Reconstruction of Myelomeningocele by Lumbar Artery Perforator Plus Flap: Retrospective Analysis of Case Series

Al Sabbahi, Mohamed; Abou Hashem, Safwat; Mostafa, Ashraf M

doi:10.21608/ejprs.2023.319957

Reconstruction of Myelomeningocele by Lumbar Artery Perforator Plus Flap: Retrospective Analysis of Case Series

Document Type : Research article

Authors

¹ The Departments of Plastic & Reconstructive Surgery, School of Medicine, Zagazig University, Egypt, and Saudi German Hospital, Riyadh

² The Departments of Neurosurgery, School of Medicine, Zagazig University and Department Neurosurgery, Saudi German Hospital, Riyadh

³ The Department of Plastic & Reconstructive Surgery, School of Medicine, Zagazig University, Egypt,

10.21608/ejprs.2023.319957

Abstract

Background: Over the last two decades, a paradigm shift
has occurred in the reconstruction of myelomeningocele
defects with the emerging concepts of perforator flaps. The
use of lumbar perforator flaps for reconstruction of those
defects has superseded any other modes of reconstruction.
This is attributed to the confidence in flap versatility and low
donor site morbidity. Although the flap has good vascular
reliability, there's still some risk for venous congestion.
Objectives: This study aims to present our experience
and the outcome in the reconstruction of myelomeningocele
defects using freestyle lumbar perforator plus flap.
Methods: Retrospective analysis of 16 newly born infants
presented to the plastic surgery department between February
2018 to June 2020 presented with thoracolumbar, lumbosacral,
or purely lumbar myelomeningocele. All patients underwent
joint neurosurgical and plastic reconstruction procedures.
Layered reconstruction was performed and dorsal intercostal
or lumbar arteries perforator plus flap were used in all patients.
Results: Out of the 16 babies in this study, 15 babies
(93.75%) had neurological deficits. The flap dimension ranged
from (3.4x5.8cm) to (6x11cm). The blood loss was minimal
with a mean of 22±4.5ml. No flap loss had occurred except
for one partial 1cm distal necrosis treated conservatively.
Follow-up for six months showed good soft tissue coverage
in all cases without any need for further reconstructive procedures.
Conclusion: The lumbar artery perforator plus flap provides
a well vascularized durable coverage, lower rate of
complications or morbidity and more aesthetic appearance.

Keywords

Main Subjects

Reconstructive surgery

References

Copp A.J., Adzick N.S., Chitty L.S., et al.: Spina bifida.
Nat. Rev. Dis. Primers, 1: 15007, 2015.
2- Turhan Haktanir N., Eser O., Demir Y., et al.: Repair of
wide myelomeningocele defects with the bilateral fasciocutaneous
flap method. Turk Neurosurg, 18: 311-315,
2008.
3- Lapid O., Rosenberg L. and Cohen A.: Meningomyelocele
reconstruction with bilobed flaps. Br. J. Plast. Surg., 54:
570-572, 2001.
4- Shaer C.M., Chescheir N. and Schulkin J.: Myelomeningocele:
A review of the epidemiology, genetics, risk factors
for conception, prenatal diagnosis, and prognosis for
affected individuals. Obstet. Gynecol. Surv., 62: 471-479,
2007.
5- Dias M. and Lane J.: Myelomeningocele Closure: An
Embryological Perspective. Cureus, 12: e9682, 2020.
6- Atalay T., Oktay K., Guzel E., et al.: Comparison of dorsal
intercostal perforator artery flap and primary closure in
myelomeningocele repair. Childs Nerv. Syst., 37: 229-
233, 2021.
7- Cologlu H., Ozkan B., Uysal A.C., et al.: Bilateral propeller
flap closure of large meningomyelocele defects. Ann.
Plast. Surg., 73: 68-73, 2014.
8- Isik D., Tekes L., Eseoglu M., et al.: Closure of large
myelomeningocele defects using dorsal intercostal artery
perforator flap. Ann. Plast. Surg., 67: 159-163, 2011.
9- UCAK M.: Myelomeningocele closure by unilateral lumbar
artery perforator flap: Experience with thirty-eight patients.
Microsurgery, 38: 752-757, 2018.
10- Emsen I.M.: Closure of Large Myelomeningocele Defects
Using the O-S Flap Technique. J. Craniofac. Surg., 26:
2167-2170, 2015.
11- Duffy F.J., Jr., Weprin B.E. and Swift D.M.: A new
approach to closure of large lumbosacral myelomeningoceles:
The superior gluteal artery perforator flap. Plast
Reconstr Surg., 114: 1864-1868; discussion 1869-1870,
2004.
12- Zakaria Y. and Hasan E.A.: Reversed turnover latissimus
dorsi muscle flap for closure of large myelomeningocele
defects. J. Plast. Reconstr. Aesthet. Surg., 63: 1513-1518,
2010.
13- Cruz N.I., Ariyan S., Duncan C.C., et al.: Repair of
lumbosacral myelomeningoceles with double Z-rhomboid
flaps. Technical note. J. Neurosurg., 59: 714-717, 1983.
14- Lien S.C., Maher C.O., Garton H.J., et al.: Local and
regional flap closure in myelomeningocele repair: A 15-
year review. Childs Nerv. Syst., 26: 1091-1095, 2010.
15- Kato H., Hasegawa M., Takada T., et al.: The lumbar
artery perforator based island flap: Anatomical study and
case reports. Br. J. Plast. Surg., 52: 541-546, 1999.
16- El-Sabbagh A.H. and Zidan A.S.: Closure of large myelomeningocele
by lumbar artery perforator flaps. J. Reconstr.
Microsurg., 27: 287-294, 2011.
17- Tenekeci G. and Basterzi Y.: Reliability of extended dorsal
intercostal artery perforator propeller flaps for reconstruction
of large myelomeningocele defects. J. Plast. Reconstr.
Aesthet. Surg., 70: 60-66, 2017.
18- Gutierrez-Ontalvilla P., Blanco E.L. and Miranda P.: Longterm
follow-up of myelomeningocele defect closure with
dorsal intercostal artery perforator propeller flaps. Childs
Nerv. Syst., 35: 1219-1222, 2019.
19- Luce E.A., Stigers S.W., Vandenbrink K.D., et al.: Splitthickness
skin grafting of the myelomeningocele defect:
A subset at risk for late ulceration. Plast. Reconstr. Surg.,
87: 116-121, 1991.
282 Vol. 47, No. 4 / Reconstruction of Myelomeningocele by Lumbar Artery Perforator Plus Flap
20- Mustarde J.C.: Meningomyelocele: The problem of skin
cover. Br. J. Surg., 53: 36-41, 1966.
21- Moore T.S., Dreyer T.M. and Bevin A.G.: Closure of large
spina bifida cystica defects with bilateral bipedicled
musculocutaneous flaps. Plast. Reconstr. Surg., 73: 288-
292, 1984.
22- Ulusoy M.G., Kocer U., Sungur N., et al.: Closure of
meningomyelocele defects with bilateral modified V-Y
advancement flaps. Ann. Plast. Surg., 54: 640-644, 2005.
23- Patterson T.J.: The use of rotation flaps following excision
of lumbar myelo-meningoceles: An aid to the closure of
large defects. Br. J. Surg., 46: 606-608, 1959.
24- Muneuchi G., Matsumoto Y., Tamai M., et al.: Rhomboid
perforator flap for a large skin defect due to lumbosacral
meningocele: A simple and reliable modification. Ann.
Plast. Surg., 54: 670-672, 2005.
25- Atik B., Tan O., Kiymaz N., et al.: Bilobed fasciocutaneous
flap closure of large meningomyeloceles. Ann. Plast.
Surg., 56: 562-564, 2006.
26- Cho E.H., Shammas R.L., Carlsen B.T. and Allen R.J.:
Perforator Plus breast reconstruction: A comparative study.
J. Plast. Reconstr. Aesthet. Surg., Nov. 66 (11): 1452-9,
2013.
27- Farber N., Kim K., Patel A., et al.: Comparison of Perforator
Plus and Muscle-sparing Transverse Rectus Abdominis
Myocutaneous Flaps for Unilateral Breast Reconstruction:
A Single-Institution Experience. J. Reconstr.
Microsurg., Nov. 33 (9): 623-628, 2017.
28- Egro F.M., Galié M., Spaggiari A., et al.: Perforator plus
flaps versus fasciocutaneous flaps for reconstruction of
lower extremity defects: A comparison of outcomes. J.
Plast. Reconstr. Aesthet. Surg., Nov. 67 (11): 1496-503,
2014.