Unilateral Bipedicled Subcostal and Lumbar Arteries Perforator Flap for Reconstruction of Large Myelomeningocele Defects

INTRODUCTION
There are plenty of methods tried for closure
of large myelomeningocele defects. Ranging from
skin grafting, local flaps, muscle flaps, musculocutaneous
flaps, perforator flaps to free flaps [1].
In this study we presented a 3 years' experience
in the repair of large myelomeningocele lumber
and lumbosacral defects utilizing bipedicled subcostal
and lumber artery perforator flaps.
Subcostal arterery perforator flaps were first
described by Feinendegen and Klos, 2002 [2] for
reconstruction of lumber defects. Its perforator
emerges at the lateral edge of latissimus dorsi
muscle just below the last rib and extends forward
toward the rectus sheath [3].
The lumbar artery perforators first reported by
Kroll and Rosenfield, 1988 [4] while it's anatomical
bases has been described by Lui et al., 2009 [5].
The perforators exit the abdominal wall just lateral
to erector spinae muscles [6].
299
PATIENTS AND METHODS
All reconstructions performed from December
2014 to June 2017. Patient's demographics, physical
examination findings, defects sizes, flap sizes and
postoperative complications were reported in Table
(1).
Over 31 months a unilateral bi-pedicle sub
costal and lumber artery perforator flap was used
to reconstruct large myelomeningocele defect.
Patients included 13 male and 10 females ranging
in age from one to 3weeks. They all had large
myelomeningocele defects.
Operative technique:
A flap marking with its size determined by the
myelomeningocele defect is made over the patients
back after determination of subcostal and upper
lumber perforators using Doppler.
The flap margins are outlined obliquely just
below the last rib and few centimeters above the
iliac crest with the distal limit at lateral edge or
over the rectus muscle.
The proximal limit is the lateral border of
erector spinae muscle. The width of the flap is
designed so that it can cover the defect without
any tension.
All surgeries performed under general anesthesia.
The flap is raised from distal to proximal and
from upward downward. Care taken to be subfascial
until the lateral edge of latissimus then continue
submuscular till the lateral edge of erector spinae
muscle. After complete rising of the flap it is
transferred to the defect and the donor site is
primary closed. (Figs. 1-7).
300 Vol. 42, No. 2 / Unilateral Bipedicled Subcostal & Lumbar Arteries Perforator Flap
Fig. (1): Case 6 a large defect after closure of the dura by
neurosurgeon.
Fig. (2): Case 6 the flap raised and shown part of latissimus
within the flap.
Fig. (3): Case 6 the flap easily reaches the defect. Fig. (4): Case 6 the defect closed and the donor closed
primary.
Fig. (5): Case 10 defect after closure of the dura by neurosurgeon.
Fig. (6): Case 10 postoperative after flap insetting.
Fig. (7): Case 10 late postoperative show
complete closure of the defect.
Egypt, J. Plast. Reconstr. Surg., July 2018 301
RESULTS
An average follows-up period was 6 months
with a range from 0 to 29 months. The flap sizes
ranged from 6x13cm to 10x18cm and all survived
without any total loss. The donor sites healed
satisfactorily.
Early and late complications were not seen
apart from one case of distal flap necrosis. Debridement
and re-suturing was performed after that
the flap showed reliable closure of the defect.
Knowledge of vascular anatomy and skin territories
supplied by arteries is essential for perforator
flap surgery [4,15].
The use of perforator flaps including the lumbar,
superior gluteal and the dorsal intercostal arteries
has also been previously described [9].
Although each flap alone is valuable option
however it seems to be useful only for small to
medium sized defects [2,12].
Also, the use of bilateral perforator flaps have
multiple drawbacks of additional donor site problems,
requirement for skin grafting and ugly scars
of skin grafting on long term [16,18].
In this study we offered a unilateral flap utilizing
two perforators of the subcostal and the lumbar
arteries. The lumbar arteries are 4 in numbers and
the perforators of the 1st, 2nd and 4th reported to
be the most constant [5,6,9].
The perforators of the lumbar vessels exiting
at 5-8cm from the posterior midline at the lateral
boder of erictor spinae muscle and extend towards
the anterior superior iliac spine and rectus muscles
[9,19].
Subcostal perforator flaps depend on subcostal
artery perforator not widely reported in literature
but it has constant anatomical location within 5cm
from the spinous process then passes below the
last rib within the latissimus dorsi before exiting
to the subcutaneous tissues at its lateral border
[3,11]. The usages of double perforators have been
reported in literatures [5,11,20]. Keles et al., 2014
[21] reported that double perforator flaps supply
satisfactory larger dimensions than single pedicle
one.
We confirmed this in our study as the flap with
these two perforators provides a well vascularized
and durable coverage. It does not cause any functional
deficit or sacrificing of any of back muscles.
Instead of including small piece of latissimus
dorsi muscle to give wide mobility and to increase
the flap length, it does not lead to any functional
disability as was reported in a study done by Sarifakioglu,
et al., 2003 [1].
Conclusion:
Bipedicled perforator flap utilizing both subcostal
and lumbar arteries perforators will provide
reliable, durable coverage of large mylomeningocele
without a need for morbidities. So, it is a
valuable option in reconstruction of large myelomeningocele
defects.
Table (1): Documentations of patients.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Defect size
(CM)
8X10
8X9
8X10
6X10
8X11
6X8
7X6
5X7
8X5
7X5
5X6
9X9
8X5
9X6
7X4
8X4
8X6
6X6
9X4
9X5
7X6
8.5X5
10X6
Pt.
no.
M
M
F
F
F
M
M
F
M
M
M
F
F
F
M
M
M
F
M
F
F
M
M
Sex Age
14
7
9
8
12
10
7
14
12
8
11
10
12
7
8
13
14
10
8
8
7
9
13
9X16
8.5X16
9X18
9X17
10X19
7X16
6.5X14
6.5X13
7X15
6.5X13
5.5X12
8X15
7.5X14
8.8X18
6.5X14
7X15
7.5X14
6X12
8.5X15
8X14
6.5X13
8X14
9.5X19
Flap size
CM)
Lumbosacral
Lumbosacral
Lumbosacral
Lumbosacral
Lumbosacral
Lumbosacral
Lumbosacral
Lumbar
Lumbosacral
Lumbar
Lumbar
Lumbosacral
Lumbar
Lumbosacral
Lumbosacral
Lumbosacral
Lumbar
Lumbar
Lumbosacral
Lumbosacral
Lumbar
Lumbar
lumbosacral
Region
None
None
None
None
None
None
None
None
None
None
None
None
None
Distal
necrosis
Noe
None
None
None
None
None
None
None
None
Complication
DISCUSSION
Several reconstructive methods have been described
for closure of large myelomeningocele
defects. These methods including skin grafting [7],
tissue expansion [8], limberg rhomboid flap [9]
bipedicle flaps [10], biloped flaps [9] bilateral v-y
advancement [11] Z-plasty [12] and bilateral latissimus
dorsi flaps [1].
The disadvantages of skin graft is that it could
not provide sufficient soft tissue cover for the
neural tissues beside the risk of ulceration and
recurrent gibbus [13]. Disadvantages of random
pattern flaps are distal flap necrosis, the need for
extensive undermining and suture line over the
repair [12]. The disadvantage of muscle and/or
musculoculocutaneous flaps are increased blood
loss, long operating time and disruption of the
muscles carry potential risk of functional loss in
a potentially paraplegic wheel chair patient [14].

Knowledge of vascular anatomy and skin territories
supplied by arteries is essential for perforator
flap surgery [4,15].
The use of perforator flaps including the lumbar,
superior gluteal and the dorsal intercostal arteries
has also been previously described [9].
Although each flap alone is valuable option
however it seems to be useful only for small to
medium sized defects [2,12].
Also, the use of bilateral perforator flaps have
multiple drawbacks of additional donor site problems,
requirement for skin grafting and ugly scars
of skin grafting on long term [16,18].
In this study we offered a unilateral flap utilizing
two perforators of the subcostal and the lumbar
arteries. The lumbar arteries are 4 in numbers and
the perforators of the 1st, 2nd and 4th reported to
be the most constant [5,6,9].
The perforators of the lumbar vessels exiting
at 5-8cm from the posterior midline at the lateral
boder of erictor spinae muscle and extend towards
the anterior superior iliac spine and rectus muscles
[9,19].
Subcostal perforator flaps depend on subcostal
artery perforator not widely reported in literature
but it has constant anatomical location within 5cm
from the spinous process then passes below the
last rib within the latissimus dorsi before exiting
to the subcutaneous tissues at its lateral border
[3,11]. The usages of double perforators have been
reported in literatures [5,11,20]. Keles et al., 2014
[21] reported that double perforator flaps supply
satisfactory larger dimensions than single pedicle
one.
We confirmed this in our study as the flap with
these two perforators provides a well vascularized
and durable coverage. It does not cause any functional
deficit or sacrificing of any of back muscles.
Instead of including small piece of latissimus
dorsi muscle to give wide mobility and to increase
the flap length, it does not lead to any functional
disability as was reported in a study done by Sarifakioglu,
et al., 2003 [1].
Conclusion:
Bipedicled perforator flap utilizing both subcostal
and lumbar arteries perforators will provide
reliable, durable coverage of large mylomeningocele
without a need for morbidities. So, it is a
valuable option in reconstruction of large myelomeningocele
defects.