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This series highlights the success and utility of perforator flaps in microsurgical reconstruction of the foot and ankle. The greatest advantage of perforator flaps is the diminished donor site morbidity, which was achieved while maintaining high microsurgical success rates. These skin and fat flaps remained pliable and contracted less than muscle flaps, allowing for smooth tendon gliding and easy flap elevation for secondary orthopaedic procedures.

The most common form of neural tube defect is the myelomeningocele, developing during the fourth week of gestation. The era of early closure of myelomeningoceles began in the sixties with the demonstration that these patients had a lower rate of mortality. 1 The goals of early surgical closure are to (1) prevent infection, (2) eliminate cerebrospinal fluid leaks, (3) preserve neural function, and (4) diminish negative late sequelae such as pain over the closure site and possibly even tethered cord. 2 After closure of the neural tube and dura, the majority of these patients have enough local skin to allow for simple closure of the skin over the dural closure. When the skin defect is large or the surrounding skin quality is poor, more elaborate methods of obtaining stable skin closure over the dural closure must be devised. 3 Multiple methods of soft-tissue closure for larger lumbosacral myelomeningocele defects have been described, including skin grafting, 4 random flaps, 5 skin undermining with relaxing incisions, 6 and musculocutaneous flaps. 7,8 None of these approaches are ideal, however, particularly when the skin defect is large and/or the quality of the surrounding skin is poor. We have developed a new approach to closure of large lumbosacral defects with superior gluteal artery perforator flaps. PATIENTS AND METHODSSix patients were operated on over an 18-month period. During this period, our neurosurgical group treated a total of 34 myelomeningocele patients. Plastic surgical consultation was initiated by the pediatric neurosurgeon when he felt the defect was too large for closure with simple skin advancement flaps. The average birth weight of the six patients was 3237 grams and the average cutaneous defect covered with the superior gluteal artery perforator flaps was 4.8 ϫ 6.8 cm. The flaps were designed to match the cutaneous defect. Two of the patients were prenatally diagnosed with the myelomeningocele. All of the patients were operated on within 36 hours of birth. All patients were operated on in the prone position under general endotracheal anesthesia. The average blood loss during the procedures was 12 cc, and no patients required blood transfusions intraoperatively. The average operative time for the combined procedure was 190 minutes; the average plastic surgical operative time for flap elevation and insetting was 115 minutes. Neurosurgical management included initial placode dissection, spinal cord reconstruction and closure, and dural elevation and closure. 9 The first patient this approach was used on showed a very large myelomeningocele with very poor quality surrounding skin. Figure 1 demonstrates the flap design and marked perforators before the start of the operation; the neural tube has been imbricated and dural closure is about to be performed.The plastic surgical component of the operation begins with Doppler identification and From Medical City Dallas and the