RECONSTRUCTIVE SURGERY
Bilateral Propeller Flap Closure of Large Meningomyelocele Defects Harun C¸o¨lo?lu, MD,* Burak O¨zkan, MD,Þ Ahmet C¸a? rı Uysal, MD,Þ O¨zlem C¸o¨lo?lu, MD,þ and Hu¨seyin Borman, PhDÞ Background: Meningomyelocele is a defect of the spinal cord, vertebral spine, and overlying skin and is the most common form of spinal dysraphism. Multiple methods of soft tissue closure for larger myelomeningocele defects have been described, including skin grafting, random fasciocutaneous flaps, skin undermining with relaxing incisions, and musculocutaneous flaps. Most current methods for closure of defects of 8 cm and greater and kyphotic spines usually remains inadequate. In this study, we present our clinical experience with a new surgical procedure, bilateral propeller (BP) flaps based on dorsal intercostal and lumbar artery perforator, for the closure of large thoracolumbar meningomyelocele defects. Patients and Method: Between January 2011 and April 2012, 7 newborns (5 males and 2 females) with thoracolumbar large meningomyelocele were included in the study. Six patients had lumbar kyphosis. Myelomeningocele defects with a mean size of 89.3 cm2 (range, 58.9Y136.8) were closed with BP flaps. Results: All flaps survived; hematoma, seroma, wound dehiscence, flap necrosis, or infection was not observed. No patients required any surgical revisions. The patients had a follow-up of 4 to 16 months with a mean of 10 months, and no long-term complications, including necrosis of flap edges, wound breakdown, or instability, have been apparent in our series. Conclusions: We believe that the BP flaps represent a useful tool in the management of soft tissue defects associated with especially kyphotic large thoracolumbar and lumbosacral myelomeningoceles. Key Words: meningomyolecele, propeller flaps, large defects (Ann Plast Surg 2014;73: 68Y73)
M
eningomyelocele is a defect of the spinal cord, vertebral spine, and overlying skin and is the most common form of spinal dysraphism.1 The etiology of spinal canal defects is multifactorial. Widely known causes are genetic properties, geographic factors, low socioeconomic status, and deficiency of folic acid.2,3 Its incidence is declared as 1 per 1,000; however, the incidence of this anomaly is on the decline in relation with the developments in the prenatal diagnosis of neural tube defects and the aborted pregnancies as a result of these defects.4,5 This anomaly should be surgically repaired immediately after birth. The aim of the early surgical closure is to prevent infection and leakage of cerebrospinal fluid, besides protecting the neural elements. Mortality rate is approximately 65% to 70% for patients untreated in the first 6 months of life.6
Received April 10, 2012, and accepted for publication, after revision, July 31, 2012. From the *Medical Faculty, Department of Plastic and Reconstructive Surgery, Baskent University, Adana; †Medical Faculty, Department of Plastic and Reconstructive Surgery, Baskent University, Ankara; and ‡Medical Faculty, Department of Pediatric Surgery, Cukurova University, Adana, Turkey. Conflicts of interest and sources of funding: none declared. Reprints: Harun C ¸ o¨lo?lu, MD, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Baskent University, Gazipas¸a mah. Baraj cad. No. 7, 01140 Seyhan, Adana, Turkey. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-0068 DOI: 10.1097/SAP.0b013e31826caf5a
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Multiple methods of soft tissue closure for larger myelomeningocele defects have been described, including skin grafting,7 random fasciocutaneous flaps,8 skin undermining with relaxing incisions,9 and musculocutaneous flaps.10,11 Small defects (G5 cm in diameter) can usually be closed primarily by undermining the surrounding tissues. Most current methods for closure of defects more than 8 cm and kyphotic spines usually remain inadequate. Because operative stress, postoperative infection, wound dehiscence, or flap necrosis may have disruptive results, short operation time, less bleeding, safe flap perfusion, and good coverage of the wound are important to obtain satisfactory results and avoid any possible complications. ‘‘Propeller flap’’ was introduced in 1991 by Hyakusoku et al12 to describe an adipocutaneous flap, based on a random subcutaneous pedicle, with a skin island of a length largely exceeding its width, made of 2 portions: one at either side of the pedicle. A number of authors reported the application of the perforator propeller concept to the reconstruction of soft tissue defects in different areas of the body.13Y17 In this study, we present our clinical experience with a new surgical procedure, bilateral propeller (BP) flaps based on dorsal intercostal and lumbar artery perforator (DIAP and LAP), for the closure of large thoracolumbar meningomyelocele defects.
PATIENTS AND METHOD Between January 2011 and April 2012, 7 newborns (5 males and 2 females) with thoracolumbar large meningomyelocele were included in the study. This study was approved by Baskent University institutional review board (project no: KA12/59). Six patients had lumbar kyphosis. Myelomeningocele defects with a mean size of 89.3 cm2 (range, 58.9Y136.8) were closed with this technique. All of the patients were operated on within 120 hours of birth. Preservation of neural elements and watertight dural closure over the exposed neural plate were performed by the neurosurgical team. The plastic surgery team then completed wound closure with BP flaps. Details of the patients and mean values were documented in Table 1.
Surgical Method The patient was placed in the prone position, with rolls under the chest and hip to allow the abdomen to hang freely. The vertebral column was drawn in the midline in the dorsal region. The plastic surgical component of the operation begins with Doppler identification and 4-power loupe magnification and microsurgical instruments. Dorsal intercostal and lumbar artery perforator were located by a hand Doppler in the medial one third of the dorsal region. Bilateral elliptical propeller flaps based on LAP and DIAP were planned (Fig. 1A). All the flaps were raised in a fasciocutaneous manner. Dissections of the flaps were performed on the subfascial plane with meticulous hemostasis and in a careful manner. Pedicles (1 or 2 bundles) were observed and protected by careful dissection. The flap was moved to the defect site, and meticulous hemostasis and singlelayer skin closure with 4/0 and 5/0 Prolene (Ethicon/Edinburg) were accomplished. The flap donor site was then primarily closed in all patients (Fig. 1B). In all patients, a suction drain was placed and kept in place for 3 to 5 days after surgery. The patients received care after surgery in the prone position until wound healing was completed, which lasted Annals of Plastic Surgery
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Bilateral Propeller Flap
TABLE 1. Detailed Documentation of the Patients Patient No.
Sex
Birth Week
Age at Operation, d
Size of Skin Defect, mm
Size of Flap, cm*
Operating Time, min
Blood Loss, mL
1
F
Full term
3
108 72
8 6/7 5
65
35
2 3 4 5 6 7 Mean
M F M M M M
Full term Full term Full term Preterm Full term Full term
1 3 3 3 2 3
120 114 90 84 83 71 98 85 110 95 105 84 102 86
9 7/8 6 8 6/7 5 7 6/7 5 8 5/7 4 8 5/8 6 8 5/8 6
70 58 62 55 58 52 61.7
40 25 20 30 35 30 30.7
Region
Kyphosis Complications
Thoracal Thoracolumbar Thoracal Thoracal Thoracolumbar Thoracolumbar Thoracolumbar
+ + + + j + +
None None None None None None None
F, female; M, male. *Lumbar artery perforatorYbased propeller flap/DIAP-based propeller flap.
from 5 to 6 days. Starting the day before the surgery, a third-generation cephalosporin was used during the first week after surgery in all patients, although a ventriculoperitoneal shunt was placed in all patients to protect the flaps from the tension caused by increased cerebrospinal pressure.
Illustrative Case Reports Case 1 A 3-day-old female full-term newborn with a large thoracolumbar meningomyelocele defect was treated on the request of the neurosurgery department in the same institute. The size of the meningomyelocele sac was measured as 10.8 7.2 cm. She had a lumbar kyphosis (Fig. 2). After placement of an abdominoventricular shunt and closure of the placode were done by neurosurgeons, the defect closure was accomplished by using BP flaps technique as described previously (Fig. 3). Both flaps were elevated as pure fasciocutaneous flaps based on the perforator vessels from the right dorsal intercostal artery (1 bundle) and left lumbar artery (2 bundles; Fig. 4). The sizes of the flap were 7 5 and 8 6 cm, respectively. By transposing the flaps toward the defect area, a tension-free closure was obtained (Figs. 5 and 6). The flaps healed uneventfully, and the patient was discharged at day 7 after operation. During 8 months of follow-up, no complication was observed (Figs. 7Y9).
Case 2
abdominoventricular shunt and closure of the placode were done by neurosurgeons, the skin defect was measured as 12 11.4 cm in diameter, extending two third of the total width of the back (Fig. 10). He also had a lumbar kyphosis. The defect closure was accomplished by using BP flaps technique; an excellent tension-free coverage was obtained in this patient with an unusually large meningomyelocele defect. Both flaps were elevated as pure fasciocutaneous flaps based on the perforator vessels from the right dorsal intercostal artery (1 bundle) and left lumbar artery (1 bundle; Figs. 11Y13). The sizes of the flap were 8 6 and 9 7 cm, respectively. The flaps healed with no complication (Fig. 14). The LAPYbased propeller flap developed mild venous congestion. It was resolved on postoperative second day uneventfully. The result at 8 months after surgery is shown in Figures 15 and 16. Although the patient had a remarkable gibbus deformity, there was no wound breakdown at late term, and the skin flap was found to be sufficient to provide a proper padding on the neural tissues.
RESULTS The mean age at the time of surgery was 72 hours; 5 patients were male, and 2 were female. The defects were either in the thoracolumbar or the lumbar region in all patients. The largest was 12 11.4 cm, the smallest was 8.3 7.1 cm, and the mean dimension was 10.2 8.6 cm. All defects developing after myelomeningocele repair were successfully closed using BP flaps. In all patients, a tension-free
A day-old male infant was admitted with a large meningomyelocele associated with hydrocephalus. After placement of an
FIGURE 1. A, Design of the BP flaps. B, Closure patterns of BP flaps. DIAP PF, Dorsal intercostal perforator propeller flap. LAP PF, lumbar artery perforator propeller flap. * 2014 Lippincott Williams & Wilkins
FIGURE 2. Intraoperative view of the skin defect. www.annalsplasticsurgery.com
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FIGURE 3. Design of the BP flaps based on DIAP and LAP.
FIGURE 6. Completed single-layer skin closure at the end of the operation.
FIGURE 4. Elevated of propeller flap based on DIAP.
FIGURE 7. Postoperative view at second month.
FIGURE 5. Bilateral propeller flaps extension of skin defect.
FIGURE 8. Postoperative view at seventh month.
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Bilateral Propeller Flap
FIGURE 9. Postoperative lateral view at seventh month.
FIGURE 11. Elevated of propeller flap based on DIAP.
closure was obtained. Flap donor sites were closed primarily. All patients tolerated the procedure without blood transfusion and without perioperative complications. The mean (range) blood loss and operation time for flap elevation and closure were 30.7 (20Y40) mL and 61.7 (52Y70) minutes, respectively. All flaps survived, although venous congestion developed immediately after surgery on LAPbased flaps with 3 patients. Venous congestions were improved on postoperative second day. Additional complication was not observed in these patients. Hematoma, seroma, wound dehiscence, flap necrosis, or infection was not observed. No patients required any surgical revisions. All patients required subsequent ventriculoperitoneal shunts for hydrocephalus, and these procedures were uneventful; there were no shunt infections. All donor incisions healed without complication. The patients had a follow-up of 4 to 16 months with a mean of 10 months, and no long-term complications, including necrosis of flap edges, wound breakdown, or instability, have been apparent in our series.
Myelomeningocele closure consists of spinal cord repair, closure of the dura, and closure of the soft tissue and skin adjacent to the defect. There are 2 broad goals for this composite closure. First, the surgeon hopes to provide a generous, durable, and tension-free soft
tissue and skin covering over the repaired dura, thus minimizing the risk of cerebrospinal fluid leak and infection. Second, it is best to restore the natural soft tissue contours and to minimize morbidity secondary to local rearrangement of muscle and soft tissue. After the pediatric neurosurgeon has closed the neural tube, the role of the plastic surgeon in these larger defects is to provide durable coverage of the neural tube to prevent damage to or infection of the neural structures. Therefore, the closure of defects must have well-perfused blood supply without tension. Approximately 75% of meningomyelocele defects can be treated by primary closure; only large defects (95 cm), comprising the remaining 25%, cannot be closed primarily and also may require more complex procedures.2,18Y20 Various methods have been described in the literature, including primary closure, skin grafts, local flaps, muscular-musculocutaneous flaps, and fasciocutaneous flaps.1Y6 Mustarde21 was the first to suggest split-thickness skin grafts in the closure of meningomyelocele. Luce and Walsh22 applied delayed split-thickness skin grafting or simultaneous dural closure and skin grafting with a low incidence of complications. Despite its being a simple procedure with satisfactory postoperative results, skin graft repair is frequently complicated by gibbus deformity, ulceration, and infections in the long-term follow-up. Some authors have reported a successful method for closure of a defect area using musculocutaneous flaps. Major advantages of
FIGURE 10. Design of the BP flaps based on DIAP and LAP.
FIGURE 12. Elevated of propeller flap based on LAP.
DISCUSSION
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FIGURE 13. Bilateral propeller flaps extension of skin defect.
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FIGURE 15. Postoperative view at sixth month.
muscle flaps include high blood flow, provision of sufficient soft tissue over the repaired dura, and accelerated healing. However, some disadvantages that belong to this procedure have also been described, such as loss of major muscles, increased blood loss, and prolonged operation time.18,23Y25 The sacrifice of intact back muscles will be a challenge for the future use of wheelchairs in these patients, most of whom are paraplegic. In addition, these patients will be vulnerable to decubitus ulcers, and the treatment would be difficult because the local muscles would have been used before. Many scientists have preferred the less traumatic fasciocutaneous flaps for meningomyelocele repair. Moore et al23 developed bilateral bipedicled advancing flaps in large meningomyelocele closures. Cruz et al24 reported satisfactory results with double Z-rhomboid flaps in 10 newborns. Limberg flap by Campobasso et al18 and modified V-Y advancing flap by Ulusoy et al25 were all applied successfully, the size of which ranged from 35 20 to 80 50 mm2. In 2001, Lapid et al3 used bilobed flaps for closure of myelomeningocele defects. Atik et al26 reported that they closed large myelomeningocele defects using bilobed flaps in 20 patients, and it was reported as the gold standard in myelomeningocele defect repair. We also prefer bilobed fasciocutaneous flaps to the 5- to 8-cm defect in our clinic.
Perforator flaps have provided a contribution to plastic surgery. Recently, Duffy et al27 repaired lumbosacral myelomeningocele defects using a superior gluteal artery perforator flap in 6 patients. They reported advantages such as less bleeding during the operation, closure of the defect using soft tissue, and better vascularity of the flap. The superior gluteal artery perforator flap for the closure of lumbosacral meningomyelocele defects had a mean defect size of 4.8 6.8 cm2. Atik et al28 described the anatomical localization and diameter of DIAPs in 10 cadavers. They found that there were 1 artery, 1 vein, and 1 nerve emerging from each intercostal space in the dorsal region, and they also found that these were indirect muscle perforators and that the secondary perforators entered the skin. They successfully used the DIAP flap in 8 patients with large myelomeningocele defects. This was the first study where DIAP was used in the repair of a myelomeningocele defect with the mean defect size of 7 5.5 cm2, whereas it was 10.2 8.6 cm2 in our series. It seems to have several promising features such as well-vascularized healthy soft tissue padding; the flap is limited for the small and medium meningomyelocele defects.29 The LAP flap was used in a small number of cases previously in a variety of defects in the back. However, it was not used previously in meningomyelocele defects.30Y33
FIGURE 14. Postoperative view at second month.
FIGURE 16. Postoperative lateral view at sixth month.
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Based on our experience and the previous information, meningomyelocele skin defects need to classify as small (G5 cm), moderate (5Y8 cm), and large (98 cm). We believe that moderate defects are enough for the use of unilateral flap methods, but large defects require the use of bilateral flap methods. The term propeller flap was first used in axiller and wrist burn contracture defects.12 Subsequently, Hallock33 used the term propeller to define a fasciocutaneous flap that he raised over the adductor compartment of the posterior thigh. The flap was similar in shape to the one described by Hyakusoku et al,12 but it was based on a skeletonized perforating vessel, and the skin island was rotated 180 degrees. By doing this, a part of the flap (the larger blade) was used to resurface the defect, and the other part of the flap (the minor blade) was positioned over the donor site of the larger blade facilitating its direct closure. Teo13 (Teo, personal communication) greatly contributed to the definition and to the details of the surgical technique of perforator-based propeller flaps. A number of authors reported the application of the perforator propeller concept to the reconstruction of soft tissue defects in different areas of the body.14Y17 In this study, the LAP- and DIAP-based BP flaps were used to maintain skin closure without tension in cases with large myelomeningocele defects (Q8 cm) and kyphotic spines. The most important factor in preventing early and late complications is skin closure without tension. This is exceeded with bilateral flaps. In contrast to prior opinions, blood loss was less with carefully dissection and hemostasis. Operating times remained at an acceptable level. In addition, dog ear and torsion deformities do not develop, requiring second surgical intervention.
CONCLUSIONS We believe that the BP flaps represent a useful tool in the management of soft tissue defects associated with large thoracolumbar and lumbosacral myelomeningoceles because it has the following advantages: closure with a nontense skin, high safety, bringing soft tissue with a good blood supply onto the neural structures, enabling the primary closure of donor site, no overlapping between the skin suture line and the dura suture line, no pressure on the dura, no wasting of the neighboring muscles, shorter operation time, and less blood loss. The most important disadvantage of the technique is the large amount of scarring. The procedure allows for the transfer of healthy, vascularized tissue over the dural closure, likely diminishing both cerebrospinal fluid leaks and cerebrospinal fluid infections. Because the dural repair is covered with well-padded tissue using this flap, we are hopeful that this approach will diminish the chronic pain at the closure site that many of these patients have later in life. REFERENCES 1. Oakes WJ. Spinal dysraphism. In: Serafın D, Georgiade N, eds. Pediatric Plastic Surgery. St Louis, MO: Mosby; 1984. 2. Turhan Haktanir N, Eser O, Demir Y, et al. Repair of wide myelomeningocele defects with the bilateral fasciocutaneous flap method. Turk Neurosurg. 2008;18:311Y315. 3. Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg. 2001;54:570Y572. 4. Sarifakioglu N, Bingul F, Terzioglu A, et al. Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg. 2003;5:303Y306.
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Bilateral Propeller Flap
5. Gumus N. A new approach to closure of myelomeningocele defect: z advancement-rotation flap. Ann Plast Surg. 2008;61:640Y645. 6. Laurence KM. Effect of early surgery for spina bifida cystic on survival and quality of life. Lancet. 1974;23:301Y304. 7. Luce EA, Stigers SW, Vandenbrink KD, et al. Split-thickness skin grafting of the myelomeningocele defect: a subset at risk for late ulceration. Plast Reconstr Surg. 1991;87:116Y121. 8. Bajaj PS, Welsh F, Shadid EA. Versatility of lumbar transposition flaps in the closure of meningomyelocele skin defects. Ann Plast Surg. 1979;2:103Y108. 9. Salasin RI, Briggs RM. Closure of a large myelomeningocele: case report. Plast Reconstr Surg. 1973;51:464Y466. 10. Munro IR, Neu BR, Humphreys RP, et al. Limberg latissimus dorsi myocutaneous flap for closure of myelomeningocele. Childs Brain. 1983;10:381Y386. 11. Ramirez OM, Ramasastry SS, Granick MS, et al. A new surgical approach to closure of large lumbosacral meningomyelocele defects. Plast Reconstr Surg. 1987;80:799Y809. 12. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg. 1991;44:53Y54. 13. Teo TC. Perforator local flaps in lower limb reconstruction. Cir Plast Iberolatinoam. 2006;32:15Y16. 14. Moscatiello F, Masia J, Carrera A, et al. The ‘‘propeller’’ distal anteromedial thigh perforator flap: anatomic study and clinical applications. J Plast Reconstr Aesthet Surg. 2007;60:1323Y1330. 15. Pignatti M, Pasqualini M, Governa M, et al. Propeller flaps for leg reconstruction. J Plast Reconstr Aesthet Surg. 2008;61:777Y783. 16. Georgescu AV, Matei I, Ardelean F, et al. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery. 2007;27:384Y394. 17. Mateev MA, Ogawa R, Trunov L, et al. Shape-modified radial artery perforator flap method: analysis of 112 cases. Plast Reconstr Surg. 2009;123:1533Y1543. 18. Campobasso P, Pesce C, Costa L, et al. The use of the Limberg skin flap for closure of large lumbosacral myelomeningoceles. Pediatr Surg Int. 2004; 20:144Y147. 19. Blanco-DaC ¸ vila F, Luce E-A. Current considerations for myelomeningocele repair. J Craniofac Surg. 2000;11:500Y508. 20. Patterson T-J, Till K. The use of rotation flaps following excision of lumbar myelo-meningoceles: an aid to the closure of large defects. Br J Surg. 1959; 46:606Y608. 21. Mustarde JC. Meningomyelocele: the problem of skin cover. Br J Surg. 1966;53:36. 22. Luce EA, Walsh J. Wound closure of the meningomyelocele defect. Plast Reconstr Surg. 1985;75:389Y393. 23. Moore TS, Dreyer TM, Bevin AG. Closure of large spina bifida cystica defects with bilateral bipedicled musculocutaneous flaps. Plast Reconstr Surg. 1984;73:288Y292. 24. Cruz NI, Ariyan S, Duncan CC, et al. Repair of lumbosacral myelomeningoceles with double Z-rhomboid flaps. J Neurosurg. 1983;59:714Y717. 25. Ulusoy GM, Kocer U, Sungur N, et al. Closure of meningomyelocele defects with bilateral modified V-Y advancement flaps. Ann Plast Surg. 2005;54: 640Y644. 26. Atik B, Tan O, Kıymaz N, et al. Bilobe fasciocutaneous flap closure of large meningomyeloceles. Ann Plast Surg. 2006;56:562Y564. 27. Duffy FJ Jr, Weprin BE, Swift DM. A new approach to closure of large lumbosacral myelomeningoceles: the superior gluteal artery perforator flap. Plast Reconstr Surg. 2004;53:305Y310. 28. Atik B, Tan O, Mutaf M, et al. Skin perforators of back region: anatomical study and clinical applications. Ann Plast Surg. 2008;60:70Y75. 29. Mutaf M, Bekerecioglu M, Erkutlu I. A new technique for closure of large meningomyelocele defects. Ann Plast Surg. 2007;59:538Y543. 30. Kato H, Hasegawa M, Takada T, et al. The lumbar artery perforator based island flap: anatomical study and case reports. Br J Plast Surg. 1999;52: 541Y546. 31. Arco G, Horch RE, Arkudas A, et al. Double pedicled perforator flap to close flank defects: an alternative for closure of a large lumbar defect after basalioma excisionVa case report and review of the literature. Ann Plast Surg. 2009; 63:422Y424. 32. Kiil BJ, Rozen WM, Pan WR, Grinsell D, et al. The lumbar artery perforators: a cadaveric and clinical anatomical study. Plast Reconstr Surg. 2009;123: 1229Y1238. 33. Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg. 2006;56: 540Y542.
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Bilateral Propeller Flap Closure of Large Meningomyelocele Defects Harun C¸o¨lo?lu, MD,* Burak O¨zkan, MD,Þ Ahmet C¸a? rı Uysal, MD,Þ O¨zlem C¸o¨lo?lu, MD,þ and Hu¨seyin Borman, PhDÞ Background: Meningomyelocele is a defect of the spinal cord, vertebral spine, and overlying skin and is the most common form of spinal dysraphism. Multiple methods of soft tissue closure for larger myelomeningocele defects have been described, including skin grafting, random fasciocutaneous flaps, skin undermining with relaxing incisions, and musculocutaneous flaps. Most current methods for closure of defects of 8 cm and greater and kyphotic spines usually remains inadequate. In this study, we present our clinical experience with a new surgical procedure, bilateral propeller (BP) flaps based on dorsal intercostal and lumbar artery perforator, for the closure of large thoracolumbar meningomyelocele defects. Patients and Method: Between January 2011 and April 2012, 7 newborns (5 males and 2 females) with thoracolumbar large meningomyelocele were included in the study. Six patients had lumbar kyphosis. Myelomeningocele defects with a mean size of 89.3 cm2 (range, 58.9Y136.8) were closed with BP flaps. Results: All flaps survived; hematoma, seroma, wound dehiscence, flap necrosis, or infection was not observed. No patients required any surgical revisions. The patients had a follow-up of 4 to 16 months with a mean of 10 months, and no long-term complications, including necrosis of flap edges, wound breakdown, or instability, have been apparent in our series. Conclusions: We believe that the BP flaps represent a useful tool in the management of soft tissue defects associated with especially kyphotic large thoracolumbar and lumbosacral myelomeningoceles. Key Words: meningomyolecele, propeller flaps, large defects (Ann Plast Surg 2014;73: 68Y73)
M
eningomyelocele is a defect of the spinal cord, vertebral spine, and overlying skin and is the most common form of spinal dysraphism.1 The etiology of spinal canal defects is multifactorial. Widely known causes are genetic properties, geographic factors, low socioeconomic status, and deficiency of folic acid.2,3 Its incidence is declared as 1 per 1,000; however, the incidence of this anomaly is on the decline in relation with the developments in the prenatal diagnosis of neural tube defects and the aborted pregnancies as a result of these defects.4,5 This anomaly should be surgically repaired immediately after birth. The aim of the early surgical closure is to prevent infection and leakage of cerebrospinal fluid, besides protecting the neural elements. Mortality rate is approximately 65% to 70% for patients untreated in the first 6 months of life.6
Received April 10, 2012, and accepted for publication, after revision, July 31, 2012. From the *Medical Faculty, Department of Plastic and Reconstructive Surgery, Baskent University, Adana; †Medical Faculty, Department of Plastic and Reconstructive Surgery, Baskent University, Ankara; and ‡Medical Faculty, Department of Pediatric Surgery, Cukurova University, Adana, Turkey. Conflicts of interest and sources of funding: none declared. Reprints: Harun C ¸ o¨lo?lu, MD, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Baskent University, Gazipas¸a mah. Baraj cad. No. 7, 01140 Seyhan, Adana, Turkey. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-0068 DOI: 10.1097/SAP.0b013e31826caf5a
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Multiple methods of soft tissue closure for larger myelomeningocele defects have been described, including skin grafting,7 random fasciocutaneous flaps,8 skin undermining with relaxing incisions,9 and musculocutaneous flaps.10,11 Small defects (G5 cm in diameter) can usually be closed primarily by undermining the surrounding tissues. Most current methods for closure of defects more than 8 cm and kyphotic spines usually remain inadequate. Because operative stress, postoperative infection, wound dehiscence, or flap necrosis may have disruptive results, short operation time, less bleeding, safe flap perfusion, and good coverage of the wound are important to obtain satisfactory results and avoid any possible complications. ‘‘Propeller flap’’ was introduced in 1991 by Hyakusoku et al12 to describe an adipocutaneous flap, based on a random subcutaneous pedicle, with a skin island of a length largely exceeding its width, made of 2 portions: one at either side of the pedicle. A number of authors reported the application of the perforator propeller concept to the reconstruction of soft tissue defects in different areas of the body.13Y17 In this study, we present our clinical experience with a new surgical procedure, bilateral propeller (BP) flaps based on dorsal intercostal and lumbar artery perforator (DIAP and LAP), for the closure of large thoracolumbar meningomyelocele defects.
PATIENTS AND METHOD Between January 2011 and April 2012, 7 newborns (5 males and 2 females) with thoracolumbar large meningomyelocele were included in the study. This study was approved by Baskent University institutional review board (project no: KA12/59). Six patients had lumbar kyphosis. Myelomeningocele defects with a mean size of 89.3 cm2 (range, 58.9Y136.8) were closed with this technique. All of the patients were operated on within 120 hours of birth. Preservation of neural elements and watertight dural closure over the exposed neural plate were performed by the neurosurgical team. The plastic surgery team then completed wound closure with BP flaps. Details of the patients and mean values were documented in Table 1.
Surgical Method The patient was placed in the prone position, with rolls under the chest and hip to allow the abdomen to hang freely. The vertebral column was drawn in the midline in the dorsal region. The plastic surgical component of the operation begins with Doppler identification and 4-power loupe magnification and microsurgical instruments. Dorsal intercostal and lumbar artery perforator were located by a hand Doppler in the medial one third of the dorsal region. Bilateral elliptical propeller flaps based on LAP and DIAP were planned (Fig. 1A). All the flaps were raised in a fasciocutaneous manner. Dissections of the flaps were performed on the subfascial plane with meticulous hemostasis and in a careful manner. Pedicles (1 or 2 bundles) were observed and protected by careful dissection. The flap was moved to the defect site, and meticulous hemostasis and singlelayer skin closure with 4/0 and 5/0 Prolene (Ethicon/Edinburg) were accomplished. The flap donor site was then primarily closed in all patients (Fig. 1B). In all patients, a suction drain was placed and kept in place for 3 to 5 days after surgery. The patients received care after surgery in the prone position until wound healing was completed, which lasted Annals of Plastic Surgery
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Bilateral Propeller Flap
TABLE 1. Detailed Documentation of the Patients Patient No.
Sex
Birth Week
Age at Operation, d
Size of Skin Defect, mm
Size of Flap, cm*
Operating Time, min
Blood Loss, mL
1
F
Full term
3
108 72
8 6/7 5
65
35
2 3 4 5 6 7 Mean
M F M M M M
Full term Full term Full term Preterm Full term Full term
1 3 3 3 2 3
120 114 90 84 83 71 98 85 110 95 105 84 102 86
9 7/8 6 8 6/7 5 7 6/7 5 8 5/7 4 8 5/8 6 8 5/8 6
70 58 62 55 58 52 61.7
40 25 20 30 35 30 30.7
Region
Kyphosis Complications
Thoracal Thoracolumbar Thoracal Thoracal Thoracolumbar Thoracolumbar Thoracolumbar
+ + + + j + +
None None None None None None None
F, female; M, male. *Lumbar artery perforatorYbased propeller flap/DIAP-based propeller flap.
from 5 to 6 days. Starting the day before the surgery, a third-generation cephalosporin was used during the first week after surgery in all patients, although a ventriculoperitoneal shunt was placed in all patients to protect the flaps from the tension caused by increased cerebrospinal pressure.
Illustrative Case Reports Case 1 A 3-day-old female full-term newborn with a large thoracolumbar meningomyelocele defect was treated on the request of the neurosurgery department in the same institute. The size of the meningomyelocele sac was measured as 10.8 7.2 cm. She had a lumbar kyphosis (Fig. 2). After placement of an abdominoventricular shunt and closure of the placode were done by neurosurgeons, the defect closure was accomplished by using BP flaps technique as described previously (Fig. 3). Both flaps were elevated as pure fasciocutaneous flaps based on the perforator vessels from the right dorsal intercostal artery (1 bundle) and left lumbar artery (2 bundles; Fig. 4). The sizes of the flap were 7 5 and 8 6 cm, respectively. By transposing the flaps toward the defect area, a tension-free closure was obtained (Figs. 5 and 6). The flaps healed uneventfully, and the patient was discharged at day 7 after operation. During 8 months of follow-up, no complication was observed (Figs. 7Y9).
Case 2
abdominoventricular shunt and closure of the placode were done by neurosurgeons, the skin defect was measured as 12 11.4 cm in diameter, extending two third of the total width of the back (Fig. 10). He also had a lumbar kyphosis. The defect closure was accomplished by using BP flaps technique; an excellent tension-free coverage was obtained in this patient with an unusually large meningomyelocele defect. Both flaps were elevated as pure fasciocutaneous flaps based on the perforator vessels from the right dorsal intercostal artery (1 bundle) and left lumbar artery (1 bundle; Figs. 11Y13). The sizes of the flap were 8 6 and 9 7 cm, respectively. The flaps healed with no complication (Fig. 14). The LAPYbased propeller flap developed mild venous congestion. It was resolved on postoperative second day uneventfully. The result at 8 months after surgery is shown in Figures 15 and 16. Although the patient had a remarkable gibbus deformity, there was no wound breakdown at late term, and the skin flap was found to be sufficient to provide a proper padding on the neural tissues.
RESULTS The mean age at the time of surgery was 72 hours; 5 patients were male, and 2 were female. The defects were either in the thoracolumbar or the lumbar region in all patients. The largest was 12 11.4 cm, the smallest was 8.3 7.1 cm, and the mean dimension was 10.2 8.6 cm. All defects developing after myelomeningocele repair were successfully closed using BP flaps. In all patients, a tension-free
A day-old male infant was admitted with a large meningomyelocele associated with hydrocephalus. After placement of an
FIGURE 1. A, Design of the BP flaps. B, Closure patterns of BP flaps. DIAP PF, Dorsal intercostal perforator propeller flap. LAP PF, lumbar artery perforator propeller flap. * 2014 Lippincott Williams & Wilkins
FIGURE 2. Intraoperative view of the skin defect. www.annalsplasticsurgery.com
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FIGURE 3. Design of the BP flaps based on DIAP and LAP.
FIGURE 6. Completed single-layer skin closure at the end of the operation.
FIGURE 4. Elevated of propeller flap based on DIAP.
FIGURE 7. Postoperative view at second month.
FIGURE 5. Bilateral propeller flaps extension of skin defect.
FIGURE 8. Postoperative view at seventh month.
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Bilateral Propeller Flap
FIGURE 9. Postoperative lateral view at seventh month.
FIGURE 11. Elevated of propeller flap based on DIAP.
closure was obtained. Flap donor sites were closed primarily. All patients tolerated the procedure without blood transfusion and without perioperative complications. The mean (range) blood loss and operation time for flap elevation and closure were 30.7 (20Y40) mL and 61.7 (52Y70) minutes, respectively. All flaps survived, although venous congestion developed immediately after surgery on LAPbased flaps with 3 patients. Venous congestions were improved on postoperative second day. Additional complication was not observed in these patients. Hematoma, seroma, wound dehiscence, flap necrosis, or infection was not observed. No patients required any surgical revisions. All patients required subsequent ventriculoperitoneal shunts for hydrocephalus, and these procedures were uneventful; there were no shunt infections. All donor incisions healed without complication. The patients had a follow-up of 4 to 16 months with a mean of 10 months, and no long-term complications, including necrosis of flap edges, wound breakdown, or instability, have been apparent in our series.
Myelomeningocele closure consists of spinal cord repair, closure of the dura, and closure of the soft tissue and skin adjacent to the defect. There are 2 broad goals for this composite closure. First, the surgeon hopes to provide a generous, durable, and tension-free soft
tissue and skin covering over the repaired dura, thus minimizing the risk of cerebrospinal fluid leak and infection. Second, it is best to restore the natural soft tissue contours and to minimize morbidity secondary to local rearrangement of muscle and soft tissue. After the pediatric neurosurgeon has closed the neural tube, the role of the plastic surgeon in these larger defects is to provide durable coverage of the neural tube to prevent damage to or infection of the neural structures. Therefore, the closure of defects must have well-perfused blood supply without tension. Approximately 75% of meningomyelocele defects can be treated by primary closure; only large defects (95 cm), comprising the remaining 25%, cannot be closed primarily and also may require more complex procedures.2,18Y20 Various methods have been described in the literature, including primary closure, skin grafts, local flaps, muscular-musculocutaneous flaps, and fasciocutaneous flaps.1Y6 Mustarde21 was the first to suggest split-thickness skin grafts in the closure of meningomyelocele. Luce and Walsh22 applied delayed split-thickness skin grafting or simultaneous dural closure and skin grafting with a low incidence of complications. Despite its being a simple procedure with satisfactory postoperative results, skin graft repair is frequently complicated by gibbus deformity, ulceration, and infections in the long-term follow-up. Some authors have reported a successful method for closure of a defect area using musculocutaneous flaps. Major advantages of
FIGURE 10. Design of the BP flaps based on DIAP and LAP.
FIGURE 12. Elevated of propeller flap based on LAP.
DISCUSSION
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FIGURE 13. Bilateral propeller flaps extension of skin defect.
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FIGURE 15. Postoperative view at sixth month.
muscle flaps include high blood flow, provision of sufficient soft tissue over the repaired dura, and accelerated healing. However, some disadvantages that belong to this procedure have also been described, such as loss of major muscles, increased blood loss, and prolonged operation time.18,23Y25 The sacrifice of intact back muscles will be a challenge for the future use of wheelchairs in these patients, most of whom are paraplegic. In addition, these patients will be vulnerable to decubitus ulcers, and the treatment would be difficult because the local muscles would have been used before. Many scientists have preferred the less traumatic fasciocutaneous flaps for meningomyelocele repair. Moore et al23 developed bilateral bipedicled advancing flaps in large meningomyelocele closures. Cruz et al24 reported satisfactory results with double Z-rhomboid flaps in 10 newborns. Limberg flap by Campobasso et al18 and modified V-Y advancing flap by Ulusoy et al25 were all applied successfully, the size of which ranged from 35 20 to 80 50 mm2. In 2001, Lapid et al3 used bilobed flaps for closure of myelomeningocele defects. Atik et al26 reported that they closed large myelomeningocele defects using bilobed flaps in 20 patients, and it was reported as the gold standard in myelomeningocele defect repair. We also prefer bilobed fasciocutaneous flaps to the 5- to 8-cm defect in our clinic.
Perforator flaps have provided a contribution to plastic surgery. Recently, Duffy et al27 repaired lumbosacral myelomeningocele defects using a superior gluteal artery perforator flap in 6 patients. They reported advantages such as less bleeding during the operation, closure of the defect using soft tissue, and better vascularity of the flap. The superior gluteal artery perforator flap for the closure of lumbosacral meningomyelocele defects had a mean defect size of 4.8 6.8 cm2. Atik et al28 described the anatomical localization and diameter of DIAPs in 10 cadavers. They found that there were 1 artery, 1 vein, and 1 nerve emerging from each intercostal space in the dorsal region, and they also found that these were indirect muscle perforators and that the secondary perforators entered the skin. They successfully used the DIAP flap in 8 patients with large myelomeningocele defects. This was the first study where DIAP was used in the repair of a myelomeningocele defect with the mean defect size of 7 5.5 cm2, whereas it was 10.2 8.6 cm2 in our series. It seems to have several promising features such as well-vascularized healthy soft tissue padding; the flap is limited for the small and medium meningomyelocele defects.29 The LAP flap was used in a small number of cases previously in a variety of defects in the back. However, it was not used previously in meningomyelocele defects.30Y33
FIGURE 14. Postoperative view at second month.
FIGURE 16. Postoperative lateral view at sixth month.
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Based on our experience and the previous information, meningomyelocele skin defects need to classify as small (G5 cm), moderate (5Y8 cm), and large (98 cm). We believe that moderate defects are enough for the use of unilateral flap methods, but large defects require the use of bilateral flap methods. The term propeller flap was first used in axiller and wrist burn contracture defects.12 Subsequently, Hallock33 used the term propeller to define a fasciocutaneous flap that he raised over the adductor compartment of the posterior thigh. The flap was similar in shape to the one described by Hyakusoku et al,12 but it was based on a skeletonized perforating vessel, and the skin island was rotated 180 degrees. By doing this, a part of the flap (the larger blade) was used to resurface the defect, and the other part of the flap (the minor blade) was positioned over the donor site of the larger blade facilitating its direct closure. Teo13 (Teo, personal communication) greatly contributed to the definition and to the details of the surgical technique of perforator-based propeller flaps. A number of authors reported the application of the perforator propeller concept to the reconstruction of soft tissue defects in different areas of the body.14Y17 In this study, the LAP- and DIAP-based BP flaps were used to maintain skin closure without tension in cases with large myelomeningocele defects (Q8 cm) and kyphotic spines. The most important factor in preventing early and late complications is skin closure without tension. This is exceeded with bilateral flaps. In contrast to prior opinions, blood loss was less with carefully dissection and hemostasis. Operating times remained at an acceptable level. In addition, dog ear and torsion deformities do not develop, requiring second surgical intervention.
CONCLUSIONS We believe that the BP flaps represent a useful tool in the management of soft tissue defects associated with large thoracolumbar and lumbosacral myelomeningoceles because it has the following advantages: closure with a nontense skin, high safety, bringing soft tissue with a good blood supply onto the neural structures, enabling the primary closure of donor site, no overlapping between the skin suture line and the dura suture line, no pressure on the dura, no wasting of the neighboring muscles, shorter operation time, and less blood loss. The most important disadvantage of the technique is the large amount of scarring. The procedure allows for the transfer of healthy, vascularized tissue over the dural closure, likely diminishing both cerebrospinal fluid leaks and cerebrospinal fluid infections. Because the dural repair is covered with well-padded tissue using this flap, we are hopeful that this approach will diminish the chronic pain at the closure site that many of these patients have later in life. REFERENCES 1. Oakes WJ. Spinal dysraphism. In: Serafın D, Georgiade N, eds. Pediatric Plastic Surgery. St Louis, MO: Mosby; 1984. 2. Turhan Haktanir N, Eser O, Demir Y, et al. Repair of wide myelomeningocele defects with the bilateral fasciocutaneous flap method. Turk Neurosurg. 2008;18:311Y315. 3. Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg. 2001;54:570Y572. 4. Sarifakioglu N, Bingul F, Terzioglu A, et al. Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg. 2003;5:303Y306.
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5. Gumus N. A new approach to closure of myelomeningocele defect: z advancement-rotation flap. Ann Plast Surg. 2008;61:640Y645. 6. Laurence KM. Effect of early surgery for spina bifida cystic on survival and quality of life. Lancet. 1974;23:301Y304. 7. Luce EA, Stigers SW, Vandenbrink KD, et al. Split-thickness skin grafting of the myelomeningocele defect: a subset at risk for late ulceration. Plast Reconstr Surg. 1991;87:116Y121. 8. Bajaj PS, Welsh F, Shadid EA. Versatility of lumbar transposition flaps in the closure of meningomyelocele skin defects. Ann Plast Surg. 1979;2:103Y108. 9. Salasin RI, Briggs RM. Closure of a large myelomeningocele: case report. Plast Reconstr Surg. 1973;51:464Y466. 10. Munro IR, Neu BR, Humphreys RP, et al. Limberg latissimus dorsi myocutaneous flap for closure of myelomeningocele. Childs Brain. 1983;10:381Y386. 11. Ramirez OM, Ramasastry SS, Granick MS, et al. A new surgical approach to closure of large lumbosacral meningomyelocele defects. Plast Reconstr Surg. 1987;80:799Y809. 12. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg. 1991;44:53Y54. 13. Teo TC. Perforator local flaps in lower limb reconstruction. Cir Plast Iberolatinoam. 2006;32:15Y16. 14. Moscatiello F, Masia J, Carrera A, et al. The ‘‘propeller’’ distal anteromedial thigh perforator flap: anatomic study and clinical applications. J Plast Reconstr Aesthet Surg. 2007;60:1323Y1330. 15. Pignatti M, Pasqualini M, Governa M, et al. Propeller flaps for leg reconstruction. J Plast Reconstr Aesthet Surg. 2008;61:777Y783. 16. Georgescu AV, Matei I, Ardelean F, et al. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery. 2007;27:384Y394. 17. Mateev MA, Ogawa R, Trunov L, et al. Shape-modified radial artery perforator flap method: analysis of 112 cases. Plast Reconstr Surg. 2009;123:1533Y1543. 18. Campobasso P, Pesce C, Costa L, et al. The use of the Limberg skin flap for closure of large lumbosacral myelomeningoceles. Pediatr Surg Int. 2004; 20:144Y147. 19. Blanco-DaC ¸ vila F, Luce E-A. Current considerations for myelomeningocele repair. J Craniofac Surg. 2000;11:500Y508. 20. Patterson T-J, Till K. The use of rotation flaps following excision of lumbar myelo-meningoceles: an aid to the closure of large defects. Br J Surg. 1959; 46:606Y608. 21. Mustarde JC. Meningomyelocele: the problem of skin cover. Br J Surg. 1966;53:36. 22. Luce EA, Walsh J. Wound closure of the meningomyelocele defect. Plast Reconstr Surg. 1985;75:389Y393. 23. Moore TS, Dreyer TM, Bevin AG. Closure of large spina bifida cystica defects with bilateral bipedicled musculocutaneous flaps. Plast Reconstr Surg. 1984;73:288Y292. 24. Cruz NI, Ariyan S, Duncan CC, et al. Repair of lumbosacral myelomeningoceles with double Z-rhomboid flaps. J Neurosurg. 1983;59:714Y717. 25. Ulusoy GM, Kocer U, Sungur N, et al. Closure of meningomyelocele defects with bilateral modified V-Y advancement flaps. Ann Plast Surg. 2005;54: 640Y644. 26. Atik B, Tan O, Kıymaz N, et al. Bilobe fasciocutaneous flap closure of large meningomyeloceles. Ann Plast Surg. 2006;56:562Y564. 27. Duffy FJ Jr, Weprin BE, Swift DM. A new approach to closure of large lumbosacral myelomeningoceles: the superior gluteal artery perforator flap. Plast Reconstr Surg. 2004;53:305Y310. 28. Atik B, Tan O, Mutaf M, et al. Skin perforators of back region: anatomical study and clinical applications. Ann Plast Surg. 2008;60:70Y75. 29. Mutaf M, Bekerecioglu M, Erkutlu I. A new technique for closure of large meningomyelocele defects. Ann Plast Surg. 2007;59:538Y543. 30. Kato H, Hasegawa M, Takada T, et al. The lumbar artery perforator based island flap: anatomical study and case reports. Br J Plast Surg. 1999;52: 541Y546. 31. Arco G, Horch RE, Arkudas A, et al. Double pedicled perforator flap to close flank defects: an alternative for closure of a large lumbar defect after basalioma excisionVa case report and review of the literature. Ann Plast Surg. 2009; 63:422Y424. 32. Kiil BJ, Rozen WM, Pan WR, Grinsell D, et al. The lumbar artery perforators: a cadaveric and clinical anatomical study. Plast Reconstr Surg. 2009;123: 1229Y1238. 33. Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg. 2006;56: 540Y542.
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