Skin closure of large spina-bifida A new approach

By 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).

Docteur Ahcene Madjoudj

Definition The 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 during

embryonic life.

Question importance

The closure of large myelomeningocele is very challenging , it often requires a plastic surgeon within the surgery team .

The technique that we will describe in this presentation can be

practiced by any neurosurgeon..

Surgical techniques

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 anhydrocephaly.

Hydrocephalia problem

Before and after the intervention, the hydrocephaly mustme 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.

Existing techniques recap

The principle is to expand the adjoining healthy skin around the spina bifida by skin expanders to cover the skin defect.

Drawbacks Two surgeries. Duration of inflating: two to three months. Important morbidity.

Personally I have abandoned this technique..

Skin expanding technique

Veinous congestion

Healing difficulties ..

Muscular flaps

Latisimus dorsi flap

By 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.

Latissimus dorsi flap

Gluteal muscular flap Taken from whole buttocks muscle or partially pedicled on upper gluteal

artery

Drawbacks

This method can’t cover up the cutaneous deficit when it is important. The gluteal muscle flap rotating axis is limited.

Gluteal muscular flap

Cutaneous perforators flaps

The principle Take a large pedicled cutaneous flap on perforators vessels while 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 most used perforator flaps

The upper gluteal perforator flap advantages 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 flap It is centered on the 9th or 11th intercostal artery.

Drawbacks

The region from where the flap is taken can be wide which

makes its closure difficult.

It is taken from lumber artery, mainly for the 2th or the 4th

lumber artery

Drawback With large spina-bifida , 2 flaps must be used which is damaging.

The lumbar perforator flap

Lumbar perforator flap

lumbar cutanuous perforator flap

Our approach The Extensive cutaneous undermining

Our surgical approach makes use of the remarkable vascularization and elasticity of child’s skin

ANATOMY RECALL

Cutaneous 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.

Instrumentation

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.

Technique description

Sac treatment

Nervous tissues are detached from the sac

Sac aspect after treatment

Neural tube closure

Neural tube closure

Important skin loss..

Evaluation of the skin undermining 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.

laxity skin evaluation

Lateral skin undermining with perforator vessels sacrifice

Sens of skin laxity After testing skin laxity , we opt for the best closure

solution which can be horizontal or vertical

Vertical closures

Must 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.

6 months .. 15 days ..

Closure difficulties on some localized area

Closure difficulties on third lower

Flap raising

Cover up of the area

Results day 4

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.

Horizontal closures

Horizontal closure problems

Long term results

6 months…

Long term results

6 months..

Techniques comparison Perforator

skin flap Muscular flap

Extensive cutaneous undermining

operative time 4-5h 4-5h 2h

Blood loss important important Less important

CSF leaks n/a n/a null

Infections risks yes yes yes

Healing time long long short(15D)

Hospitalization duration

n/a n/a 8D

skills plastic surgeon

Plastic surgeon

neurosurgeon

Conclusion Closure technique by perforator flaps is a surgical achievement, but results are not superior compared to our approach. Our approach does not require the presence of a plastic surgeon 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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