Using the sac membrane to close the flap donor site in large meningomyeloceles

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1 The British Association of Plastic Surgeons (2004) 57, Using the sac membrane to close the flap donor site in large meningomyeloceles Cengiz Bozkurt a, Selçuk Akın a, *,Şeref Doğan b, Erkut Özdamar a, Selçuk Aytaç a, Kaya Aksoy b, Oktan Erol c a Department of Plastic and Reconstructive Surgery, Medical Faculty of Uludağ University, Görükle, Bursa 16059, Turkey b Department of Neurosurgery, Medical Faculty of Uludağ University, Görükle, Bursa 16059, Turkey c Department of Pathology, Medical Faculty of Uludağ University, Görükle, Bursa 16059, Turkey Received 25 March 2003; accepted 5 November 2003 KEYWORDS Meningomyelocele; Flap; Sac membrane; Graft; Donor site Summary If a large transposition flap with or without muscle is used for closure of a large meningomyelocele defect, then, a part of the donor site of the flap can be closed by split thickness skin graft, which produces an additional donor wound for the patient. We used the sac membrane instead of split thickness skin graft for closure of donor sites of fasciocutaneous flaps and latissimus dorsi musculocutaneous flaps employed to cover large meningomyelocele defects. This technique was used in three thoracolumbar and in two lumbosacral meningomyelocele patients. The sac membrane was prepared like a full thickness skin graft. Follow-up in five patients has ranged from 1 to 18 months, with a mean of 10.6 months. The donor sites that were closed by the sac membrane exhibited complete healing in all patients. We conclude that the sac membrane supplies a reserve of epithelialised tissue that can be used for repair of the meningomyelocele defects. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Meningomyelocele is a defect of spinal cord, vertebral spine, and overlying skin, and is the most common congenital defect of the central nervous system. 1 4 After neurosurgical closure of the neural tube and dura, the meningomyelocele defect requires good quality skin and subcutaneous tissue and minimal wound tension for stable coverage. 5,6 Small meningomyelocele defects can be closed primarily with simple undermining, but large meningomyelocele defects can be difficult to repair *Corresponding author. Tel.: þ ; fax: þ address: plastik@uludag.edu.tr and are associated with problems of wound breakdown and infection, 2,5 8 and neurosurgeons often request assistance from plastic surgeons. 3,9 The larger defects require coverage with flaps. Numerous flaps with or without muscle and local transposition flaps of various designs have been described in the literature Skin grafts have been also used to cover relaxing incisions, donor sites of the flaps, and the dural closures. 1,2,5,6,10,12 In this report, we describe use of the sac membrane instead of split thickness skin graft for closure of donor sites of the transposition flaps that are applied to cover the large meningomyelocele defects. S /$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 274 C. Bozkurt et al. Surgical technique At first the sac membrane is carefully excised from normal margins of the skin by neurosurgeons. Closure of the dura is carried out and tested by a valsalva manoeuvre to be watertight. The excised sac membrane is kept for subsequent use (Fig. 1). A transposition flap (fasciocutaneous flap or latissimus dorsi musculocutaneous flap) is elevated from the undamaged part of the back to cover the defect. Wound closure is performed in three layers using 4/0 polyglactin (Vicrly) sutures for the deep tissues and 4/0 polyproplent (Prolene) suture for the skin. The excised sac membrane is used to cover the flap donor site that cannot be closed primarily. The undersurface of this membrane is thinned by careful trimming with a sharp, curved scissors. The thinned membrane is laid over the flap donor site instead of skin graft and sutured using 4/0 catgut. A tie-over dressing is applied. The dressing is left in place for five days. During the postoperative period, the patient is kept in the prone position until wound healing is complete. Materials and methods We have used this new approach in the last 18 months in three thoracolumbar and in two lumbosacral meningomyelocele patients whose flap donor sites were not repaired by direct primary closure (Table 1). Their ages at the time of surgery ranged from 1 to 30 days, with an average of 15 days. Two of the patients were operated on within the first day of life. The size of the defects varied from 5 10 to 8 12 cm 2, with an average of cm 2. The sac membrane was intact in three patients. Following the dural closure of the meningomyelocele, the skin defects were covered with latissimus dorsi musculocutaneous transposition flaps in two patients and fasciocutaneous transposition flaps in three patients, with the suture line distant from the dural repair. The donor site defects varied from 10 5 to 7 5cm 2, with an average of cm 2. The thinned sac membranes were applied to all the flap donor sites instead of split thickness skin graft. Case reports Case 1 A 1-day-old full-term male infant presented a 8 10 cm 2 meningomyelocele defect of the thoracolumbar region with intact membrane (Fig. 2). The child had paralysis of both lower extremities. Following the closure of the dural defect a latissimus dorsi musculocutaneous flap was used to close the skin defect. The donor site was 9 5cm 2. And the thinned sac membrane was used to resurface this (Fig. 3). The wound healed without complication, and the child was discharged on the fifteenth postoperative day (Fig. 4(A) and (B)). Case 3 A 30-day-old full-term male infant with a 8 9cm 2 meningomyelocele defect of the thoracolumbar region with intact membrane underwent a neurosurgical watertight dural closure. The child had flaccid paralysis of both lower extremities. The skin defect was covered with a fasciocutaneous transposition flap. The thinned sac membrane was used in closing the donor site defect of 9 3cm 2. The wound healed without complications and the child was discharged on the twelfth postoperative day (Fig. 5(A) and (B)). Figure 1 The sac membrane that was excised. Figure 2 Preoperative appearance of the large thoracolumbar meningomyelocele defect in case 1.

3 Using the sac membrane to close the flap donor site in large meningomyeloceles 275 Table 1 Details of the patients treated Patient Age at operation Location Defect size (cm) No. Sex Flap Defect size of donor site (cm) Follow-up period 1 M 1 day Thoracolumbar 8 10 Latissimus dorsi months 2 M 30 days Thoracolumbar 8 12 Fasciocutaneous months 3 M 30 days Thoracolumbar 8 9 Fasciocutaneous monhts 4 F 15 days Lumbosacral 5 11 Fasciocutaneous months 5 F 1 day Lumbosacral 5 10 Latissimus dorsi month Results The follow-up period ranged from 1 to 18 months, with an average of 10.6 months. All of the defects were repaired successfully in one stage with a tension-free closure of good-quality tissue. There was no flap loss, necrosis, wound dehiscence and leakage of cerebrospinal fluid. The sac membranes exhibited complete healing in all patients. None of the patients had ulceration or loss of the sac membrane. It showed better adaptation to surrounding skin after surgery. Two patients (case 1 and 4) had hydrocephalus that required shunting after the dural closure. Two patients (case 4 and 5) died of pulmonary infection at 6 months and 1 month after surgery, respectively. The histopathological examination has demonstrated that the sac membrane includes stratified squamous epithelial cells in its outer surface, and dilated vessels, fibrocollagenous tissue, and neuroglial structures in its stroma (Fig. 6). simple procedure such as undermining and advancement of local skin flaps. 1,3,6,9 But the skin closure of large meningomyelocele defects is difficult to obtain, and the potential for complications is substantial. 1,5 In the literature, numerous techniques for closure of large meningomyelocele defects have been described, including split-thickness skin grafting, fasciocutaneous transposition flaps, rotation flaps, wide skin undermining with relaxing incisions, tissue expanders, latissimus dorsi and gluteus maximus musculocutaneous flaps Discussion The majority of the meningomyelocele defects are so small that skin closure can be accomplished by a Figure 3 Postoperative appearance of the flap donor site that was closed by the thinned sac membrane at 7 days after surgery, in case 1. Figure 4 Postoperative appearances of the flap and donor site, in case 1. The flap donor site was well healed. (a) At 10 days after surgery. (B) At 18 months after surgery.

4 276 C. Bozkurt et al. Figure 6 Microscopic appearance of the sac membrane in the meningomyelocele (H and E stain, 16). It includes stratified squamous epithelial cells in its outer surface, and dilated vessels, fibrocollagenous tissue and neuroglial structures in its stroma. Figure 5 Postoperative appearances of the flap and donor site, in case 3. The donor site was closed by the thinned sac membrane. (A) At 10 days after surgery. (B) At 12 months after surgery. The donor site was well healed. If a flap is used for closure of the meningomyelocele defect, then the suture lines of the flap should be placed away from the area of dural closure so that in the event of a suture line dehiscence, the dural closure remains relatively protected.11 A latissimus dorsi musculocutaneous flap or fasciocutaneous flap can be used in a transposition fashion to meet this requirement.4 6,10 12 The flap donor site can also be closed primarily. In large meningomyeloceles, a large flap is necessary, and part of the donor site is closed by split thickness skin graft.12 Split skin grafts have also been used for relaxing incisions of the widely undermined bilateral fasciocutaneous flaps, to cover on the dural closures, and on the muscle in the reverse latissimus dorsi flap in meningomyelocele patients.1,2,5,6,10 If split skin graft is used for repair of the donor defects, problems related to its own donor site can occur.13 Paraplegia and joint deformities may also cause difficulties for care of the graft donor site.2,5,6 The sac membrane has commonly been thrown away after excision in meningomyelocele operations, but can be used for closure of the flap donor sites, and is prepared like a full thickness skin graft. The sac membrane has several advantages. It supplies a reserve of epithelialised tissue for the patient with meningomyelocele, and avoids donor site problems.

5 Using the sac membrane to close the flap donor site in large meningomyeloceles 277 References 1. Moore TS, Dreyer TM, Bevin G. Closure of large spina bifida cystica defects with bilateral bipedicled musculocutaneous flaps. Plast Reconstr Surg 1984;73: Luce EA, Stigers SW, Vanderbrink KD, Walsh JW. Splitthickness skin grafting of the myelomeningocele defect: a subset at risk for late ulceration. Plast Reconstr Surg 1991; 87: Çeliköz B, Türegün M, Şengezer M. The repair of myelomeningocele with tissue expanders. Eur J Plast Surg 1996;19: Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg 2001;54: Jacobucci JJ, Marks MW, Argenta LC. Anatomic studies and clinical experience with fasciocutaneous flap closure of large myelomeningocoele. Plast Reconstr Surg 1996;97: Luce EA, Walsh J. Wound closure of the myelomeningocoele defect. Plast Reconstr Surg 1985;75: Hayashi A, Maruyama Y. Bilateral latissimus dorsi V Y musculocutaneous flap for closure of a large meningomyelocele. Plast Reconstr Surg 1991;88: Ramirez OM, Ramasastry SS, Granick MS, Pang D, Futrell JW. A new surgical approach to closure of large lumbosacral meningomyelocele defects. Plast Reconstr Surg 1987;80: Josvay J, Bognar L. Large lumbosacral meningomyelocele closure with gluteus maximus musculocutaneous hatchet flap. Eur J Plast Surg 2003;25: VanderKolk CA, Adson MH, Stevenson TR. The reverse latissimus dorsi muscle flap for closure of meningomyelocele. Plast Reconstr Surg 1988;81: Scheflan M, Mehrhof Jr. AI, Ward JD. Meningomyelocele closure with distally based latissimus dorsi flap. Plast Reconstr Surg 1984;73: Davies D, Adendorff DJ. A large rotation flap raised across the midline to close lumbo-sacral meningomyelocoeles. Br J Plast Surg 1977;30: Rudolph R, Ballantyne Jr.DL. Skin grafts. In: McCarthy JG, editor. Plastic surgery, 9th ed. Philadelphia: WB Saunders Company; p