Skin closure of large        spina-bifida        A new approach        By Docteur Ahcene Madjoudj
Docteur Ahcene Madjoudj Plastic Surgeon. I practice in the liberal sector in Algiers (Algeria). I also collaborate with...
DefinitionThe myelomeningocele is alterations of :  Meninges.  Roots of nervous tissues.  Medulla.  the posterior vert...
Question importanceThe closure of large myelomeningocele is very challenging , itoften requires a plastic surgeon within t...
Surgical techniques
Three forms of spina-bifida: spina-bifida Occulta: the most frequent and benign . spina-bifida meningocele: with few neu...
Hydrocephalia problem Before and after the intervention, the hydrocephaly must  me seriously monitored. If present befor...
Existing techniques recap
Skin expanding techniqueThe principle is to expand the adjoining healthy skinaround the spina bifida by skin expanders to ...
Veinous congestion
Healing difficulties ..
Muscular flaps
Latisimus dorsi flapBy using the reversed turnover latissimus dorsi muscle flap.Drawbacks Should not be used with paraple...
Latissimus dorsi flap
Gluteal muscular flap Taken from whole buttocks muscle or partially pedicled on upper gluteal  arteryDrawbacks This meth...
Gluteal muscular flap
Cutaneous perforators flaps
The principleTake a large pedicled cutaneous flap on perforators vesselswhile preserving the muscle.The perforators vessel...
Advantages  The flap might cover up a large skin loss.  Its rotation is very large.Drawbacks  On babies perforators are...
The most used perforator                   flaps
The upper gluteal perforator flapadvantages  Near the lower spina-bifida  The flap can be large.  The donar area closur...
The latero-costal perforator flapIt is centered on the 9th or 11th intercostal artery.DrawbacksThe region from where the f...
The lumbar perforator flapIt is taken from lumber artery, mainly for the 2th or the 4thlumber arteryDrawbackWith large spi...
Lumbar perforator flap
lumbar cutanuous perforator flap
The Extensive cutaneous undermining                 Our approach
 Our surgical approach makes use of the remarkable  vascularization and elasticity of child’s skin
ANATOMY RECALLCutaneous skin vascularization .Importance of perforator vessels
The technique principles The incision must be done with preserving as much skin as  possible, even if the skin doesn’t se...
Instrumentation
Peculiarity of the incision After subcutaneous infiltration around the base of the  spina-bifida xylocaine epinephrine di...
Technique description
Sac treatment
Nervous tissues are detachedfrom the sac
Sac aspect after treatment
Neural tube closure
Neural tube closure
Important skin loss..
Evaluation of the skinundermining We apply few sutures on the subcutaneous tissue at the  base of the spina-bifida. We p...
laxity skin evaluation
Lateral skin undermining withperforator vessels sacrifice
Sens of skin laxity After testing skin laxity , we opt for the best closure  solution which can be horizontal or vertical
Vertical closuresMust be favoured because often they are less problem prone
• (Photos…..)
Vertical closure problems• If desaturation occurs during closure, it may be adjusted by  discharges incisions.
15 days ..             6 months ..
Closure difficulties on somelocalized area
Closure difficulties on third lower
Flap raising
Cover up of the area
Results day 4
Horizontal closures Horizontal closure are done along the lines of the back  tensions by sacrificing the perforator vesse...
Horizontal closure problems
Long term results
Long term results                    6 months…
6 months..
Techniques comparison                   Perforator   Muscular    Extensive cutaneous                   skin flap    flap  ...
ConclusionClosure technique by perforator flaps is a surgicalachievement, but results are not superior compared to ourappr...
Bibliography• Journal of Plastic, Reconstructive & Aesthetic Surgery (2010)  63,1513e1518.• “Reversed turnover latissimus ...
Thank you ...Slides on:http://www.chirurgieesthetiquealgerie.com
Skin closure of large spina bifida myelomeningoceles
Skin closure of large spina bifida myelomeningoceles
Skin closure of large spina bifida myelomeningoceles
Skin closure of large spina bifida myelomeningoceles
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Skin closure of large spina bifida myelomeningoceles

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presentation at the international neurosurgery congress held at Oran on march 2012

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Transcript of "Skin closure of large spina bifida myelomeningoceles"

  1. 1. Skin closure of large spina-bifida A new approach By Docteur Ahcene Madjoudj
  2. 2. Docteur Ahcene Madjoudj Plastic Surgeon. I practice in the liberal sector in Algiers (Algeria). I also collaborate with neuro-surgery departments of CHU Blida and Bab-El-Oued mainly in spina-bifida and Cranio- facial surgery. I am a member of the Canadian Society for Aesthetic Plastic Surgery (csaps).
  3. 3. DefinitionThe myelomeningocele is alterations of :  Meninges.  Roots of nervous tissues.  Medulla.  the posterior vertebral wall.  Skin structures above the myelomeningocele.The cause is an absence of closure of the neural tube duringembryonic life.
  4. 4. Question importanceThe closure of large myelomeningocele is very challenging , itoften requires a plastic surgeon within the surgery team .The technique that we will describe in this presentation can bepracticed by any neurosurgeon..
  5. 5. Surgical techniques
  6. 6. Three forms of spina-bifida: spina-bifida Occulta: the most frequent and benign . spina-bifida meningocele: with few neurologic disorders. spina-bifida myelomeningocele : the severest form with important neurologic disorders often associated with an hydrocephaly.
  7. 7. Hydrocephalia problem Before and after the intervention, the hydrocephaly must me seriously monitored. If present before surgery, it must be shunted. After the surgery, we have to look out for its apparition and shunt it consequently.
  8. 8. Existing techniques recap
  9. 9. Skin expanding techniqueThe principle is to expand the adjoining healthy skinaround the spina bifida by skin expanders to cover theskin defect.Drawbacks  Two surgeries.  Duration of inflating: two to three months.  Important morbidity. Personally I have abandoned this technique..
  10. 10. Veinous congestion
  11. 11. Healing difficulties ..
  12. 12. Muscular flaps
  13. 13. Latisimus dorsi flapBy using the reversed turnover latissimus dorsi muscle flap.Drawbacks Should not be used with paraplegic patients because it causes some shoulder disabilities. This technique also requires a skin graft.
  14. 14. Latissimus dorsi flap
  15. 15. Gluteal muscular flap Taken from whole buttocks muscle or partially pedicled on upper gluteal arteryDrawbacks This method can’t cover up the cutaneous deficit when it is important. The gluteal muscle flap rotating axis is limited.
  16. 16. Gluteal muscular flap
  17. 17. Cutaneous perforators flaps
  18. 18. The principleTake a large pedicled cutaneous flap on perforators vesselswhile preserving the muscle.The perforators vessels are spotted with Doppler flowmeter.
  19. 19. Advantages  The flap might cover up a large skin loss.  Its rotation is very large.Drawbacks  On babies perforators are very small and delicate.  This technique requires the presence of a plastic surgeon with skills in microsurgery.  In large spina-bifida bilateral flaps are required for the closure thus increasing morbidity.
  20. 20. The most used perforator flaps
  21. 21. The upper gluteal perforator flapadvantages  Near the lower spina-bifida  The flap can be large.  The donar area closure is easy.Drawbacks:  Cannot cover large upper spina-bifida .  With large spina-bifida , 2 flaps must be used which is damaging.
  22. 22. The latero-costal perforator flapIt is centered on the 9th or 11th intercostal artery.DrawbacksThe region from where the flap is taken can be wide whichmakes its closure difficult.
  23. 23. The lumbar perforator flapIt is taken from lumber artery, mainly for the 2th or the 4thlumber arteryDrawbackWith large spina-bifida , 2 flaps must be used which isdamaging.
  24. 24. Lumbar perforator flap
  25. 25. lumbar cutanuous perforator flap
  26. 26. The Extensive cutaneous undermining Our approach
  27. 27.  Our surgical approach makes use of the remarkable vascularization and elasticity of child’s skin
  28. 28. ANATOMY RECALLCutaneous skin vascularization .Importance of perforator vessels
  29. 29. The technique principles The incision must be done with preserving as much skin as possible, even if the skin doesn’t seem healthy. Extensive skin undermining by sacrificing the perforator vessels. Preserve the perforators of the gluteal region for possible use of gluteal perforator flap if necessary. Use discharges incisions or z pasties to relieve the tension on the scar if necessary.
  30. 30. Instrumentation
  31. 31. Peculiarity of the incision After subcutaneous infiltration around the base of the spina-bifida xylocaine epinephrine diluted in physiological saline to the quarter to reduce bleeding. Tilt the blade N 15 to 60 degrees for cutting and maintaining the sclerotic tissue around the sac that will be used if needed for the neural tube closure.
  32. 32. Technique description
  33. 33. Sac treatment
  34. 34. Nervous tissues are detachedfrom the sac
  35. 35. Sac aspect after treatment
  36. 36. Neural tube closure
  37. 37. Neural tube closure
  38. 38. Important skin loss..
  39. 39. Evaluation of the skinundermining We apply few sutures on the subcutaneous tissue at the base of the spina-bifida. We pull together both verges so we can evaluate the dissection required for the closure.
  40. 40. laxity skin evaluation
  41. 41. Lateral skin undermining withperforator vessels sacrifice
  42. 42. Sens of skin laxity After testing skin laxity , we opt for the best closure solution which can be horizontal or vertical
  43. 43. Vertical closuresMust be favoured because often they are less problem prone
  44. 44. • (Photos…..)
  45. 45. Vertical closure problems• If desaturation occurs during closure, it may be adjusted by discharges incisions.
  46. 46. 15 days .. 6 months ..
  47. 47. Closure difficulties on somelocalized area
  48. 48. Closure difficulties on third lower
  49. 49. Flap raising
  50. 50. Cover up of the area
  51. 51. Results day 4
  52. 52. Horizontal closures Horizontal closure are done along the lines of the back tensions by sacrificing the perforator vessels. This type of closure is only possible if the surrounding skin is elastic . If tensions on the scar occurs, we use the discharges incisions or z plasties.
  53. 53. Horizontal closure problems
  54. 54. Long term results
  55. 55. Long term results 6 months…
  56. 56. 6 months..
  57. 57. Techniques comparison Perforator Muscular Extensive cutaneous skin flap flap underminingoperative time 4-5h 4-5h 2hBlood loss important important Less importantCSF leaks n/a n/a nullInfections risks yes yes yesHealing time long long short(15D)Hospitalization n/a n/a 8Ddurationskills plastic Plastic neurosurgeon surgeon surgeon
  58. 58. ConclusionClosure technique by perforator flaps is a surgicalachievement, but results are not superior compared to ourapproach.Our approach does not require the presence of a plasticsurgeon and can take place in all surgical facilities.
  59. 59. Bibliography• Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63,1513e1518.• “Reversed turnover latissimus dorsi muscle flap for closure of large myelomeningocele defects.” Yehia Zakaria a, Esam A. Hasan b• Closure of Large meningomyelocele Defects by Lumbar Artery Perforator Flaps. Ahmed Hassan El-Sabbagh(M.D.)• http://www.chirurgieesthetiquealgerie.com/la-spina- bifidaprogresse-en-algerie
  60. 60. Thank you ...Slides on:http://www.chirurgieesthetiquealgerie.com
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