Reversed latissimus dorsi muscle flap versus skin flaps in closure of myelomeningocele defects: Comparative study

Reversed latissimus dorsi muscle flap versus skin flaps in closure of myelomeningocele defects: Comparative study

Mohamed El Wahsh, MD; Mahfouz  Shehata, MD, MRCS;

Adel Tolba, MD; Ayman Fikry, MD

Plastic Surgery Unit, General Surgery Department, Zagazig University, Sharkiya, Egypt.

In cases of closure of myelomeningocele  defects, soft tissue coverage  is needed as soon as the dural closure has been achieved. Small myelomeningocele  defects can be managed by undermining ofthe surrounding skin but in the cases of large thoracolumbar  or lumbosacral defects local flaps (skin or muscle flaps) are widely used.

Purpose: To compare between two surgical techniques in repair of large myelomeningocele defects with muscle flaps and skin flaps in the different aspects and to provide a durable, protective, and tension-free soft tissue covering.

Methods: We presented a review of our 3-year experience using this approach for closure of  myelomeningocele.  Our  study  included  10  consecutive  patients  treated  using  reversed latissimus dorsi muscle flap (group A) and other 10 cases treated with skin flaps (group B) for reconstruction of the myelomeningocele  defects.

Results:  In all patients operated on a tension free closure was obtained. Complications developed in cases covered with skin flaps were one hematoma, one subclinical infection and 3 wound dehiscence while there was only one case that developed hematoma after coverage with reversed latissimus dorsi flaps. There was no patient with late breakdown ofthe wound during

2 years of mean follow-up.

Conclusion: Instead of less donor site morbidity the skin flaps have higher operative complication  rate  (dehiscence,   hematoma   and  subclinical  infection)   than  with  reversed latissimus dorsi flaps, so we can conclude that reversed latissimus dorsi flaps are still preferred to skinflaps  in closure of large myelomeningeocele  defects.

Key words: Myelomeningeocle, reversed, latissimus dorsi flap, skinflap.

Introduction:

Myelomeningocele is a defect of spinal cord, vertebral spine, and overlying skin, and is the most common congenital defect of the central nervous system.l

In the past, the abnormal anatomy of the

neural placode and spinal canal has received more  attention  among  neurosurgeons  than the corresponding defects in muscle, fascia, subcutaneous fat, and skin.2,3

The  majority   of  the  defects  are  small enough to be closed primarily with simple undermining ofthe skin edges and a tension­ free  approximation.   Although  effective  in many cases, this technique is associated with

complications   such  as  cerebrospinal   fluid

(CSF) leak, subcutaneous or deep infection.4

Several  procedures  have  been  described to   manage   large   defects,   including   skin grafts,  lateral  relaxing   inclSlons  with bipedicle flap closure, rotation flaps, double­ rhomboid z-plasty, muscle, and composite musculocutaneous flaps.5-10

In this report we described a comparative study  between  reverse  LD  and  local  skin flaps in covering oflarge myelomeningeocele defects.

Patients and methods:

Twenty  patients   in  Zagazig   University

Am-ShamsJSurg2014; 7(2):401-406

hospitals were operated on for repair of myelomeningocele  defects between October

2010 and November 2013. Patients were randomized into two groups (group A odd numbers  and group  B even  numbers).  The mean  age  for  group  A was  5.5  days(range from  3 to 10 days)  and 5.1 days for  group B( range from 2 to 9 days). Medical records were performed to document preoperative demographics,  defect  characteristics, operative techniques, postoperative hospital course,  and  early   and  late  complications. Major wound failure was that requiring reoperation  for  closure.  Isolation and repair of the neural placode and dural closure were carried  out.  Ten patients  were  operated  on for repair ofthe myelomeningocele defect by reversed  latissimus  dorsi flap and the  other ten cases were operated on by skin flaps.

Operative  technique:  After  stabilization,

thorough   examination   and   documentation of any deficit or other  congenital anomalies of the baby by neonatal intensive care unit (NICU) staff was done. General anaesthesia was  given  and  the  patient  was  placed  in prone      position.    A   neurosurgeon    started exploration by lysis of the tethered cord, then repositioning of neurofilaments followed by water-tight closure of the dural sac.

Group  A patients:  The  LD  outline  was

marked as well as its upper limit. An oblique incision   was  extended  from  the  axilla  to the  defect.  The  superficial  surface  of  the LD  superficial  surface  was  identified.  The thoracodorsal   artery,  vein  and  nerve  were exposed,  tied  off  and  then  detached.  After resection     of    its     humerus    insertion,   the deep lateral surface  of the muscle was then identified and dissection continued tward the posterior  trunk  midline.  As we  approached the  midline  care  was taken  to preserve  the segmental   pedicles.   The   sacrifice   of  the superior   pedicle   was  necessary   to   allow the  muscle to reach the defect satisfactorily without   tension.   The  muscular   flap   was then  tacked  with  some  absorbable  sutures after  covering  of the  dural  membrane.  The donor area was closed primarly then a partial thickness skin graft was then harvested from the  thigh and applied  over the  muscle.  The

estimated  amount of blood loss ranged from

15 to 25 cc.

Group B patients: Skin Flaps: Several variations  of  local  random  skin  flaps  were used  to   close  myelomeningocele   defects. Of them the lateral relaxing incisions with bipedicle flap (2 patients), rotation flaps (2 patients), V-Y advancement flaps (1 patient), double-rhomboid    z-plasty   (2  patients)   or their combination (3 patients) were applied however  all of them shared same characters of having random blood supply and required wide skin  undermining.  After the flaps had been  harvested  and  insited  the  donor  sites were primary closed.

The estimated amount ofblood loss ranged

from 5 to 15 cc.

Figures(l-5) are explaining the operative procedures.

Results:

Most of our patients (13 patients) were operated on in the first week of life, and the other 7 patients were operated on in the second week. The defect sizes ranged between  8x5 em and 9.5-7cm.

In all patients a tension free closure was obtained and there was no patient with late breakdown of the wound during 2 years of mean follow-up  (ranged from 6 months to 3 years).

The mean operative time  in group A was

120 min while in group B it was 55 min.

One patient from group A developed minimal  hematoma  that  resolved spontaneously  while the remaining patients healed without complications.

Group B patient's experienced one subclinical  infection  that  resolved  with medical  treatment,  one  minimal  hematoma and  lastly  three  partial  wound   dehiscence but all healed with secondary  intension after daily wound care. There was no further compromise affecting the vascularity of the tissues that leads to total wound breakdown over the dural repair Table (1).

Discussion:

The majority of the myelomeningocele defects  are  so  small  that  skin  closure  can

Figure (1): Preoperative.

Figures (2,3): Intraoperative: reversed latissimus dorsi and local skin flaps.

Figures  (4,5): Postoperative:  reversed  latissimus  covered  by split thickness  skin  graft  and sutured local skin.flaps.

Table (1)

be   accomplished  by   a   simple   procedure such  as  undermining and  direct  closure   of the  wound   edges.ll ,12 The  skin  closure   of large   mylomeningocele  defects   is  difficult to obtain, and in need for more complicated procedures.

The    surgical    procedures   which    have

been   currently  known   for   the   closure   of large mylomeningocele defects  can be categorized in 3 groups  as (1) skin  grafting, (2) local skin flaps, and (3) muscular and musculocutaneous flap procedures.ll Skin grafting  of a mylomeningocele is a simple procedure with  low  immediate complication rate, but late problems of gibbus deformity, ulceration  or  infection   are  not  uncommon and may  necessitate secondary surgical interventions.l3,14 Therefore, several  authors prefer flap closure to skin  grafting.  The local skin  flap procedures described for closure  of large  meningomyelocele defects  are various

in  shape  and  in the  way  of  flap  transfer.15

Although the  initial   experience  with  these skin  flaps  was quite  encouraging, the  use of the flaps for coverage of myleomeningoceles are  associated   with  high  complication  rates owing   to   ischemia  caused   by   wide   skin undermining, relaxing  incisions,  back  cuts or  tension at  the   skin  closure.l6  Of  these complications  are   the   high   incidence  of necrosis  of  wound  edges  and  not  providing as  good  amount   of  padding   as the  muscle

flaps.l0,12

The use of musculocutaneous flaps have been   reported   as  a  superior   alternative to surgical  repair of large myleomeningoceles.l7

The reversed latissimus dorsi flap needs to be covered  with  a split thickness skin  graft, which   causes   an  additional  donor   wound.

Although the  muscle  and musculocutaneous

flaps  provide  a  good  padding   with  a well­ vascularized            tissue   over      neural   repair, they  have  2 major  drawbacks as  increased blood   loss  and   longer   operating  time.   As another    potential    drawback,   is   that   the musculocutaneous flaps have been implicated in  compromising the  structural integrity   of the   spine.  Since   these   patients   often   need crutches   for   ambulation,  and   sacrifice   of the   back    muscles    may    adversely   affect crutch  walking  which  is not present  with the

cutaneous flap.18 Preserving the  integrity  of

back musculature was also reported to be important for  effective  bladder  emptying during the valsalva  maneuver.l9

Other  studies  reported  that removal  of the latissimus dorsi  muscle  does not functionally impair  the  strength nor  the  range  of  upper

extremity motion. 17,20  However  long follow

up periods  should  be available to detect  any functional disability related to the procedure.

Conclusion:

The use of the skin flap in repmr of myelomeningocele   shows    short   operative time  and  less  operative   blood  loss,  less  or no need  to be covered  with  a split thickness skin  graft,  less  compromising the  structural integrity of the spine but higher  operative complication  rate   (dehiscence,  hematoma and subclinical infection), than with reversed latissimus dorsi  flaps.  We can  conclude  that reversed  latissimus flaps are still preferred  to skin flaps.

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