to April 2018 [Table 1]. Six of the patients were girl and nine were boy. All patients were paraplegic and four patients were associated with hydrocephalus. Five defects were located in the thoracolumbar region and 10 defects in the lumbosacral region. Neurosurgical reconstruction of the myelomeningocele and watertight closure of the dural sheath was performed by the neurosurgeon. Immediately following the neurosurgical repair, all patients were treated with “ice cream-cone flap” under general anesthesia. All operations were performed by same surgeon. All patients were examined in terms of age, gender, defect size, operation time, region of the defect, postoperative complications, and the follow-up period.
After neurosurgical repair, the patient was taken over from the neurosurgeon in the prone position. No healthy skin excision was made at the edges of the defect to create a skin defect that would fit the flap shape and real appearance was circular or ellipsoid. The marking of the unilateral flap design was made according to the shape of the wound. A copy flap area which had a ratio of defect width-to-flap length of 1:1 was outlined adjacent to the lateral side of the defect [Figure 1]. Either on the superior or inferior side of the flap, an equilateral triangle was drawn each edge of which is equal to the length of the defect diameter. The region where the triangle area will be marked was determined according to anatomical suitability, tissue elasticity and skin tension lines. The curvilinear line in the triangular area was approximately a third of the entire circumference of the circular flap. The total incision length of the curvilinear flap was determined as twice that of this curvilinear line [Figure 1]. Curvilinear flap derived its blood supply from the perforators of the thoracodorsal and intercostal vessels [Figure 1]. Care was taken not to damage these perforators during dissection.
|Figure 1: Designing of “ice cream-cone flap”. (a) a flap area of the same shape as the defect is drawn adjacent to the defect. (b) A triangle with edges equal to the length of the defect diameter was drawn on the free lateral edge of the flap. Vascular supply of the flap is provided by thoracodorsal and intercostal perforators (dashed lines: Flap incision line)|
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The surgical procedure was started with the de-epithelialization of the triangular area. Skin incisions were made to the curvilinear flap line and one edge of the triangular area [Figure 2]. The fasciocutaneous curvilinear flap and de-epithelialized triangular tissue were dissected at the base line [Figure 2]. The de-epithelialized tissue was anchored on the ground adjacent to the margin of the skin defect on the neural repair line with absorbable sutures [Figure 3]. The skin protrusion resulting from curvilinear flap elevation was transposed to shorten the unequal length between the peripheral border length of the wound (defect width plus flap incision) and flap length [Figure 3]. The direction of transposition was decided based on anatomical suitability and skin elasticity. Meticulous hemostasis was achieved with bipolar cautery and a suction drain was placed under the flap as a routine procedure. Sliding of curvilinear flap was accomplished to the defect with minimal closure tension, and curvilinear off-midline closure was done. The operation was completed by the layered wound closure.
|Figure 2: Stages of surgical technique. (a) Planning of flap. (b) The view of curvilinear flap and the deepithelialized triangular flap after incision. (c) The direction of advancement of the flap and other skin tissues. (d) The postoperative view|
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|Figure 3: A thoracolumbar meningomyelocele in one-day-old man infant. (a) Preoperative view of the defect. (b) Planning of flap. (c), postoperative 1st day. (d) 1 year after surgery|
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| Results|| |
All the patients were paraplegic. The flaps survived completely in all patients without complications such as hematoma, wound infection, flap necrosis, cerebrospinal fluid leakage, and menengitis. Two patients had partial wound dehiscence, which was healed with secondary wound healing without further surgery. Suction drain was taken out on the first postoperative day in all cases. All operations were performed by the same surgeon. All patients were examined retrospectively in terms of age, gender, defect size, operation time, region of the defect, postoperative complications, and the follow-up period. The mean operation time was 36.3 ± 4.9 min. The amount of blood loss was minimal and none of the patients received intraoperative or postoperative blood transfusion. The defect sizes were ranging 10 cm × 8 cm to 4 cm × 4 cm diameter with the mean diameter of 7.2 cm × 5.4 cm [Figure 3]. The flap donor sites were closed primarily without using skin graft or another flap [Figure 4]. Patients were kept in prone position until wound healing was completed and the position was changed in a controlled manner at the end of the postoperative 7th day. Sutures were removed on the postoperative 10th day. The mean follow-up period was 1.8 ± 0.5 years (1–3 years). All patients had stable and reliable wound coverage and none of them showed any complication related to the flap surgery.
|Figure 4: A 1-day-old man new born with a large thoracolumbar meningomyelocele. (a) Intra-operative view of the defect after debridement. (b) 2 years after surgery|
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| Discussion|| |
Closure of myelomeningocele defects as soon as possible in the neonatal period is vital to prevent serious nervous system infections such as meningitis and encephalitis. It is recommended that myelomeningocele defects larger than 5 cm in diameter be treated using flap methods. Many local skin flaps such as V-Y advancement flap, Limberg flap, rotation flap, and bilobed flap have been used to close meningomyelocele defects.,,,,, One of the most important factors affecting the outcome of myelomeningocele surgery is wound closure tension. Because excessive wound closure tension may results in dehiscence, skin necrosis, and flap loss as it leads to inadequate blood flow. To overcome this problem, Zook et al. used delay procedure on the bilateral bipedicled skin flaps to increase vascular supply of flaps. Davies and Adendorff reported that they achieved the tension-free and off-midline closure using unilateral rotation flap. The authors cited that unilateral rotation flap was required wide flap dissection and placement of a skin graft to the donor site of the flap. Campobasso et al. used unilateral Limberg flap in small and medium sized myelomeningocele wounds. Although the Limberg flap has the advantage of transferring the maximum tension from the distal part of the flap to the closure line of the flap donor site, the technique requires excessive flap dissection and the circular shape of the wound to be converted into rhombus shape with extra healthy skin excision.
Given that the newborn has a smaller back area than an adult; it seems that bilateral skin flaps are preferred by surgeons more than unilateral ones, as they allow using of both sides of the wound and result in less tension. Bilateral flaps have been reported in various geometric configurations such as curvilinear, rectangular, and triangular in shape.,, The main advantages of bilateral flaps; the closure tension is shared by two flaps, and there is no need the skin graft to the donor site of the flaps. However, bilateral techniques require the dissection for two flaps, and result in partial or complete overlap of the skin closure line on neural repair line. The complications such as flap necrosis and wound dehiscence make the neural repair line vulnerable to the infections, and may require a second surgery with reduced surgical options.
We have devised a unilateral advancement-transposition flap technique based on the idea that a random pattern flap can be designed similar to the defect shape that like in a free flap planning. In this concept, the shape of the flap is determined by the shape of the defect. The technique was named “ice cream-cone flap” due to the similarity of the preoperative planning design. Additional procedures are required to achieve this “flap to defect concept” and to distribute the wound closure tension along the entire suture lines. For this purpose, a triangular deepithelialized area was created on one side of the flap. The fixation of deepithelialized tissue to the ground adjacent to the defect margin works like “a load-bearing anchor” at the subcutaneous level, brings the defect and flap closer, and provides layered repair line. The second problem in the technique to overcome is that it creates a situation where there exists an unequal length of the borders of the wound once the flap is transferred to their respective recipient site. The skin protrusion that appeared after the flap elevation on the peripheral border of the wound was used to reduce the difference in length. The transposition of this skin protrusion has the effect of shortening the peripheral border.
Bilateral V-Y flap is the only advancement flap used for reconstruction of myelomeningocele wounds. Ulusoy et al. reported the use of bilateral V-Y fasciocutaneous flap with apical extensions of the V-Y flap*s modification. They included 10 defects in their study, the largest of which was 9 × 8.5 cm and an average operative time of 51.7 min. The authors reported no wound complication. Komuro et al. used bilateral flaps consisting of bipedicular V-Y advancement flaps for 11 myelomeningocele defects, the largest of which was 8 cm × 5 cm in size without wound complication. Kesan et al. used bilateral advancement flap in 35 myelomeningocele defects with an average size of 8.5 cm (range 6.5–11 cm). They planned the height of the each V flaps measuring 1.5–2 times the diameter of the defect and reported wound complications such as fat necrosis, flap necrosis, hematoma, cerebrospinal fluid leakage, and meningitis. Remarkable common details in V-Y flap method and its modification are that;
- Bilateral flaps are used
- Each V flap is planned larger than the size of the wound
- The flaps have linear and triangular configuration
- Two flaps join at the mid-closure line.
In our technique;
- The unilateral flap is planned equal to the size of the wound
- It has the curvilinear configuration
- It provides off-midline closure
- Other sides of the defect are suitable for the use of a second surgery in case of wound complications. The comparison of our technique with bilateral V-Y advancement flap techniques is summarized in [Table 2]. We operated 15 patients and the largest defect size was 10 cm × 8 cm. The mean operation time was 37.5 min.
|Table 2: Comparing of ıce cream-cone flap and bilateral V-Y advancement flaps|
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Our flap design prevents to square off the meningomyelocele defect. However, curvilinear rotational, quadrangular, and triangular flaps require to square off the circular defect by extra healthy skin tissue excision.,,
Other advantages of our flap are simplicity of the technique, easy applicability, less blood loss, good tolerance, short healing period, and good cosmetic outcome with minimal complications.
The retrospective nature and limited number of patients are important limitations of this study. The technique was not used in cases associated with Gibbus deformity.
| Conclusion|| |
“Ice cream-cone flap” a surgical option that can be preferred for reconstruction of medium and large sized myelomeningocele defects with easy applicability and low incidence of postoperative complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Botto LD, Moore CA, Khoury MJ, Erickson JD. Neural-tube defects. N Engl J Med 1999;341:1509-19.
Patel KB, Taghinia AH, Proctor MR, Warf BC, Greene AK. Extradural myelomeningocele reconstruction using local turnover fascial flaps and midline linear skin closure. J Plast Reconstr Aesthet Surg 2012;65:1569-72.
Zide BM. Spina bifida. In: McCarthy JG, editor. Plastic Surgery. Philadelphia: W.B. Saunders Co.; 1990. p. 3780-8.
Kesan K, Kothari P, Gupta R, Gupta A, Karkera P, Ranjan R, et al
. Closure of large meningomyelocele wound defects with subcutaneous based pedicle flap with bilateral V-Y advancement: Our experience and review of literature. Eur J Pediatr Surg 2015;25:189-94.
Emsen IM. Closure of large myelomeningocele defects using the O-S flap technique. J Craniofac Surg 2015;26:2167-70.
Kemaloğlu CA, Özyazgan İ, Ünverdi ÖF. A decision-making guide for the closure of myelomeningocele skin defects with or without primary repair. J Neurosurg Pediatr 2016;18:187-91.
Kocak OF, Demir CY. An ıdeal flap alternative for closure of myelomeningocele defects: Dorsal ıntercostal artery perforator flap. J Craniofac Surg 2016;27:1951-5.
Sarifakioglu N, Bingül F, Terzioglu A, Ates L, Aslan G. Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg 2003;56:303-6.
Campobasso P, Pesce C, Costa L, Cimaglia ML. The use of the Limberg skin flap for closure of large lumbosacral myelomeningoceles. Pediatr Surg Int 2004;20:144-7.
Shim JH, Hwang NH, Yoon ES, Dhong ES, Kim DW, Kim SD. Closure of myelomeningocele defects using a limberg flap or direct repair. Arch Plast Surg 2016;43:26-31.
Davies D, Adendorff DJ. A large rotation flap raised across the midline to close lumbo-sacral meningomyelocoeles. Br J Plast Surg 1977;30:166-8.
Patterson TJ. The use of rotation flaps following excision of lumbar myelomeningoceles: An aid for the closure of large defects. Br J Surg 1959;46:606e8.
Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg 2001;54:570-2.
Zook EG, Dzenitis AJ, Bennet JE. Repair of large meningomyeloceles. Arch Surg 1969;98:41-3.
Mutaf M, Bekerecioğlu M, Erkutlu I, Bulut O. A new technique for closure of large meningomyelocele defects. Ann Plast Surg 2007;59:538-43.
Ulusoy MG, Koçer U, Sungur N, Karaaslan O, Kankaya Y, Ozdemir R, et al
. Closure of meningomyelocele defects with bilateral modified V-Y advancement flaps. Ann Plast Surg 2005;54:640-4.
Komuro Y, Yanai A, Koga Y, Seno H, Inoue M. Bilateral modified V-Y advancement flaps for closing meningomyelocele defects. Ann Plast Surg 2006;57:195-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]