Skin closure of large spina bifida myelomeningoceles
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 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).
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.
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..
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.
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.
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..
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.
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.
The principleTake a large pedicled cutaneous flap on perforators vesselswhile preserving the muscle.The perforators vessels are spotted with Doppler flowmeter.
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.
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.
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.
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.
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 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.
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.
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.
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.
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
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.
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
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